Proteomics has emerged as a powerful tool for characterizing toxicant-induced pathologies, providing comprehensive datasets that include protein expression profiles, pathway alterations, and molecular interactions. However, the translation of these extensive datasets into practical clinical applications, such as diagnostic tools and targeted therapies, remains a major challenge. In this study, we employed a sarin exposure model to investigate long-term neurotoxic effects. Sarin is a highly toxic volatile AchE inhibitor that rapidly induces seizures, which result in prolonged abnormal brain activity and damage. Rats were exposed to sarin (1.2LD50. i.m.) and were treated with TA (TMB-4, atropine;1 min post exposure i.m.) resulting in acute seizures and abnormal behavior 2 weeks post-exposure. Three weeks post-exposure histological analysis revealed severe brain deficit. At that time point their brain tissues were dissected into cortical and hippocampal regions, followed by protein extraction and mass spectrometry-based proteomic analysis.
In an effort to decipher this long-term damage and establish novel therapeutic options, we focused on understanding proteomic alterations in the rat brain three weeks post-sarin exposure. Bioinformatics and artificial intelligence-driven computational tools were applied to process and interpret the data, enabling the identification of region-specific and shared proteomic signatures. Our analysis revealed 333 cortical proteins and 227 hippocampal proteins with elevated expression levels after sarin exposure compared to naïve. We delineated key molecular pathways involved in sarin- induced neurotoxicity and identified novel biomarkers for monitoring exposure-related damage. Furthermore, we leveraged these insights to map protein expression patterns to known pathologies, facilitating disease classification and prediction of clinical outcomes. Finally, we proposed therapeutic strategies, including broad-spectrum treatment approaches as well as targeted interventions aimed at specific dysregulated proteins.
This study demonstrates the potential of integrating advanced proteomics with computational analytics to bridge the gap between molecular research and clinical application, paving the way for improved diagnostics and precision medicine in sarin induced brain damage and neurological pathology.

Background and purpose:
Ocular exposure to organophosphate (OP) irreversible acetylcholinesterase inhibitors, results in long-term miosis and visual impairment. This study aims to improve an anti- cholinergic treatment that effectively mitigates miosis and visual impairment induced by the nerve agent's sarin and VX while minimizing adverse effects.
Experimental approach:
Rat pupil width and light reflex were measured from 15 min up to two weeks following whole-body or topical OP exposure. Treatments including topical atropine or tropicamide or an intramuscular administration of TMB-4 and atropine (TA) were evaluated using the topical OP model. Visual function following exposure and treatment was evaluated using a cued Morris water maze test.
Results:
Whole body exposure to sarin or VX induced a dose-dependent miosis, observed even at one-hundredth or one-fortieth of the LCt50, respectively. Similarly, topical exposure to sarin or VX presented a dose-dependent miosis and a significant visual impairment post exposure and thus was used as a model for treatment evaluation. Treatment with 0.1% and 0.5% (w/v) atropine effectively mitigated miosis and visual impairment in OP exposed eyes with minimal adverse effects of mydriasis on exposed and non-exposed eyes, outperforming 1% atropine which induced long term mydriasis. Intramuscular TA or 2 topical drops of tropicamide were sufficient to counteract sarin-induced ocular impairment. However, for VX exposure, additional topical treatment with 0.1 or 0.5% atropine was required.
Conclusions and complications:
Commercially available 0.5% atropine eye drops effectively mitigated ocular insult caused by VX or sarin exposure with minimal adverse effects and should be considered a universal treatment for such intoxication. The findings also emphasize the need for supplementary ocular treatment in addition to the systemic treatment in visually impaired casualties following VX exposure.

This study presents a novel computational approach for identifying repurposing opportunities of existing treatments against chemical, biological, radiological, and nuclear (CBRN) threats. Utilizing advanced text mining methodologies through the SPIKE platform for extractive search, CoreMine Medical, Embase, and Clinical Queries, we developed a structured framework for mapping hazardous agents to potential therapeutic interventions. Our approach involved constructing specialized threat categories and cross-referencing them with comprehensive drug databases to identify evidence-based connections. To enhance precision, we employed contextual keyword enhancement and AI-driven (LLM) validation strategies, effectively filtering irrelevant associations. The methodology can identify promising treatment candidates for toxic industrial gases, nerve agents, opioid toxicity, and radiation exposure, with specific emphasis on combinatorial interventions. This systematic approach bridges critical gaps in CBRN preparedness by leveraging existing medical knowledge and provides a scalable framework for future countermeasure development. Our approach demonstrates the value of computational text mining in accelerating the identification of viable treatment options for complex threat scenarios while minimizing resource expenditure.

There are three components in the antidotal medical mixture used toward organophosphorus nerve agents (OPNA) poisoning: 1. oxime reactivator of OPNA- inhibited acetylcholinesterase (AChE), (e.g. 2-PAM, HI-6), 2. Anticholinergic drug (e.g. atropine, scopolamine) and 3. anti-convulsant (e.g. diazepam, midazolam). Despite extensive translational research over the last 50 years only few antidotal drugs were introduced to clinical use and there are still efficacy gaps to surmount in the treatment of certain OPNA intoxications. In particular, insufficient recovery, long term neurotoxic effects and fatalities have been observed during treatment of respiratory and skin-exposure to the A-series Novichoks nerve agents. We believe that the key component of the antidotal mixture is the oxime reactivator that displaces the OPNA from the covalent OPNA-AChE complex. Based on HTS-driven approach, we have recently discovered new non-quaternary oximes that are efficient and safe reactivators of sarin- and VX-inhibited BChE (Amitai et al. Comms. Biol. 2021). These non-quaternary oximes could potentially penetrate through the blood-brain barrier (BBB) and reactivate brain ChEs. In addition, during the last two years we have been focused on the development of new ketoximes rather than clinically approved aldoximes. The notion is that the spontaneous degradation of Phosphoryl- Ketoxime intermediate formed during reactivation of OPNA- AChE is catalytic, allowing turnover of the oxime for multiple reactivation cycles, effectively reducing the dose required for reactivation. In contrast, aldoximes reactivators produce a nitrile upon hydrolysis of their respective phosphoryl- oxime intermediate, an irreversible process. Therefore, we have prepared new ketoximes with enhanced nucleophilic potency. This project involves newly synthesized compounds that include substitution of aromatic rings by halogens (e.g. F and Cl) as an electron withdrawing group (EWG) as well as lipophilic group. The EWG effect is expected to lower the pKa of the ketoxime group and lipophilic efficiency is predicted to increase by Chlorine (Cl) substitution. Lower pKa values could induce higher concentration of oximate anion at physiological pH (7.4). The oximate anion is an active nucleophilic species that attacks the bound OP during reactivation. Indeed, calculated pKa and log P values (ACD Labs) demonstrate decrease in pKa values from 9-10 to pKa 7-8 together with increase in log P of Cl-substituted ketoximes compared to non-Cl ketoixmes. Notably, some newly synthesized Cl-Ketoximes demonstrated enhanced in vitro reactivation kinetics of sarin- and/or VX-inhibited AChE compared to 2-PAM and TMB-4.

Chlorine is a corrosive irritant widely used in the chemical industry. Since it was first used as a chemical warfare agent in World War I in the battle of Ypres, Belgium, hundreds of attacks were reported, many of which in the last two decades in Syria. Acute exposure to chlorine gas due to industrial accidents or military activity may cause severe airway irritation and inflammation, respiratory distress and pulmonary edema injury, and in severe cases respiratory failure and death. Survivors of acute chlorine exposure present long-term effects such as bronchitis, emphysema, airway obstruction, encephalopathy and cardiac pathology. Currently, the treatments of acute inhalation of chlorine gas are supportive and symptom oriented.
Our work aims to characterize a rat model of acute and chronic injuries following a whole-body exposure to high concentrations of chlorine gas, which can serve for evaluations of emerging treatments.
Groups of awake adult Sprague-Dawley rats were exposed to 500ppm or 600ppm chlorine gas for 20-30 minutes in 70% humidified whole-body exposure system. Clinical evaluations including body weight, clinical severity score, respiratory functions, circadian activity and changes in blood count were performed for a period of 16 days after the exposure. Following euthanasia, lung and trachea tissues were processed for histological evaluation.
Exposed rats developed chlorine acute intoxication symptoms including skin injuries, changes in white blood cells counts, breathing difficulties, impaired circadian activity and weight loss. Death rates after 24 hours were 11% and 25% for 600ppm for 20 min and 500ppm for 30 min, respectively. Although gradual healing process was seen clinically, respiratory measurements using plethysmography presented ongoing dysfunction during the 16 days of monitoring. In addition, skin injuries around the eyes, nose and tail, did not heal during the follow-up period. Histological analysis revealed inflammatory cell infiltration and airways obstruction in the lungs, tracheal obstruction and severe damage to tracheal cilia and epithelium.
This study presents a model of an acute injury following a whole-body exposure of rats to a high concentration of chlorine, as expected in a real scenario. A comprehensive characterization of various clinical and histological parameters of acute chlorine induced injury was performed. This model will serve as a tool for emerging treatment evaluation.

The development of refractory status epilepticus (SE) following sarin intoxication presents a therapeutic challenge. In this current research we evaluated the efficacy of a delayed combined double or triple treatment in reducing the abnormal electrographic seizure activity (ESA) and ensuing long-term neuronal insult. SE was induced in rats by exposure to 1.2LD50 sarin followed by treatment with atropine and TMB4 (TA) 1 min later. Double treatment of ketamine and midazolam or a triple treatment of ketamine, midazolam and levetiracetam was administered 30 min post exposure and was compared to a delayed single treatment with midazolam alone or to the triple treatment of ketamine, midazolam, and valproate, which was shown previously to ameliorate this neuro-insult. Toxicity and electrocorticogram activity were monitored during the first week, and behavioral evaluation was performed 3 weeks post exposure followed by biochemical and immunohistopathological analyses. The triple and to less extent the double treatment significantly ameliorated the duration and intensity of the seizures and the ESA. Both treatments reduced the sarin-induced increase in the neuroinflammatory marker PGE2, the brain damage marker TSPO, decreased gliosis, astrocytosis and neuronal damage compared to the TA only or TA + midazolam treated groups. Finally, both double and triple treatments prevented behavioral impairment using the open field test. The delayed double and to more extent triple treatment may serve as an efficient delayed therapy, which prevents brain insult propagation following sarin-induced refractory SE.

Synthetic opioids, such as fentanyl, are widely used to manage chronic and severe pain. Over recent decades, fentanyl and some of its analogs, such as carfentanil, have become increasingly prevalent among drug users. The relative ease of synthesis and the growing prevalence of these drugs pose a significant threat, as they could potentially be used as chemical agents in terror attacks against civilian population. These compounds can be fatal in relatively small amounts. Aims:
1. To evaluate and compare the efficacy of i.m. and i.v. naloxone administration for the treatment of high dose fentanyl and carfentanil intoxication.
2. To assess the efficacy of i.m. antidotal treatment with naltrexone and nalmefene in counteracting fentanyl and carfentanil intoxication and in preventing re- narcotization.
Methods:
Rabbits were administered varying doses of naloxone at different time points (20, 60, 120 sec) following i.v. injection of high doses of fentanyl or carfentanil. Naloxone was administered by either i.v. or i.m. route, protection factor was calculated and the efficacy of each injection method was determined. Additionally, the efficacy of i.m. naltrexone and nalmefene treatments against fentanyl and carfentanil intoxication was evaluated in rabbit and rats.
Results:
All rabbits and rats exhibited typical symptoms of opioid intoxication that started within seconds of fentanyl or carfentanil injection. Symptoms included stretching, opisthotonos, breathing distress, loss of righting reflex and loss of corneal reflex, loss of consciousness and in some cases, apnea and death.
Naloxone treatment was highly effective as long as it was administered within 1 minute following intoxication. Both, the i.m. and the i.v. routes afforded high protection, yet the i.v. route was more effective, allowing longer delay between intoxication and treatment.
Both, naltrexone and nalmefene also provided high protection, with efficacy comparable to naloxone in the rabbit model and proved to decrease and even eliminate occurrence of re-narcotization.
Conclusions:
The results of these experiments clearly indicated that i.m. antidotal treatments with naloxone as well as naltrexone or nalmefene are very effective against both, fentanyl and carfentanil high dose intoxication, provided treatment is initiated immediately after intoxication. These findings highlight the need for readily available automatic autoinjectors these antidotes, particularly for use by first responders.

Low volatility organophosphorus chemical warfare agents (OP CWAs) such as VX and Novichok, are potent cholinesterase inhibitors that can easily penetrate the skin, creating a dermal depot from which the agent gradually penetrates the bloodstream. This results in prolonged cholinergic overstimulation, which can be fatal if not properly treated. Current countermeasures are not suitable for neutralizing the dermal depot. Accordingly, we developed the potassium salt of acetohydroxamic acid (AHAK), as a “catch-up” therapy lotion intended to penetrate the skin and neutralize the low volatility OP CWA dermal depot by decomposing it. Our results demonstrate the efficacy of combining dermal application of the AHAK lotion, together with standard antidotal treatment against OP CWAs poisoning, in protection against dermal exposure to low volatility OP CWAs in an unanesthetized swine model. Specifically, our results show that the combined treatment provided complete rescue of all exposed animals and significantly reduced the recurrence of intoxication signs, leading to a significant shortening of the medical supervision duration required. Hence, our results provide the first demonstration of the efficacy of a “catch-up” therapy in protection against low volatility OP CWAs dermal exposure and delineate the AHAK lotion as an effective such therapy.

Israel’s National Health Intelligence Agency was established post COVID-19 pandemic to enhance early detection and response to public health threats. It supports risk-based decision-making, detecting outbreaks, assessing risks, and guiding strategic actions. A structured threat classification model is essential for shifting from reactive to proactive public health management.
Purpose:
To develop a standardized model for classifying public health threats based on national risk levels and potential disease importation.
Methods:
The model evaluates five key factors:
1. Anomaly detection – Identifying unusual health events. 2. Severity assessment – Mortality and transmissibility.
3. Population vulnerability – Immunization levels,
healthcare burden.
4. National preparedness – Policies, stockpiles, governance. 5. Additional considerations – Political, economic, and
public concerns.
Results & Implications:
1. A real-time, adaptable threat classification tool.
2. Standardizes risk levels for national health events.
3. Supports evidence-based decision-making and response
planning.
4. Enhances coordination across health authorities and
emergency systems.
Existing models often focus on travel-related threats or pandemics, neglecting broader risk factors. This model integrates comprehensive public health risks to guide national preparedness and response strategies effectively.
Overall, the threat classification model based on national risk levels provides an organized, insightful snapshot of the threat landscape. It helps leaders and planners swiftly grasp which threats present the most serious challenges, fostering informed decision-making to enhance national resilience and security. Each threat category is addressed in proportion to its risk, thereby optimizing mitigation efforts for better protection of the nation’s people, infrastructure, and interests.

Field-deployable bio/chemical sensor devices are essential for real-time detection of chemical and biological threats across diverse, non-laboratory settings. These portable “labs-on- a-chip” enable rapid on-site identification of contaminants, addressing critical needs in environmental monitoring, public safety, defense, and smart city infrastructure. Modern biosensors leverage miniaturized microfluidic systems and sensitive transducers to deliver fast, reliable, and automated detection. In this work, we present our efforts to overcome three key challenges in developing an integrated, field-ready biosensing platform:
1. Bioassay Development – We designed a microfluidic bioassay for the detection of toxins and pathogens, enabling rapid and specific identification of biological threats.
2. Automated Sample Handling – We engineered microfluidic tools for critical sample preparation functions, including filtration, mixing, and dilution, ensuring consistent and reliable fluid processing.
3. Electrochemical Sensor Integration – We initiated the incorporation of an electrochemical biosensor into the system to provide sensitive, real-time signal transduction for enhanced detection accuracy.
By combining automated sample processing with high- sensitivity biosensing, our platform aims to bridge the gap between laboratory-based analysis and real-world deployment. This development represents a step toward a fully autonomous, high-performance biosensing device for broad applications in environmental and biological threat detection.

Botulinum neurotoxin A (BoNT/A), produced by Clostridium botulinum, is one of the most potent toxins known. Understanding the mechanism of its activation is crucial, as BoNT/A has significant medical and cosmetic applications, in addition to its role in botulism. Identifying the endogenous protease responsible for BoNT/A activation is particularly important, as it sheds light on the toxin's biosynthesis and regulation, providing insights that could influence therapeutic developments and safety protocols. BoNT/A is initially synthesized as a 150-kDa polypeptide with limited potency and requires proteolytic cleavage to become fully active. Surprisingly, the endogenous protease that transforms this polypeptide into an activated, full-potency toxin, consisting of a 100-kDa heavy chain (HC) connected to a 50-kDa light chain (LC) by a disulfide bond, is still unknown. This study aimed to identify the BoNT/A-activating protease. We screened cation-exchange chromatography fractions of C. botulinum A culture supernatant for activity using a toxin-simulating substrate comprising the LC and the translocation domain (HN). Proteomic analysis of the active fraction identified α-clostripain as a candidate BoNT/A-activating protease. Recombinant α-clostripain cleaved the simulating substrate between the toxin LC and HN. However, incubation of recombinant α-clostripain with recombinant inactivated BoNT/A (rBoNT/Ai) resulted in non-specific digestion of the toxin. Since similar non-specific digestion was observed also by C. botulinum A culture supernatant, we hypothesized that the toxin should be protected by an accessory protein to prevent non-specific cleavage. Indeed, incubation of rBoNT/ Ai with α-clostripain or culture supernatant in the presence of recombinant non-toxic non-hemagglutinin (NTNH) resulted in specific cleavage of the toxin into 100- and 50-kDa fragments. Functional validation showed a 77-fold increase in toxicity after α-clostripain-mediated activation in the presence of NTNH, as confirmed in a mouse model. These findings elucidate for the first time the activation mechanism of BoNT/A, highlighting the coordinated interaction between α-clostripain and NTNH.

Rift Valley fever virus (RVFV) is a zoonotic pathogen that causes significant morbidity and mortality in both humans and livestock. While veterinary vaccines exist, no licensed vaccines or therapeutics exist for human use. Neutralizing monoclonal antibodies (mAbs) represent a promising strategy for prophylactic and therapeutic interventions, particularly targeting the viral glycoproteins Gc and Gn, which contain key neutralizing epitopes.
This study aims to identify rare, potent mAbs against RVFV using high-throughput single-cell transcriptomics, facilitating the discovery of novel therapeutics for RVFV infections. Mice were immunized with live attenuated rMP-12-GFP virus and boosted with recombinant Gc/Gn antigens. Memory B cells were isolated from splenocytes via flow cytometry, and single-cell RNA sequencing (scRNA-seq) was performed using 10x Genomics technology. Bioinformatics analyses identified B cell receptor (BCR) pairs based on abundance and specificity. A panel of 23 recombinant mAbs was generated and characterized for antigen-binding affinity.
Approximately half of the generated mAbs exhibited strong and specific binding to their cognate antigen, validating the effectiveness of the single-cell sequencing approach. These findings demonstrate the feasibility of using scRNA-seq for high-throughput antibody discovery against RVFV.
Single-cell transcriptomics is a powerful tool for identifying potent neutralizing mAbs, which can be leveraged for the development of RVFV-targeted therapeutics. This methodology may also be applied to other emerging viral threats, facilitating rapid antibody-based countermeasure development. This study demonstrates the power of single- cell sequencing for rapid antibody discovery, enabling the identification of potent mAbs against RVFV. While monoclonal antibodies offer a promising therapeutic approach, challenges remain in clinical translation, including production and regulatory approval. Optimizing this strategy for other emerging viruses could enhance outbreak preparedness.

Fentanyl is a family of potent synthetic opioids legally used for anesthesia and analgesia, as well as illegally in the illicit drug trade. Fentanyl have also been used as a neutralizing agent, specifically aerosolized for inhalational exposure. As such, this family of drugs poses a severe threat from use by nefarious actors, both for incapacitation and kidnapping of civilians or soldiers, as well as for lethal attacks. We describe our approach to setting up an experimental system to perform inhalational exposures of rabbits to aerosols generated from fentanyl solutions, as a means to studying this potential threat and supplying a platform for testing treatments and countermeasures.

Effective disease surveillance is critical for early detection, risk assessment, and response to public health threats. This lecture explores key methodologies for tracking and analyzing outbreaks, highlighting the vital role of health intelligence in preparedness and decision-making.
Real-time data plays a crucial role in identifying emerging health risks. For example, West Nile fever outbreaks have been detected through mosquito surveillance, allowing authorities to implement vector control measures and reduce transmission. Similarly, health intelligence has been instrumental in tracing Hepatitis A outbreaks, enabling public health interventions such as vaccinations.
By leveraging epidemiological modeling, data analytics, and cross-sector collaboration, health intelligence assesses risks and provides actionable insights to policymakers and healthcare professionals.
Through case studies and real-world examples, this session will demonstrate how a proactive and intelligence-driven approach strengthens public health resilience, ultimately leading to more effective outbreak prevention and response.

The West Nile virus (WNV), which is the etiological agent for West Nile fever, is a member of the Flaviviridae family. It is predominantly transmitted to humans through the bite of infected mosquitoes, with birds acting as the primary natural reservoir for the virus. First identified in Uganda, WNV has spread worldwide. In the United States, WNV is considered as a significant public health concern. It is the leading cause of mosquito-borne disease, with thousands of reported cases annually, especially in the summer and fall.
Approximately 20% of those infected develop symptoms, typically mild flu-like fever lasting a week, without the need for treatment. In approximately 1 in 150 cases, particularly among individuals aged 60 and above, those with weakened immune systems, the disease may be prolonged and severe. Complications can include central nervous system involvement, such as meningitis and encephalitis, with a fatality rate of 10% among severe cases.
In this study, we administered WNV-NY99 to mice via intra- footpad injection to model the natural route of infection and disease progression. Based on this disease model, we tested potential treatment. A single-dose of poly(I:C), showed significant efficacy. Early treatment with poly(I:C) resulted in survival rates of 60-100% in the animals. In poly(I:C)-treated mice, the virus was undetectable in the blood, spleen, and draining lymph nodes. Although the brain remained a target organ for the virus, the viral load in the brain was lower in treated mice at day 6 post-infection, and by day 8, the virus was cleared from the brain. Histological analysis further supported these findings, showing a significant reduction in viral load and tissue damage following treatment. Additionally, the established model was used to evaluate the pathogenicity of the WNV strain caused an unprecedented surge of WNV disease in Israel during 2024.

Antibiotics are essential for medical procedures, food security, and public health. However, ill-advised usage leads to increased pathogen resistance to antimicrobial substances, posing a threat of fatal infections and limiting the benefits of antibiotics. Therefore, early detection of antimicrobial resistance genes (ARGs), especially in pathogens, is crucial for human health. Most computational methods for ARG detection rely on sequence homology to a predefined database and therefore are limited in their ability to discover novel genes.
I will present DRAMMA, a machine-learning method for predicting new ARGs without relying on sequence similarity to known ARGs or any annotated gene. DRAMMA utilizes various features of ARGs and their products, including protein properties, genomic context, and evolutionary patterns. The model demonstrated robust predictive performance both in cross-validation and an external validation set annotated by an empirical ARG database. Analyses of the high-ranking model- generated candidates revealed a significant enrichment of candidates within the human, animal and plant microbiomes. DRAMMA enables rapid ARG identification in global-scale genomic and metagenomic samples, thus holding promise for the discovery of novel ARGs that lack sequence similarity to any known resistance genes. Further, our model has the potential to facilitate early detection of specific ARGs, potentially influencing the selection of antibiotics administered to patients and guiding drug development and policies.

We developed novel small molecules targeting DnaG primase, an essential enzyme in bacterial DNA replication and a promising antibacterial drug target. The molecules originate from early NMR screening studies that identified scaffolds for a universal bacterial primase model. Our work integrates experimental and computational approaches to investigate how specific modifications on the fragment hit molecule influence the inhibition of DnaG primase activity, enabling the rational design of effective compounds across diverse bacterial species. Through detailed design and synthesis of small molecules, biochemical assays, and structural analyses, we optimized a series of inhibitors and identified a few as highly effective primase inhibitors. Few small molecules inhibited DnaG primase activity in eight bacterial species, including clinically relevant pathogens, emphasizing.

Ricin, a plant-toxin derived from the seeds of Ricinus communis, irreversibly inactivates ribosomes by site-specific depurination, thereby arresting cell protein synthesis. Pulmonary exposure to ricin represents a bona fide model for acute respiratory distress syndrome (ARDS) characterized by an intense pulmonary inflammation involving massive neutrophil recruitment accompanied by a severe disruption of the alveolar-capillary barrier leading to life-threatening pulmonary edema, compromised gas exchange and respiratory failure. We have previously shown that following pulmonary ricin intoxication there is a massive infiltration of neutrophils to the inflamed lung that damage the parenchyma by metalloproteinase dependent proteolysis of cell-cell junction proteins. Neutrophils are known to form neutrophil extracellular traps (NETs), as a part of innate mechanism for pathogen clearance. However, it is evident that NETs have detrimental impact in sterile inflammations, as in the case of ricin intoxication. In the current study we show that following pulmonary ricin intoxication, there is an increase in the levels of the nuclear enzyme protein-arginine deiminase 4 (PAD4) followed by histone citrullination, chromatin decondensation and DNA release from neutrophils, which are hallmarks of NETosis. In addition, we show that neutrophils efficiently produced NETs in the lungs of ricin exposed mice. Innovative treatment of ricin exposed mice with PEGylated long- acting recombinant DNase (PRX-119), targeted against NET- associated extracellular DNA, administrated in combination with ricin specific antitoxin, dramatically decreased the levels of extracellular DNA, effectively mitigated lung damage and significantly reduced the disruption of the alveolar-capillary barrier. Moreover, this combined treatment facilitated attenuated reduction in body weight, accelerated recovery and conferred higher protection levels to mice in comparison to sole administration of antitoxin. This data highlights the potential clinical benefit of NET inhibition drugs in pulmonary ricinosis.

Military public health units play a crucial role in supporting forces, including cross-border operations, by implementing proactive, continuous, and innovative disease prevention measures. The Iron Swards War presented unique challenges that significantly affected epidemiological conditions on the battlefield. Prolonged deployments in enemy territory, contact with local populations in unsanitary and densely populated areas, poor living conditions in abandoned locations, and exposure to contaminated food and water heightened the risk of disease outbreaks.
To mitigate health risks and maintain operational readiness, military public health services adopted a holistic and adaptive approach, integrating preventive strategies, immediate interventions, and information dissemination. The implementation of high-standard operational procedures ensured the rapid prevention of infectious diseases and effective outbreak management. Key measures included vaccination operations, pest control, environmental sanitation, and stray animal management, alongside the distribution of protective resources.
To ensure operational readiness, military health services implemented evidence-based prevention strategies, including immediate intervention, information dissemination, and the allocation of tailored medical resources. An analysis of morbidity trends highlighted the importance of stringent operational protocols, enabling rapid disease prevention and effective outbreak management during prolonged combat.
A hygiene and sanitation approach were established to safeguard soldiers from infectious diseases and to enable effective combat execution. By reinforcing combat units with qualified personnel and cross-functional teams, the military public health system provided consistent medical support to frontline forces. This approach not only prevented illness but also allowed commanders to remain focused on their operational objectives.
The experience gained during the Iron Swards War contributed to the modernization of military health procedures, improving disease control strategies for future conflicts. The success of these interventions underscores the critical role of military public health services in sustaining combat readiness and protecting forces in prolonged and complex military operations.

In warfare, soldiers face not only armed enemies but also infectious diseases, which have historically caused more casualties than battle injuries.
Poor sanitation and hygiene in combat zones significantly increase the risk of disease outbreaks, jeopardizing both soldiers' health and operational effectiveness. During the "Iron Swords" war, the IDF implemented a proactive and innovative disease prevention strategy to mitigate these risks. This approach emphasized real-time field reporting, identification of critical intervention points, and a shift from reactive to preventive measures.
Key components included personal responsibility for hygiene, continuous supply of sanitation equipment, and structured layers of protection against disease, akin to protective measures against missile threats. Additionally, vaccination programs, enhanced water and food security protocols, and technological advancements played crucial roles in maintaining troop health.
These efforts were aimed to prevent infectious diseases transmission among soldiers, the local population, and hostages while preserving combat effectiveness and legitimacy. The IDF's experience highlights the critical importance of integrating comprehensive disease prevention strategies in military operations.

Ensuring a safe drinking water supply for soldiers is critical, as waterborne diseases are among the most common and rapidly debilitating health threats in military operations. Contaminated water can significantly impair operational readiness, making water quality management a strategic priority.
In Israel, drinking water quality is exceptionally high, with over 60% of the supply originating
from desalinated seawater. However, in conflict zones such as Gaza and Lebanon, the situation is vastly different. In Gaza, groundwater is heavily contaminated and unfit for consumption. Under normal conditions, water was supplied through pipelines from Israel and seawater desalination. However, with the onset of the war, these sources became unavailable, necessitating the supply of bottled water and water tankers. As operations stabilized, water pipes were installed from Israel to forward logistics centers, and on- site water production facilities were deployed, including desalination units and atmospheric water generators.
In Lebanon, water quality is generally better, primarily sourced from groundwater and natural springs. However, most of these sources are also unsuitable for direct consumption. Water was supplied via bottled water and tankers. Recently, an innovative system for converting snow into potable water was developed and deployed for use in remote locations with limited water access.
In conclusion, ensuring a continuous and safe drinking water supply is a vital operational necessity, directly impacting soldiers’ health, readiness, and combat effectiveness. Reliable water provision strategies must be an integral part of military logistics, ensuring that troops always have access to safe drinking water in any operational environment.

Military public health is a critical component of force readiness, particularly during prolonged combat operations. As part of routine infectious disease prevention, the military monitors environmental contaminants in combat zones to assess health risks. When the presence of hepatitis A was detected in Gaza, soldiers were vaccinated to prevent infection due to potential exposure to contaminated food and water. Additionally, tetanus vaccination was administered to mitigate the risk of battlefield injuries. In July 2024, the detection of poliovirus type 2 in sewage in Gaza posed an immediate threat to IDF soldiers operating in the area. To mitigate the risk of infection and potential viral spread, the Ministry of Health mandated the urgent administration of an inactivated poliovirus vaccine (IPV) booster to all forces entering Gaza.
With only 36 hours to execute the operation, the vaccination campaign required precise coordination between medical and operational units. Logistical challenges included distributing vaccines to 18 dispersed units, maintaining cold chain integrity in field conditions, and efficiently administering intramuscular injections under combat constraints. The IPV, as opposed to the oral poliovirus vaccine (OPV), provides systemic immunity without the risk of viral shedding, making it the preferred choice in this operational context. Unforeseen obstacles, such as cold chain failures and last-minute force reallocations, demanded rapid problem-solving to prevent mission delays.
Despite these challenges, over 4,200 soldiers were successfully vaccinated within the designated timeframe, with additional doses administered in the following days to ensure full immunization prior to deployment. No cases of polio were reported among IDF soldiers despite exposure to contaminated environments.

Background:
Pertussis remains a global public health challenge despite widespread vaccination. Israel has observed cyclical outbreaks, including a recent rise in cases from 2023 to 2024. The IDF faces unique challenges due to high transmission risk in training environments, impacting operational readiness. Purpose:
To analyze pertussis trends in Israel and the IDF, assess the disease’s burden on military personnel, and evaluate the impact of integrating pertussis vaccination into military service.
Methods:
A retrospective review of pertussis cases in the IDF (2023– 2025) was conducted using serology and PCR data. The study examined infection rates, operational disruptions, and the effect of a standardized pertussis vaccination program introduced in July 2024.
Results:
A surge in pertussis cases was observed in early 2024, with peak transmission in training units. After vaccine implementation, cases declined, and no PCR-confirmed infections were reported in vaccinated soldiers. The findings underscore the vaccine’s effectiveness in reducing morbidity and maintaining force readiness.
Conclusions & Discussion:
The IDF vaccination program has proven effective in outbreak control, emphasizing the need for routine adult booster immunization. These results support the expansion of booster programs in military and institutional settings, with implications for global public health policy.

Background:
Leishmania major and Leishmania infantum infections were evaluated in rodents and sand flies during a 2022–2023 cutaneous leishmaniasis (CL) outbreak in two military camps in southern Israel. The efficacy of novel rodent control intervention was also assessed.
Methods:
Sand flies and rodents were tested for Leishmania by PCR targeting the ITS1 locus. Precision spreading of pesticides using drones was performed in April 2023 in Camp 2, while Camp 1 served as a control. Infection rates in the vector sand fly and reservoir hosts and CL incidence in soldiers were compared to pre- and post-intervention.
Results:
Of 9,696 Phlebotomus papatasi females collected, 7,204 were analyzed for Leishmania DNA. L. major infection rates in sand flies from Camp 2 significantly decreased from 1.23% (2022) to 0.03% (2023) (p=0.034). No significant change occurred in Camp 1 (0.5% vs. 0.22%, p=0.622). Among 63 rodents tested, 8 were infected: L. infantum was found in 2/11 (18.2%) Mus musculus and 3/52 (6%) Meriones tristrami, while L. major was detected in 3/52 (6%) M. tristrami. Leishmania infection in rodents significantly declined in both camps combined, particularly in Camp 2 (33.6% in 2022 vs. 3.3% in 2023, p=0.032, p=0.02). CL incidence in soldiers also dropped significantly from 17.1 to 2.6/1000 in Camp 1 and 33.3 to 4.9/1000 in Camp 2 (p<0.001).
Conclusions:
Significant reductions in Leishmania infection in vectors and reservoir hosts followed the intervention. However, as leishmaniasis is multifactorial, attributing this decline to a single factor is challenging. Further studies are needed to evaluate the efficacy of new technologies in vector-borne disease control

Background:
Tick-borne relapsing fever (TBRF), caused by Borrelia persica, is endemic to Israel and highly prevalent among military personnel. Prevention in the Israel Defense Force (IDF) relies on awareness campaigns in hyperendemic areas and selective post-exposure prophylaxis (PEP) with doxycycline. This study aims to reduce TBRF exposure by (1) collecting soft ticks and environmental data from training locations with and without reported cases, (2) conducting molecular identification of B. persica, (3) developing a TBRF infection map and (4) refinement of disease prevention guidelines and environmental treatment in affected sites.
Methods:
TBRF case data was obtained from public health officers. Ticks were collected using carbon dioxide traps from caves and bunkers, morphologically identified, and molecularly analyzed for B. persica via PCR, targeting the Borrelia flaB gene at the Hebrew University’s Veterinary School. Environmental treatment with lambda-cyhalothrin (9.7%) was applied in seven bunkers.
Results:
Mapping vector dispersion
Surveillance covered 23 locations (5 caves, 14 bunkers, 4 burrows), yielding 5,507 Ornithodoros Tholozani ticks. A total of 530 were analyzed, 9 (1.7%) from 4 sites tested positive for B. persica (range: 0–4.9%). A TBRF infection map was created using GOVMAP, covering 23 training sites and 24 civilian locations.
Case study – bunker related outbreak
A suspected outbreak in four soldiers who spent 30 hours in an abandoned bunker led to the collection of 255 O. Tholozani ticks, with 1% testing positive. Additional surveys in 13 bunkers found ticks in two, though all tested negative. The presence of earth or sand inside caves or bunkers was significantly associated with tick infestations (p=0.03, OR=26.4). Pest control was 100% effective, with no ticks recovered after 117 days.
Conclusions:
Military bunkers may harbor B. persica-infected soft ticks, posing a risk similar to caves and archaeological sites. The TBRF infection map will help prevent training in high-risk locations and reduce exposure.

Feeding military personnel remains a dynamic and multifaceted challenge that requires continuous evaluation to ensure optimal nutrition, performance, and well-being. This update builds upon the initial findings of the Military General Health and Nutrition Descriptive Survey (MABAT-IDF) thatwaspresentedduringpreviousShoreshconference,with data collected from a significantly larger and more diverse sample of IDF personnel. The expanded dataset provides a more comprehensive analysis of dietary consumption patterns, nutritional adequacy, and health-related behaviors across different military populations. It includes a refined assessment of energy intake, macronutrient distribution, and adherence to recommended dietary guidelines. Additionally, longitudinal comparisons highlight trends in eating habits, physical activity, body weight, and smoking prevalence. The study further explores the impact of sleep patterns and body image perception on overall health. These findings provide critical input for future adjustments to the IDF’s nutritional policies, enhancing the effectiveness of dietary planning and implementation.

Background:
In recent decades, the body mass index (BMI) of Israeli adolescents eligible for military service has steadily increased, reflecting broader shifts in lifestyle and health behaviors. Additionally, emergencies and crises—such as wars, terrorist attacks, and economic instability—significantly impact health-related behaviors. Research following the October 7th attack has identified notable behavioral changes, including increased smoking rates, weight fluctuations, and reduced physical activity. These findings highlight the psychological distress experienced by individuals and their direct influence on health choices, emphasizing the need for effective public health strategies during and after crises.
Rationale:
This study aims to analyze trends in health behaviors and BMI among IDF combat unit recruits before and during the "Iron Swords" war, covering the period from January 2021 to December 2024. Data were collected from standard enrollment questionnaires completed by recruits on their recruitment day, alongside measured body weight records. Key variables include physical activity levels, smoking status, significant weight loss (>5 kg in the past three months), and dietary preferences.
Methods:
Our analysis examines these trends across different demographic factors, such as residential area, gender, and religiosity. We anticipate observing shifts in smoking habits, BMI patterns, and physical activity levels among recruits, aligning with findings from previous studies. A systematic evaluation of these trends will provide valuable insights for shaping health policies and designing targeted public health interventions within the IDF.

Background and Purpose:
The IDF Medical Corps achieved one of the lowest recorded case fatality rates in modern warfare during Swords of Iron War, largely attributed to the effective management of critically injured patients who, despite their severe injuries, could reach hospitals for definitive care. However, the higher severity of these injuries placed them at significant risk for infectious complications. Current IDF protocols recommend prophylactic antibiotics for penetrating trauma when evacuation exceeds one hour. Recent reports of fatalities among severely injured combatants caused by infections from resistant microorganisms underscore the pressing need to reevaluate and enhance infection prevention and management strategies.
Methods:
This planned retrospective study will analyze battlefield trauma casualties evacuated during one year of ground maneuver, starting October 2023. Data collection will involve prehospital records from the IDF Trauma Registry detailing injury mechanisms, treatments (including antibiotic prophylaxis), and evacuation characteristics. Alongside hospital records documenting clinical outcomes, infectious diagnoses, microorganisms isolated in the first week and those linked to infectious events, and antibiotic treatments. Additionally, long-term infectious outcomes up to three months post-hospitalization will be assessed.
Results:
This study aims to include 2,074 casualties hospitalized for ≥ 24 hours across 10 medical centers nationwide, capturing nearly all eligible cases. The cohort consists of casualties with injury severity score (ISS) distributed as follows: 1-8 (57%), 9-14 (22%), 16-24 (11%), and ≥ 25 (9.6%). Among casualties, 719 (35%) were hospitalized for > 1 week, and 512 (25%) required intensive care unit admission. The median evacuation time was 78 minutes (IQR 58-113), with urgent cases evacuated in a median of 72 minutes (IQR 56-100). Integrating prehospital data with the temporal dynamics of microbiological findings will allow us to better characterize infectious complications in military trauma.
Conclusion:
This study aims to address key gaps in understanding infectious complications in military trauma. By identifying risk factors, correlating prehospital data with clinical and microbiological outcomes, and characterizing pathogen profiles, the findings are expected to inform updated infection management strategies, ultimately enhancing care for military casualties.

Background:
Impetigo is a highly contagious bacterial skin infection, commonly seen in crowded environments such as military training bases. In June 2024, an outbreak of Impetigo occurred at the Kfir training base, affecting a significant number of trainees.
Objective:
To review the epidemiological characteristics, risk factors, and management strategies of the outbreak, highlighting key lessons for prevention and control in similar settings. Methods:
A retrospective analysis of the outbreak was conducted, including clinical presentation, laboratory findings, and treatment approaches. Infection control measures and their effectiveness in containment were also assessed.
Results:
The outbreak affected 151 trainees. The primary pathogen identified was Staphylococcus aureus. Initial treatments included topical and systemic antibiotics. Key risk factors include skin to skin contact and shared equipment. Conclusions:
This outbreak underscores the importance of early detection, strict hygiene protocols, and prompt medical intervention in controlling impetigo in high density military environments. Recommendations for future prevention include enhanced hygiene education and improved infection surveillance.

Effective disease surveillance is critical for early detection, risk assessment, and response to public health threats. This lecture explores key methodologies for tracking and analyzing outbreaks, highlighting the vital role of health intelligence in preparedness and decision-making.
Real-time data plays a crucial role in identifying emerging health risks. For example, West Nile fever outbreaks have been detected through mosquito surveillance, allowing authorities to implement vector control measures and reduce transmission. Similarly, health intelligence has been instrumental in tracing Hepatitis A outbreaks, enabling public health interventions such as vaccinations.
By leveraging epidemiological modeling, data analytics, and cross-sector collaboration, health intelligence assesses risks and provides actionable insights to policymakers and healthcare professionals.
Through case studies and real-world examples, this session will demonstrate how a proactive and intelligence-driven approach strengthens public health resilience, ultimately leading to more effective outbreak prevention and response.

Israel’s National Health Intelligence Agency was established post COVID-19 pandemic to enhance early detection and response to public health threats. It supports risk-based decision-making, detecting outbreaks, assessing risks, and guiding strategic actions. A structured threat classification model is essential for shifting from reactive to proactive public health management.
Purpose:
To develop a standardized model for classifying public health threats based on national risk levels and potential disease importation.
Methods:
The model evaluates five key factors:
1. Anomaly detection – Identifying unusual health events. 2. Severity assessment – Mortality and transmissibility.
3. Population vulnerability – Immunization levels,
healthcare burden.
4. National preparedness – Policies, stockpiles, governance. 5. Additional considerations – Political, economic, and
public concerns.
Results & Implications:
1. A real-time, adaptable threat classification tool.
2. Standardizes risk levels for national health events.
3. Supports evidence-based decision-making and response
planning.
4. Enhances coordination across health authorities and
emergency systems.
Existing models often focus on travel-related threats or pandemics, neglecting broader risk factors. This model integrates comprehensive public health risks to guide national preparedness and response strategies effectively.
Overall, the threat classification model based on national risk levels provides an organized, insightful snapshot of the threat landscape. It helps leaders and planners swiftly grasp which threats present the most serious challenges, fostering informed decision-making to enhance national resilience and security. Each threat category is addressed in proportion to its risk, thereby optimizing mitigation efforts for better protection of the nation’s people, infrastructure, and interests.

Background:
In October 2023, the Israel Defense Forces (IDF) restructured its pharmacy services by outsourcing to civilian pharmacy chains. This reform expanded service locations and extended hours to reduce logistical barriers and improve prescription fulfillment.
Purpose:
This study examines how decentralization affected pharmaceutical consumption, assessing whether increased access led to higher utilization.
Methods:
A retrospective analysis compared pharmacy dispensing records from October 2014 to September 2024. Total prescription dispensation before and after decentralization was compared and specific therapeutic categories were examined. The average annual growth rate during the centralized pharmacy system was calculated, along with 95% confidence intervals (CIs), and compared to the growth rate in the year following decentralization.
Results:
Decentralization expanded pharmacy service points from 9 to 297 locations. The annual prescription growth rate before decentralization was 8.81% (95% CI: -0.34%-17.97%), rising to 405.41% post-reform. Specific medication categories saw notable increases: oral contraceptives from 2.42% (95% CI: -10.82%-59.12%) to 288.84%; asthma inhalers from 1.91% (95% CI: -26.34%-30.16%) to 323.46%; and stimulants from 8.64% (95% CI: -7.79%-25.06%) to 978.07%.
Conclusions:
Decentralization significantly increased prescription dispensation, especially for chronic medications. Findings suggest access barriers previously limited demand, and their removal boosted utilization. Further research is needed to assess clinical and economic impacts, including long-term health benefits and financial sustainability.

Background:
Asthma affects 5–10% of young adults and presents challenges to operational readiness due to potential exacerbations. Purpose:
Early identification and targeted interventions of soldiers at high risk can maintain soldier fitness and prevent severe outcomes.
Methods:
We utilized a large dataset of risk factors associated with asthma exacerbations among active Israel Defense Forces personnel. Recruits underwent medical evaluations to assess fitness, with asthma diagnoses based on personal history, clinical presentation, and lung function tests. Asthma severity was classified into inactive (a history of childhood asthma), mild, moderate, severe (asthma-related hospitalization), and disqualified from service. Asthma worsening during service was defined as any worsening of asthma severity. The Wilson score interval was used to calculate 95% confidence intervals for proportion estimates.
Results:
As of January 2025, 5.9% of IDF active-duty personnel had asthma. Between 1996 and 2016, there were 97,411 recruits with a history of asthma: 17,446 were classified as inactive, 28,957 as mild, 43,593 as moderate, and 7,415 as severe at recruitment. During active service, 3,228 (3.3%) experienced a worsening of their asthma status. Worsening occurred in 312 (1.8%) inactive cases, 1,807 (6.2%) mild cases, 965 (2.2%) moderate cases, and 144 (1.9%) severe cases. Among recruits with mild to moderate asthma (N=72,550), 1,329 (1.8% [95% CI 1.7, 1.9]) progressed to severe asthma during their service. Furthermore, 340 soldiers (0.3% [95% CI 0.3, 0.4]) with asthma at recruitment were discharged due to severe asthma. Discussion:
These findings emphasize the need for early identification of soldiers at risk for asthma worsening. Efforts are underway to develop an AI-assisted model to help physicians detect high-risk individuals in real time, improving outcomes and operational readiness.
Conclusions:
The findings reveal that a notable percentage of recruits with mild to moderate asthma experience worsening conditions during their service, which can lead to severe asthma and potential discharge.

Background:
The past year and a half have seen the highest number on record of reservists for service in the IDF. In the recruitment process of these reservists, vast amounts of medical documentation had to be examined to assess the fitness for service in these cases. The integration of artificial intelligence (AI) into healthcare systems has shown significant potential in streamlining administrative processes, particularly in the summarization of medical documentation.
Purpose:
This study explores the implementation of AI-driven natural language processing (NLP) tools to automate the summarization of clinical notes, discharge summaries, and other medical records in the reservist population of the IDF. Methods:
Implementation worked by leveraging advanced machine learning algorithms, including Optical Character Recognition (OCR), Document Intelligence, Generative Pre-trained Transformers (GPT), and a brand-new document splicing tool invented by the IDF. Using these tools, the AI system was trained to extract key information, condense lengthy documents, and generate concise, accurate summaries while preserving critical clinical context.
Conclusions:
A pilot implementation is being conducted over six months, involving a large amount of reservist candidates with medical documents across multiple departments. During this pilot, a study will be conducted, and the AI-generated summaries will be evaluated by a panel of clinicians for accuracy, relevance, and time savings.
Future research should focus on scaling the technology, addressing ethical considerations, and integrating AI summaries into Electronic Health Record (EHR) systems for seamless adoption across healthcare organizations.

Background:
The Israeli Defense Forces (IDF) allows citizens with Inflammatory Bowel Disease (IBD) among other chronic medical conditions to volunteer for military service through a special medical volunteer program. No comprehensive study has examined the impact of military service on disease progression or military performance.
Purpose:
To evaluate the association between military service and IBD among medical volunteers, focusing on service completion rates, professional functioning and disease progression. Methods:
This retrospective study examined 734 volunteer soldiers with IBD who served in the IDF between 2019-2024. Data was collected from computerized medical records and included demographic, occupational and medical information. Results:
Of the subjects, sixty percents (n=437) were males and 39% (n=289) served in combat units in non-combat roles. 2.5% (n=18) required hospitalization during their service, while 20% (n=148) took more than 30 sick days. Regarding occupational stability, 93% (n=683) maintained their role or transitioned to equivalent or better positions, while only 7% (n=51) required reassignment to less demanding positions. Early discharge occurred in 4.2% (n=31) of cases, while approximately 8.4% (n=62) extended their service.
Logistic regression revealed that male soldiers and soldiers with ≤30 sick days had significantly higher service completion rates (OR=3.55, p<0.05; OR=3.38, p<0.05 respectively). Conclusions:
The findings suggest that in the current sample, no significant negative association was found between military service and disease control, nor was there a negative impact of the disease on military service completion among volunteers.
Given these outcomes, consideration should be given to including IBD patients in remission within the standard medical classification system with a non-combat profile, rather than through the volunteer program.

Background:
On January 19, 2025, the release of Israeli and foreign abductees from Hamas captivity commenced. Mental health officers, doctors, and nurses provided initial assistance as part of this mission. The exposure to this extraordinary event, following approximately 500 days of hostage captivity by terrorist organizations, may have significant implications for the health of the involved medical personnel, particularly given their repeated participation in the mission.
Purpose:
This study aims to assess the levels of compassion fatigue, burnout, and psychological strain among mental health officers, nurses, and physicians across multiple time periods, examining changes from baseline to several weeks post- mission completion.
Methods:
A mixed-methods approach was employed. Quantitative data collection involved 24 certified nurses, 27 mental health officers, and 18 physicians, utilizing the Professional Quality of Life Scale (ProQOL-5), Maslach Burnout Inventory (MBI- HSS), and Depression Anxiety Stress Scales-21 (DASS-21), administered pre- and post-mission. Qualitative data were gathered through semi-structured interviews exploring experiences, coping strategies, and reflections.
Results:
Mental health officers demonstrated improved scores across all questionnaires between the mission period and later assessment, indicating decreased stress and fatigue levels. Conversely, physicians exhibited worsening stress and fatigue scores between the two test dates. Nurses showed a slight trend towards deterioration in stress and fatigue scores.

Background:
Oral contraceptive pills (OCPs) are widely used among young women, including military personnel. Evidence is conflicting on whether OCPs affect mental health.
Purpose:
In the Israel Defense Forces (IDF), servicewomen receive free OCPs, providing an opportunity to examine their impact on mental health.
Methods:
We analyzed IDF servicewomen aged 18-24 (2004-2020) by using dispensation records to identify servicewomen prescribed OCP. Logistic regression models evaluated socio-demographic factors linked to OCP use. We also fitted multivariable-adjusted models to explore the relationship between OCP use and new mental health diagnoses during service. Multivariate models were adjusted to demographic characteristics, medical history, and combatant roles. Results:
Among 385,176 women, 135,852 (35.3%) used OCPs. Users were more likely to have a high-school education, higher cognitive function (OR 1.35-1.38), and combat service (OR 1.54, 95% CI: 1.50-1.59). They were less likely to have overweight/ obesity (OR 0.65, 95% CI: 0.64-0.66), mood disorders (OR 0.71, 95% CI: 0.60-0.83), or anxiety disorders (OR 0.76, 95% CI: 0.70-0.84) at recruitment. OCP use correlated with fewer new diagnoses of mood (OR 0.78, 95% CI: 0.70-0.87) and eating disorders (OR 0.84, 95% CI: 0.75-0.95), but not anxiety disorders. Persistent users (≥12 months) had even lower odds of mood (OR 0.55, 95% CI: 0.45-0.67), eating (OR 0.66, 95% CI: 0.54-0.80), and anxiety disorders (OR 0.83, 95% CI: 0.74-0.93). Conclusions and discussion:
Servicewomen with higher cognitive function, full high-school education, combat service, and normal weight were more likely to use OCPs. OCP use was associated with a lower risk of newly diagnosed mental health disorders, particularly among long-term users.

Background:
Urinary tract infections (UTIs) are among the most common bacterial infections, predominantly affecting young, sexually active women. While generally benign, UTIs cause significant discomfort and negatively impact quality of life. Studies from Western countries report high UTI incidence and recurrence rates, but no prior research has examined the prevalence among Israeli women, particularly female soldiers in the Israel Defense Forces (IDF). Military service conditions, including limited access to bathrooms, crowded living spaces, and poor sanitation, may increase UTI risk.
Purpose:
This study aimed to estimate UTI incidence among IDF female soldiers, identify occupational and behavioral risk factors, assess perceptions, and propose preventive measures. Methods:
This study comprised three studies: (1) a historical cohort analysis of 389,254 female soldiers (2000–2015) using IDF medical databases, (2) qualitative interviews with 15 female soldiers and commanders regarding experiences and perceptions of UTIs, and (3) a cross-sectional survey of 689 participants to examine risk factors and hygiene behaviors. Results:
Results showed that 34.8% of female soldiers had at least one UTI during service, with 43.7% experiencing recurrence. Combat soldiers had the highest UTI risk, while office workers and officers had significantly lower risks. Identified risk factors included prior UTI history, poor sanitation, service in field conditions, and lack of access to clean toilets. Education level was inversely associated with UTI risk, though mediation factors such as knowledge and behaviors had minimal impact. Conclusions:
The findings highlight UTIs as a widespread issue among female IDF soldiers, influenced by environmental and occupational factors. Preventive strategies should focus on improving sanitary conditions, promoting hydration, and implementing health education programs. Further research is needed to develop tailored interventions for different military roles and ensure better management of UTIs among female soldiers.

Background:
The conscription of women in Israel predates the state's establishment, with female citizens serving in diverse roles, including combat and frontline positions. Israeli law mandates compulsory service for all citizens, regardless of gender. Purpose:
This study aims to examine the significance of women's service across various military roles for all service members, exploring pertinent issues and contributing to the broader perception of women's military service in Israel and internationally. Methods:
A systematic review analysis was conducted, synthesizing findings from previous studies by the Behavioral Sciences Division, Medical Corps, IDF Senior Command Schools, and other relevant sources. Recurring themes and significant findings were identified and presented in this study.
Results:
Women's contributions to the IDF have been substantial and evolving. The 1970s and 1980s saw an expansion of roles available to women, while a High Court petition in the 1990s opened pilot courses to female recruits. Currently, women are actively participating in elite units such as Unit 669 and the IDF Special Operations Command. Women's service extends beyond equal opportunity initiatives and compliance with Israeli basic laws; it significantly benefits the military system. In some ranks, women constitute a higher percentage than men, including key combat and combat support roles. Conclusions:
Continued efforts are necessary to further integrate women into the Israeli military. Ongoing research and engagement are crucial to identify and implement necessary adjustments and relevant support systems for women in specific roles or operational contexts.

Background:
The number of women combatants in the Israel Defense Forces (IDF) has risen significantly. The “Iron Swords” war began on October 7, 2023.
Purpose:
This study compares healthcare demands, service utilization, and health-related dropout rates of women combatants during the war versus their male counterparts.
Methods:
We analyzed data from 10 gender-integrated IDF combat units (search and rescue, border defense) using health records. We assessed primary care visits, expert consultations, and health- related dropouts between October 2023 and June 2024, comparing them to the previous year. Chi-square tests were used for statistical comparisons.
Results:
A total of 3,814 women and 2,395 men participated, compared to 3,534 and 2,569 in the previous year. During the war, women had 660.1 primary care visits per 100 participants, up from 573.5 in peacetime, while men had 310.0 visits, up from 278.7. Expert consultations (excluding gynecology) were lower in wartime for both women (102.3 vs. 121.2) and men (69.1 vs. 80.6). Gynecologic consultations slightly increased (29.2 vs. 25.4 per 100).
Health-related dropout rates were lower for women than men (0.89% vs. 1.63%, p=0.001), including both mental (0.63% vs. 1.01%, p=0.088) and non-mental health reasons (0.29% vs. 0.62%, p=0.044).
Conclusions:
Despite increased medical visits during war, women did not show a disproportionate rise in healthcare needs. Women had lower health-related dropout rates than men, a trend consistent across mental and physical health categories. Discussion:
The lower dropout rates among women combatants can indicate their ability to adapt to the physical and psychological demands of combat, challenging concerns about their long- term viability in these roles. Additionally, as medical visits increased for both genders, providing targeted medical and psychological support could further enhance soldier retention and operational effectiveness.

Background:
Gestational glucose intolerance is a well-established risk factor for adverse perinatal outcomes, but its long-term implications for both mothers and offspring, particularly when glucose intolerance does not meet the formal criteria for gestational diabetes, remain unclear.
Purpose:
To explore the intergenerational impact of gestational glucose intolerance, particularly its association with offspring obesity and maternal type 2 diabetes, within a military and national healthcare framework.
Methods:
This study utilized linked national databases, including the Israel Defense Forces (IDF) military conscription dataset and Maccabi Healthcare Services (MHS). Pregnant women underwent a two-step gestational diabetes screening (50g GCT; 100g OGTT if abnormal). Glucose tolerance categories included normoglycemia, abnormal GCT with normal OGTT, impaired glucose tolerance (IGT; one abnormal OGTT value), and gestational diabetes. Long-term outcomes were assessed for 177,241 women and 33,482 mother-offspring pairs. Multivariate analyses adjusted for pre-pregnancy BMI, adolescent risk factors, and sociodemographic variables. Results:
Among 177,241 women, 12% had glucose intolerance without meeting gestational diabetes criteria. Compared to normoglycemia, women with an abnormal GCT and normal OGTT had adjusted HR of 3.39 (95%CI, 2.77 - 4.16) for type 2 diabetes, those with one abnormal OGTT value had an adjusted HR of 9·11 (95%CI, 7·64–10·86); p<0·0001 and those with gestational diabetes had an adjusted HR of 24·84 (21·78– 28·34); p<0·0001. In a cohort of 33,482 mother-offspring pairs, maternal glucose intolerance was associated with a higher prevalence of offspring being overweight and obesity in late adolescence. The prevalence of overweight/obesity increased across categories from 19% in normoglycemia, to 22% in abnormal GCT, 24% in gestational IGT, and 25% in gestational diabetes, (P < 0.0001).
Conclusions/Possible Implementations:
Gestational glucose intolerance, including categories not meeting the gestational diabetes threshold, was associated with increased risk for offspring overweight/obesity at late adolescence and conferred a high risk for the mothers of type 2 diabetes in young adulthood.

Background:
Obesity-related morbidities are often influenced by severity and duration. However, the development of serious health conditions in early adulthood among adolescents with obesity remains understudied. This study examines the association between adolescent BMI and the risk of developing serious morbidities before age 25.
Purpose:
We aimed to assess whether BMI in late adolescence is linked to an increased risk of serious health conditions before age 25. Methods:
This nationwide retrospective cohort study included Israeli conscripts aged 17–21 who underwent pre-recruitment medical evaluations between 1996 and 2017. Participants deemed eligible for service were followed from enlistment until service completion, onset of serious morbidity that disqualified them from service, or December 31, 2021. Baseline BMI was converted into age-specific and sex- specific percentiles using US Centers for Disease Control and Prevention criteria. Cox regression models adjusted for socioeconomic factors were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for serious morbidity across BMI groups.
Results:
Among 1,118,653 participants (55.7% male, 44.3% female), 23,347 cases of serious morbidity were recorded over 2,534,873 person-years. The incidence of serious morbidity increased with higher BMI. Compared to normal BMI, adjusted HRs for males were 0.89 (95% CI 0.83–0.95) for underweight, 1.21 (95% CI 1.16–1.27) for overweight, 1.39 (95% CI 1.32–1.47) for obesity class 1, 2.82 (95% CI 2.60–3.06) for obesity class 2, and 5.14 (95% CI 4.37–6.04) for obesity class 3. For females, HRs were 0.95 (95% CI 0.84–1.09) for underweight, 1.27 (95% CI 1.17–1.37) for overweight, 1.63 (95% CI 1.45–1.82) for obesity class 1, 4.00 (95% CI 3.46–4.61) for obesity class 2, and 7.30 (95% CI 5.65–9.43) for obesity class 3.
Conclusions:
Obesity in otherwise healthy adolescents is strongly associated with increased morbidity risk before age 25.

Background:
The prevalence of adolescent obesity has risen sharply in recent decades, posing a major public health concern. However, its long-term cardiometabolic effects in young adults remain unclear.
Purpose:
To evaluate the impact of adolescent obesity on cardiometabolic morbidities and mortality using nationwide population-based cohorts.
Methods:
One year prior to mandatory military service, all Israeli adolescents undergo a pre-recruitment evaluation, including weight and height measurements, medical history review, medical examination, cognitive assessment, and sociodemographic data collection. The Israel Defense Forces national database, digitized since 1967, currently includes over 3 million adolescents. This database was linked to national registries to assess associations between adolescent obesity and various health outcomes.
Results:
Cardiovascular mortality risk increased with BMI, with a 3.5-fold higher risk in obese adolescents compared to lean peers. Obesity was associated with early stroke and chronic kidney disease, independent of baseline health status or later development of hypertension or diabetes. Among men, obesity was linked to higher cancer risk (HR=1.26 [1.18–1.35]), while no overall association was found in women due to inverse relationships with cervical and breast cancers (when excluded HR=1.27 [1.13–1.44]). HRs for Type 2 diabetes ranged from 1.7 (50th – 74th BMI percentile) to 25.8 (severe obesity) in men and from 2.2 to 44.7 in women, with earlier onset in those with higher baseline BMI. Adolescent obesity was linked to type 1 diabetes as well. Population Attributable Risk for these outcomes ranged from 5.3%-60%.
Conclusion:
Adolescent obesity is strongly associated with increased cardiometabolic risks by early adulthood, even in the absence of baseline comorbidities. Rising obesity prevalence may further elevate the burden of obesity-related diseases and underscore the need for early prevention strategies.

Background:
Prematurity affects 11% of births worldwide and is linked to long-term kidney complications due to incomplete nephrogenesis. This increases the risk of hypertension, proteinuria, and chronic kidney disease (CKD) later in life. Purpose:
This study examines whether adolescents born prematurely or small for gestational age (SGA) have higher blood pressure (BP) than those born at term with normal birth weight. Methods:
A retrospective cohort study analyzed medical data from 513,802 late adolescents (ages 16–18) examined at Israel Defense Forces (IDF) medical facilities (2005–2018). Participants were categorized by birth weight and gestational age. BP measurements were analyzed while adjusting for confounders like BMI and sex.
Results:
Preterm and VLBW/ELBW adolescents had a higher prevalence of hypertensive-range BP. Obesity was strongly associated with hypertension, independent of birth weight. Proteinuria was rare, with no significant differences across birth weight categories.
Conclusions/Possible Implementations:
Prematurity and low birth weight are early risk factors for adolescent hypertension, highlighting the need for long-term monitoring. Military medical evaluations could incorporate birth history to identify at-risk recruits early.

Background:
Historically, women soldiers weighing ≤49 kg at enlistment have been disqualified from combat roles in the Israel Defense Forces (IDF), regardless of their body mass index (BMI), due to concerns about injury risk. However, this policy lacks direct empirical support. Identifying potentially unnecessary disqualifying criteria is essential for optimizing combat readiness while ensuring soldier health and performance. Objective:
This study aims to examine the association between body weight—particularly in the underweight range—and the risk of overuse injuries among women serving in combat roles. Methods:
We will analyze data from women soldiers recruited for combat roles, assessing the relationship between body weight, BMI at enlistment, and overuse injuries. Injury outcomes will be determined based on physicians’ diagnoses and recommended accommodations for physical strain. We will focus on women who, despite weighing ≤49kg at enlistment, were still assigned to combat roles.
Preliminary Findings:
Between 2014 and 2023, 8,045 women soldiers were diagnosed with stress fractures, identified using the ICD-10Z codes. Among combat women soldiers, the prevalence of stress fractures was 13.9%. Of the 461 women who enlisted weighing ≤49 kg, 56 (12.1%) sustained a stress fracture. Statement of significance:
Our preliminary findings suggest that the current weight- based disqualification criteria may warrant reevaluation. The outcome of this research has direct implications for military policy, contributing to evidence-based decision-making that balances operational effectiveness with soldier health and safety.

Background:
During candidate screening for military service, the Israel Defense Forces (IDF) assigns a medical profile—encompassing physical and mental health—to determine role eligibility. Candidates may be eligible for positions requiring a higher threshold based on their motivation and the medical committee chairman’s discretion, following established protocols.
Rationale:
Soldiers assigned to roles exceeding their medical profiles face an increased risk of injury, dropout, or early discharge. However, their strong motivation may also enable them to outperform peers in roles assigned according to their profiles. Comparing service outcomes between soldiers accepted into roles despite sub-threshold medical profiles and those assigned roles within their designated profiles.
Methods:
We will perform a retrospective cohort study using electronic health records and human resources databases. We will include recruits assigned to elite unit combatants, infantry combatants, armor combatants, air defense combatants, and combat fitness instructor roles. We will compare service- related outcomes between soldiers with sub-threshold medical profiles and those meeting standard medical requirements. Assessed outcomes will include training completion, role retention, timely service completion, service extension, and officer training.
Statement of importance:
Although approving soldiers for positions beyond their designated medical profiles is standard practice, its effectiveness has never been rigorously evaluated. This unexamined approach raises concerns about operational efficiency and soldier well-being, highlighting the need to reassess and validate current policies.

Background:
Musculoskeletal overuse injuries are a common cause of disability in military personnel, often resulting in reduced operational readiness and increased healthcare burden. Structural orthopedic abnormalities such as flat feet (pes planus) and scoliosis may predispose soldiers to overuse injuries, especially under physically demanding conditions. Rationale:
The Israel Defense Forces (IDF) permit individuals with mild to moderate scoliosis or pes planus to serve in combat roles. Still, the extent to which these conditions contribute to injury and lost duty time remains unclear. Assessing these relationships could optimize assignment policies and preventive care strategies. Comparing the incidence of overuse injuries and duty days loss, between soldiers with mild to moderate flat feet or scoliosis and their peers without these conditions. Methods:
This retrospective cohort study will analyze the medical records of soldiers on active duty between 2014 and 2023. We will compare soldiers diagnosed with mild to moderate flat feet or scoliosis and a control group of matched soldiers without these conditions in similar military roles. Participants will be categorized based on their military roles. The outcomes will be the incidence of overuse injuries, including stress fractures and duty days lost. Outcomes will be assessed using regression models adjusted for demographic variables and medical history.
Preliminary Findings:
Pes planus and scoliosis prevalence among combat soldiers between 2014-2023 was 14% and 3.1%, respectively. The proportion of soldiers experiencing stress fractures among those with pes planus or scoliosis was 1,806 out of 24,464 (7.4%) and 356 out of 4849(6.8%, compared to 10,932 out of 142,958 (7.6%) in those without pes planus and 12385 out of 162230(7.6%) in those without scoliosis.
Statement of Importance:
Understanding the relationship between structural orthopedic abnormalities and the rate of overuse injury in military personnel will optimize assignment policies and targeted interventions, ultimately enhancing force readiness and reducing preventable morbidity.

Background:
Health-related attrition significantly affects active-duty personnel in the Israel Defense Forces (IDF). Early identification of soldiers at high risk of attrition could enable targeted interventions and optimize workforce efficiency.
Rationale:
IDF soldiers receive full medical coverage with no out-of- pocket costs. We hypothesized that higher medical service utilization correlates with attrition. Understanding this relationship could help identify those at higher risk of service discontinuation. Assessed the association between early post- enlistment healthcare utilization and attrition risk.
Methods:
Using the medical-corps electronic health records, we included all IDF enlistees (2004–2024) who served for at least 90 consecutive days. We identified enlistees deemed ineligible for service by a certified medical board. We assessed the association between healthcare utilization within the first 90 days of service and attrition afterward.
Preliminary Findings:
We included 987,975 soldiers (392,709 [39.7%] women). Among men, 44,737 (7.5%) experienced attrition, and 16,370 (4.2%) among women. The means (SD) primary-care visits per patient-year for those with versus without attrition were 22.9 (17.5) versus 16.2 (14.1) for men and 27.1 (19.7) versus 17.5 (14.7) for women. The respective means expert consultations were 2.9 (5.4) versus 2.2 (4.6) for men and 2.7 (5.2) versus 1.9 (4.0) for women.
Statement of Importance:
This study will highlight different healthcare utilization patterns among newly recruited soldiers. Its findings could support early identification of those at risk for medical-related attrition, enabling timely medical and command intervention to prevent discharge.

Background:
The stocking of medications at all unit-level pharmacies in the Israel Defense Forces (IDF) follows a standardized regulatory framework (internally termed 'standard 15'). In addition, a 2024 policy reform provides soldiers’ access to medications from nationally distributed civilian pharmacies, reducing soldiers' reliance on military clinics.
Rationale:
The rigid structure of ‘standard 15’ does not account for variations in clinic needs, soldier demographics, and accessibility to civilian pharmacies. As a result, unused medications may expire, leading to resource waste and added logistical challenges. Given the evolving healthcare landscape, a dynamic and responsive system can optimize medication distribution to the unit level, thereby minimizing waste and enhancing operational efficiency. We aim to assess dispensation data associated with the current "standard 15", and propose a more efficient, needs-based model for medication stocking for IDF unit-level pharmacies.
Methods:
We will conduct a retrospective analysis to assess dispensation trends across a sample of IDF unit-level pharmacies. Data will be categorized based on clinic location, soldier demographics, and degree of access to civilian pharmacies. Statistical modeling will be applied to assess the association of these factors with medication dispensation, guiding the development of an adaptive supply model.
Statement of Importance:
Optimizing medication management within the IDF may reduce unnecessary expenditures, enhance logistical efficiency, and ensure soldiers receive timely and appropriate medical care.

Background:
Soldiers in the Israel Defense Forces (IDF) receive complete medical coverage without out-of-pocket expenses. Some procedures require approval by the Medical Services Branch. Shoulder arthroscopy is approved only for individuals experiencing two clinically confirmed shoulder dislocations requiring reduction or those with superior labrum anterior and posterior (SLAP) lesion type 3 or 4 on imaging. Similarly, functional endoscopic sinus surgery (FESS) and submucosal resection (SMR) are approved only for individuals with nasal congestion after three months of nasal corticosteroids and saline irrigation, provided allergic rhinitis requiring immunotherapy and for FESS, asthma has been ruled out. Rationale:
Five years ago, before these policy changes, any surgery referral was automatically
approved. These changes aim to optimize resource use and avoid complications associated with unnecessary surgeries, yet their impact on soldier functionality remains unquantified. To identify data markers of functionality within the IDF and evaluate outcomes before and after the revised policies for shoulder arthroscopy and nasal surgeries (FESS and SMR). Methods:
This historical cohort study using data from the entire IDF serving population, past and present. For shoulder arthroscopy, we will include individuals who underwent magnetic resonance arthroscopy, ensuring injury data availability. For FESS and SMR, patients will be grouped by referral timing relative to the policy changes, with controls defined as those referred before the changes who fully exhausted conservative treatment (per drug dispensing and allergy referral records). Outcomes will include hospitalization metrics, rest days, changes in occupational assignments, with at least one year of follow-up (up to 2024). A multivariate logistic regression model will evaluate the likelihood of experiencing each outcome returning to duty, controlling for sociodemographic and functional factors.
Preliminary findings:
Under the revised policies, 40–50% of surgery referrals are not approved by the IDF Medical Services Branch.
Statement of importance:
This study tests recent IDF health services policy changes by establishing reliable functionality markers and offers a framework for future revisions to enhance patient care and operational readiness.

Background:
Psoriasis is a chronic inflammatory dermatological condition characterized by its systemic effects, which substantially undermining patients’ quality of life. Pharmacological treatment of psoriasis can be classified into local and systemic therapies. There is limited data comparing different advanced biological therapies and the rate of treatment persistence and other healthcare services utilization outcomes.
Rationale:
Treatment persistence is often used as a surrogate marker for therapeutic success when assessing treatments for psoriasis, particularly advanced biological therapies. The Medical Corps of the Israel Defense Forces (IDF) has access to comprehensive data on patient diagnoses and medication dispensation, allowing for a robust analysis of treatment outcomes. Methods:
This historical cohort study consists of soldiers with psoriasis treated with systemic and biological therapies between 2002-2025. Using electronic health records, we will include those with >=3 months on specific treatment. We would use dispensation data to assess the treatment persistence of each systemic psoriasis therapy. Analyses would be repeated by baseline characteristics such as age, sex, body mass index, and history of mental disorders. Additional outcomes would include the number of visits with primary care physicians, dermatologists’ and other experts’ consultations, mental health-related visits, and more.
Preliminary results:
Between 2014 and 2024, 2540 soldiers with a history of psoriasis were recruited (0.3% of all recruits; 1481 men). As of February 2025, there were 49 soldiers with psoriasis requiring biological treatment (17 active-duty and 32 career soldiers). Statement of importance:
Given the limited data in Israel, this research will determine drugs’ effectiveness and patients’ tolerability of various biological treatments for psoriasis in the setting of military service, with direct implications for clinical practice and policymaking.

Background:
Chronic pain is usually defined as pain persisting for more than 3 months, following an acutely painful event, without an alternative identifiable cause. In patients who suffer from trauma events, chronic pain syndrome often occurs after orthopedic injuries and nerve damage. The Recovery and Rehabilitation Center of the Medical Corps was established during the “Iron Swords” war in order to provide multidisciplinary treatment to war trauma patients in the IDF. Rational:
Early detection and prevention of patients at high risk of developing chronic pain syndromes may allow early intervention and prevention, thereby enhancing patients’ quality of life, return to duty, and long-term outcomes. We aim to develop a predictive model that will provide early identification of patients at high risk of developing chronic pain syndrome among soldiers experiencing war trauma events.
Methods:
We will use data collected during the “Iron Swords” war, focusing on patients treated in the Recovery and Rehabilitation Center. We will assess the association of demographic and medical variables, as well as data collected during the trauma event, with the risk of developing chronic pain syndrome. The outcome of chronic pain syndrome will be defined using a list of diagnoses supported by decisions made by certificated medical boards.
Preliminary findings:
The Recovery and Rehabilitation Center has treated over 2,800 patients who experienced war-related trauma during the "Iron Swords" war, including approximately 1,000 with major orthopedic injuries. The majority received treatment for pain, and some have developed chronic pain syndrome. Statement of importance:
Early detection of patients at high risk for chronic pain syndrome will allow early intervention, reducing the risk of long-term sequelae. In addition, it would lay the groundwork for follow-up studies that compare different interventions using real-world data or clinical trials.

Background:
Celiac disease is an autoimmune disorder triggered by gluten ingestion that affects approximately 1% of the population. Traditionally, individuals with celiac disease were deemed unsuitable for high-demand military roles due to their dietary restrictions and associated health risks. In 2014, a new Israel Defense Forces (IDF) policy allowed patients with serology- controlled celiac disease to be enlisted in combat positions. Rationale:
This policy change has expanded the recruitment pool, fostering inclusivity and diversity. While the IDF has implemented adaptations such as allowances for gluten-free nutrition and a medical follow-up protocol, it remains unclear whether soldiers with celiac disease in combat roles were able to maintain adequate disease control.
Aim:
We aim to evaluate the association of enlisting soldiers with celiac disease to combat roles and the risk of disease control loss.
Methods:
We propose a historical prospective cohort study using the medical corps electronic health records, comparing combat soldiers diagnosed with celiac disease to their non-combat counterparts (2014-2024). The main outcome will be the incidence of loss of disease control, as measured using anti- transglutaminase antibodies (aTTG) IgA>15U/ml in serum. We will also assess patients’ compliance with laboratory follow- up as required every six months.
Preliminary findings:
During the study period, 4390 people with celiac disease were recruited, 810 (18.5%) of them to combat roles. The proportions of soldiers with celiac disease receiving a referral to aTTG test were 85.6% versus 80.8% among those in combat versus non- combat roles, respectively. The respective proportions of patients who performed aTTG tests during service were 77.0% (n=624) and 66.3% (n=2372).
Statement of Importance:
The policy change allowing individuals with celiac disease to serve in combat roles was implemented in 2014, but its impact on soldier’s health has not been assessed. This study will provide data on the integration of soldiers with celiac disease in combat roles and lay the groundwork for the possible inclusion of additional populations currently exempt from service.

Background:
The opening events of the Iron Swords War on October 7, 2023, posed immense challenges for the IDF's mental health system. Necessitating action on two fronts. On one hand, there was an urgent need for intensive treatment of combat stress reactions in multiple battle zones within Israel, affecting entire units exposed to intense combat, casualties, and injuries—both among IDF soldiers and civilians. On the other hand, the rapid recruitment of thousands of reservists and the preparation of forces for maneuvering in enemy territory to the north and the south, required immediate preparation and preventative interventions. The sheer scale of those exposed and affected called for broad, immediate measures—both for primary prevention to strengthen the resilience of IDF soldiers and for secondary prevention to mitigate the risk of long-term mental health consequences.
Mental resilience Branch:
The IDF Mental Health Center has long been dedicated to strengthening soldiers' psychological resilience. However, the current Mental Resilience Division was established during the war to enhance resilience among active-duty and reserve soldiers and to reduce mental health disorders among service members. Throughout the war, numerous intervention protocols were developed and launched, based on research available and trauma literature. Simultaneously, programs were designed to integrate these approaches from enlistment onward, preparing soldiers for military service. Given the war's uncertain duration and the limited global literature on such a conflict, addressing these challenges remains complex. The Mental Resilience Division positions itself as a leading professional body in Israel, setting directives for resilience- building efforts. It collaborates with Mental Health professionals in academia and civilian Resilience Centers in Israel. Protocols have been developed for transitions between mental states and combat zones, post-battle trauma processing, coping with mass casualties, physical and emotional regulation, mind-body workshops, crisis communication skills, and more. Additionally, informational videos were produced to guide soldiers’ families on supporting their loved ones returning from war. The Research Department of the Mental Resilience Branch focuses on evaluating the protocols developed during the war, including the effectiveness of the "Resources Protocol," "iCOVER," and post-combat processing methods. Additionally, we explore mind-body intervention practices that enhance resilience, such as yoga, Pilates, biofeedback, and improving communication patterns and their impact on psychological resilience measures.

Background and Rationale:
The tragic UAV crash on January 13, 2024, at the Golani Brigade training camp injured 62 soldiers and claimed the lives of four, posing an unexpected psychological challenge outside the combat zone. The primary question addressed is how to efficiently manage psychological crises in non-combat environments. The findings of this intervention offer valuable insights into reducing psychological morbidity, ensuring rapid recovery and resilience within military units.
Methodes:
This qualitative intervention focused on the entire affected unit, emphasizing soldiers directly exposed to the event. The intervention was structured around stress response treatment principles, centering on proximity, immediacy, and expectancy. Data collection occurred through 84 group discussions and 167 individual sessions over the first two weeks, alongside continuous clinical support within the unit. Results:
The intervention's effectiveness was highlighted by an exceptionally low dropout rate, with only a few soldiers experiencing unresolved emotional crises despite intensive care. This underscores the program's success in mitigating psychological attrition and facilitating a swift return to routine. The approach focused on immediate, tailored interventions demonstrated significant resilience enhancement among soldiers.
Conclusions:
The intervention emphasizes the crucial role of rapid, differentiated responses, continuous clinical support, and commander presence during crises. These elements were instrumental in reducing emotional distress and ensuring a smooth transition back to normalcy. The study's implications suggest that maintaining these principles in future interventions will bolster resilience and psychological well- being in military contexts, providing a model for addressing similar challenges in the future.

Background and Rationale:
The collected information on treating Acute Stress Disorder (ASD) shows that cognitive-behavioral therapy is effective, but there is no evidence supporting the effectiveness of anxiolytic and sedative medications in preventing PTSD. However, due to the clinical needs of patients, medications are widely used based on clinicians' preferences, despite limited and low- quality studies. Since October 7th, hundreds of soldiers have been treated for ASD in Combat Stress Reaction units, both pharmacologically and non-pharmacologically. The study aims to compare the medications used for treating ASD in IDF soldiers and assess their impact on the progression to PTSD. Research Methodology:
The study is a retrospective case-control analysis involving active-duty IDF soldiers diagnosed with ASD and treated in the Combat Stress Reaction units during the Iron Swords war (October 2023 - May 2024). A sample of 80 soldiers treated with CBT and 80 soldiers treated with CBT and medications will be analyzed. Data will be collected from the military's computerized patient records system (CPR) for both the initial treatment and outcomes.
Results:
The study will analyze the relationship between pharmacological/ non-pharmacological treatment and PTSD development using a Chi-square test and odds ratio. Multivariate logistic regression will control for severity and demographic factors. Dichotomous and categorical variables will be presented as frequencies and percentages, while continuous variables will be shown with mean, standard deviation, median, and range.
Conclusions:
Due to limited and low-quality studies on pharmacological treatment for ASD symptoms, there are no consensus guidelines, and significant variability exists among clinicians. The research may clarify
existing knowledge and help refine the choice of the most effective treatment, possibly contributing to prevention of PTSD among soldiers.

Background and Rationale:
Exposure to combat may influence the development of post- traumatic stress disorder (PTSD). Although Written Exposure Therapy (WET) is an effective treatment for PTSD in soldiers, there is limited evidence supporting its effectiveness in a group therapy setting. Considering the efficacy of the treatment protocol in individual therapy, efforts were made to adapt the protocol for group therapy. This study examined the outcomes of the group-based application of the protocol to offer an evidence-based, trauma-focused treatment capable of addressing the needs of multiple patients simultaneously. Method:
This is a cohort study conducted from October 7, 2023, to August 1, 2024, during the Iron Swords War. Subjective Unit of Distress (SUDS) were assessed across five WET meetings. Additionally, we utilized the PTSD Checklist (PCL-5), the Difficulties in Emotion Regulation Scale (DERS), the Negative Mood Regulation Scale (NMR), and the Group Cohesiveness Scale (GCS) both before and after participants engaged in group therapy based on WET. We used a Repeated Measures test to evaluate the linear association of SUDS scores along the five WET active treatment sessions.
Results:
Of the 45 participants (mean age 29.58 [SD 5.88]), 80% (n = 36) were stationed in the Gaza zone, and 13.3% were officers (n = 6). The analysis revealed a significant difference before the start of the treatment and in the end in Total PCL, NMR, and GCS. Additionally, the four PCL sub-scales were found significant, and only awareness (DERS) was found statistically significant. A linear correlation trend was found between the end-of-session SUDS scores from the five active treatment sessions of WET.
Conclusion:
Our findings contribute to an increasing body of literature demonstrating the initial effectiveness of WET in a group setting.

The Oketz Unit lost 24 service dogs during the first few months of Iron Swords War, creating a unique grief response among handlers not addressed by standard combat stress protocols. Based on requests from the soldiers, this intervention was developed to facilitate healthy grief processing for soldiers who lost their canine partners, recognize the legitimacy of their emotional response, and support their psychological readiness to return to operational duties. Based on attachment theory, the intervention acknowledges that losing a service dog triggers significant bereavement processes and also Traumatic grief, requiring specialized therapeutic approaches for military personnel.
The program targeted soldiers who lost canine partners in combat. Implemented as a one-time intervention for 11 soldiers, the intervention utilized the "Photo Album Protocol," adapted specifically for the military context. The structured session provided a safe environment for emotional expression, memory sharing, and collective meaning-making around the unique bond formed in combat settings. The intervention addressed the dual identity of service dogs as both operational tools and emotional companions, a complexity that complicates the grieving process in military environments.
The intervention's effectiveness was assessed through facilitator observations, participant feedback, and thematic analysis of session content. Key outcomes included normalization of grief responses, reduced emotional isolation, enhanced unit cohesion, and increased psychological readiness to form new operational partnerships. Following the initial session, additional groups were requested, indicating the intervention addressed a previously unmet need within the unit. Preliminary feedback suggested the intervention helped soldiers integrate their loss experience into their professional identity without compromising combat readiness.
This intervention provides a framework for structured emotional support following service animal loss. Recommendations include incorporating canine loss protocols into standard mental health procedures and implementing follow-up assessments. Further development should focus on creating sustainable support mechanisms that acknowledge the human-canine bond while ensuring operational continuity and soldier wellbeing.

Background:
During the ‘Swords of Iron’ war, under the guidance of the IDF mental Health Center, hundreds of cross-border interventions (within combat zones) were carried out by mental health officers (MHO) on a regular and ongoing basis throughout the war. These interventions were not part of the official emergency response protocol of the IDF mental Health Center and are unique. The commanders in the field expressed their need and we had to adjust during war and find a solution. We needed to provide interventions that help soldiers reduce combat reactions and rapidly return to mental and emotional readiness for combat.
Rational:
The aim of the research is to identify the key themes emerging from these interventions and to provide qualitative insights for determining in which situations cross-border interventions are beneficial and whether there are situations in which it would be preferable to refrain from such interventions and choose alternative options. We seek to integrate findings from the interviews and use them for developing a professional protocol with guidelines for such interventions.
Methods:
The study is based on a qualitative research approach, utilizing semi-structured interviews. The sample includes: 15 MHOs and 10 commanders. Data collection method is based on a narrative approach using Thematic Analysis, aimed at identifying key themes and examining their interconnections. Preliminary Conclusions:
The initial conclusions, based on partial data analysis, point to trends requiring further examination.

Background and Rationale:
he literature on the course, treatment, and return to readiness of soldiers with Acute Stress Reactions (ASR) and Acute Stress Disorder (ASD) is limited. This study aims to describe the disease trajectory of Israeli soldiers with ASR who were treated at frontline treatment centers using the Proximity- Immediacy- Expectation (PIE) approach.
Methods:
A retrospective chart review was conducted on 1,450 soldiers who received treatment at frontline treatment centers between October 2023 and January 2024. The primary outcome measure included a one-year follow-up to assess the diagnosis of Post-Traumatic Stress Disorder (PTSD) and its severity, along with the return to operational readiness in original units or transfer to different units. Additionally, the need for referral to rear treatment centers for more intensive care was evaluated. Data were collected from soldiers' medical records, and statistical analyses were conducted to examine the relationship between treatment outcomes and various factors.
Results:
Of the 1,450 soldiers, 81% were not diagnosed with PTSD and remained in their original units. 12% were diagnosed with moderate PTSD and transferred to different units, while 7% were discharged due to severe PTSD. Among conscripted soldiers, 65% were not diagnosed with PTSD and stayed in their original units, while 13% were discharged due to severe PTSD.
Conclusions:
These results highlight the importance of early intervention in maintaining operational readiness. The majority of soldiers remained in their original units, indicating that effective frontline treatment can preserve readiness. The 19% who were transferred or discharged due to severe PTSD emphasize the need for ongoing mental health support. Integrating comprehensive psychological care into military readiness strategies is essential for maintaining the effectiveness of combat units.

Background and Rationale:
On October 7, 2023, following Hamas' attack on Israel, the IDF Medical Corps recognized the urgent need for accessible psychological support for soldiers. Traditionally, military mental health care adheres to Salmon’s principles of proximity, immediacy, and expectation of return to function. While mental health officers (MHOs) are deployed in combat zones to provide face-to-face intervention, the unprecedented scale of the attack required an immediate, professional, and accessible response for soldiers exposed to trauma. Intervention Description:
In response, a Psychological Support Hotline was launched on October 8, 2023, this hotline enabled soldiers from any location to connect with an MHO within minutes. Available 24/7, the hotline filled a critical gap until field-based mental health teams could fully mobilize.
Findings:
In the first four months, the hotline handled 3,326 calls. Usage was highest in the initial phase, averaging 72 calls per day in the first month, dropping to 24 daily thereafter. Approximately 40% of calls were urgent, from soldiers directly exposed to combat, while others involved severe distress, such as grief and anxiety. 48% of cases were resolved within the call, while others required referrals for further treatment.
Conclusions:
The hotline introduced a new model of remote psychological intervention in the military, providing immediate and structured support. It also served as a resource for families, commanders, and civilian professionals. This approach highlights the importance of rapid-access psychological care and underscores the need for further research on long-term effects and potential integration into standard military mental health protocols.

On October 7, the Rear Rehabilitation Unit received (MALSHA) orders to commence operations. This reserve unit is activated in emergencies (war), and its mission is to treat soldiers no longer in the front lines suffering from Acute Stress Reactions (ASR) or Disorder (ASD) following operational activities. The first time activated since 1982, in the weeks and months following October 7, the unit faced a series of challenges: the number of patients was five times greater than the planned maximum capacity; the principles of Closeness, Immediacy, and Expectancy (CPI), which are the military’s basis for treating ASR and ASD, did not fit the unit’s treatment framework; the patients and families experienced a lack of trust and a feeling of abandonment; and there was a need to implement an overall uniform therapeutic approach among a diverse population of veteran therapists, all of whom were reservists. In this talk, I will describe how we addressed these challenges during the unit’s operational period focusing on: 1. Alternatives CPI, balancing regression with the option to return to active duty if at all possible; 2. Addressing the soldiers’ need for security and containment while simultaneously exposing them to the ongoing military reality; 3. Providing a uniform approach for treatment without undermining the therapeutic identity of the therapists and their professional freedom, acknowledging that therapeutic flexibility is essential in treating the ASD phase.
I will conclude by referring to the uniqueness of the Rear Rehabilitation Unit as a military therapeutic body that treats soldiers suffering from trauma within the military system, and the inherent tension between the need to encourage the traumatized soldiers for regression and return to functioning. The statistic that more than 80% of the soldiers returned to service supports the assumption that encouragement toward regression did not significantly harm the soldiers' return to military service.

Background:
Depression, anxiety, and obsessive-compulsive disorder (OCD) affect up to 20% of young adults. Until 2020, candidates for military service in the Israel Defense Forces (IDF) with any history of mental health-related disorder were ineligible for combat roles. A policy change introduced in 2020 allowed individuals with documented remission of at least one year and positive prognostic characteristics to serve in combat units.
Purpose:
This study examines the implications of integrating individuals with a history of remitted mental health disorders into combat settings and estimates the proportion of mental health relapse.
Methods:
We included soldiers with a history of depression, anxiety, or OCD who were screened before enlistment and confirmed to be in remission for at least one year. We assessed the proportion of soldiers disqualified from service post-assignment. The Wilson score interval was used to calculate 95% confidence intervals for disqualification rates.
Results:
Between November 2020 and September 2024, 837 candidates with remitted depression, anxiety, or OCD were eligible for combat roles. Of them, 659 were recruited: 359 (54.5%) with anxiety disorders, 191 (29.0%) with major depressive disorder, and 117 (17.8%) with OCD. Seventy-two soldiers (10.6%, 95% CI: 8.5 to 13.2) were medically disqualified: 43 with anxiety disorders (12.0%), 23 with major depressive disorder (12.0%), and 6 with OCD (5.1%).
Conclusions:
Most soldiers with documented one-year remission from psychiatric disorders successfully completed combat service. An ongoing study compares these soldiers with a control group to assess long-term viability. The findings suggest a practical pathway for integrating individuals with remitted mental health conditions into combat roles.

Havat HaShomer is a unique training base in the IDF designed for soldiers from challenging backgrounds, including those from low socioeconomic status and those who struggle to adapt to a structured environment. Through a specialized training program that provides a supportive and encompassing atmosphere, these soldiers are prepared not only for military service but also for successful civilian life.
The IDF, as a people's army with mandatory service, must cater to the diverse population it recruits, ensuring equal opportunity and maximizing each soldier's potential contribution. The demands of the military framework can either lead to further failure (as it is not inherently a therapeutic or rehabilitative setting), or, through a successful combination of external boundaries and extensive support addressing emotional and physical needs, facilitate a change in established patterns and foster experiences of success.
The role of the mental health officer (social worker) encompasses diagnosis, treatment, and support for soldiers; referral to psychiatric care when necessary; and mediation with commanders. A dedicated pathway exists for soldiers who subsequently pursue further training, culminating in combat roles. Counseling and guidance are also provided to staff and commanders.
Upon completion of the program, soldiers are assigned to various IDF units based on their abilities and personal and family circumstances. The aim is to maximize their potential and open doors that would otherwise be inaccessible. Approximately 8% of these soldiers proceed to combat service. The majority complete meaningful full service, with a high percentage serving in special units and command positions.

Background and Rationale:
As part of the conscription process to the IDF, individuals undergo a thorough occupational evaluation, which may include advanced psychiatric testing. As a result, some individuals are excluded based on presentations of psychiatric diagnoses, such as autism spectrum disorder (ASD). They can volunteer with the IDF in special capacities. This study aimed to examine completion rates and correlations of psychiatric volunteers during the first year of service. Individuals with ASD may meaningfully benefit from – and contribute to – military service.
Research Methodology:
We used historical data maintained by the human resource database and medical records in the IDF to identify psychiatric volunteers between the years 2008 to 2017 (N = 1,159). 76.9% were male and the mean age was 19.65. Overall, 32.3% (n = 374) of psychiatric volunteers had a diagnosis of ASD and 67.7% (n = 785) had other psychiatric diagnoses.
Findings:
We used survival analysis. Overall, 59.5% (n=690) of the sample completed their first year of volunteering. Non-ASD compared with ASD psychiatric diagnoses (OR = 2.057, p < .001) was at greater risk to dropout in the first year. Conclusions:
Those diagnosed with ASD are more likely than individuals with other psychiatric disorders to stay in the military as part of volunteer service. Placing soldiers with ASD in an exclusive, way and in accordance with their abilities may contribute to their successful integration.

Background and Rationale:
Adverse childhood experiences (ACE) are recognized risk factors for post-traumatic stress disorder (PTSD). However, limited research explores their specific impact on PTSD development among soldiers in combat and combat support roles.
Research Methodology:
This retrospective cohort study analyzed data from 288,633 IDF soldiers assessed between the years 1998-2019. ACEs were assessed using a 9-item adaptation of the ACE questionnaire. PTSD diagnoses were determined by licensed clinicians at enlistment and discharge.
Findings:
PTSD prevalence increased from 0.01% at enlistment to 0.06% at discharge. ACE exposure was common (27.8% reported ≥1 ACE). Sexual abuse (OR = 4.14) and Emotional neglect (OR = 1.92) were the strongest PTSD predictors. ACEs significantly predict PTSD due to combat severity in military recruits beyond and over being in combat roles.
Conclusions:
Findings highlight the need for pre-enlistment screening and targeted interventions for high-risk recruits. A trauma- informed approach to military psychiatry may mitigate long- term psychiatric morbidity. Our study suggests that military enlistment should include ACE screening as part of routine mental health evaluations.

Background and Rationale:
Caregivers exposed to war events face increased risks of Post-Traumatic Stress Disorder (PTSD) and Moral Injury (MI). The research aims to assess the frequency of PTSD and MI in military medical caregivers with different combat exposure events, compared to civilian doctors who treated combat casualties in ER. Findings could aid in developing prevention programs and interventions for high-risk military caregivers. Research Methodology:
This cross-sectional quantitative study targets four groups Combat medics (CMs), who fought as part of organic combat teams non-combat medics (non-CMs) who crossed border lines to evacuate casualties without engaging in combat, military medical caregivers who treated casualties without crossing border lines, civilian doctors in hospitals near combat zones.
Data collection will be conducted by the lead researcher using validated Hebrew questionnaires, including Combat Exposure Scale (CES), PTSD Checklist (PCL-5), Brief Symptom Inventory (BSI), Moral Injury Events Scale (MIES), and Mental Health Continuum Short Form (MHC-SF).
Results:
The study will assess and compare the severity and prevalence of PTSD and MI across the four groups. Data analysis methods and main findings will be determined after the study is conducted.
Conclusions:
The research aims to provide insights into the mental health risks faced by military medical personnel and civilian doctors in combat-related situations. Results may inform the development of targeted prevention and intervention strategies for these high-risk populations.

Traditionally, Western medicine focuses on illness. Questions arising from the pathogenic model, which centers on origins of disease, include: What causes illness? How is illness diagnosed, treated, and prevented? Until the 1970s, the medical establishment did not address the question of what constitutes the origins of health.
During that time, a study on Holocaust survivors raised the question: "How did they manage to survive and even find satisfaction in life?" That brought medical sociologist Aaron Antonovsky to develop the salutogenic model of health, centered around the question of what helps people move toward health. According to this perspective, we are not dichotomously either suffering from or free of a specific disease; rather, we are always on an ease/dis-ease continuum. Life is not a state of balance and harmony where one occasionally falls ill; instead, the living organism continuously faces internal and external challenges. The salutogenic question of how one copes with challenges is a question of health promotion, not disease prevention—concepts that are not two sides of the same coin and therefore can coexist. Aaron Antonovsky’s answer was the core concept of his model: the sense of coherence (SOC), which is an orientation toward life comprising three components:
(a) Comprehensibility – the ability to understand challenges and to predict, to some extent, what life will look like ahead. (b) Manageability – the perception that one has the resources to cope with challenges.
(c) Meaningfulness – the feeling that there is a reason to face these challenges.
The salutogenic approach has guided numerous studies and interventions in the IDF aimed at strengthening the SOC. Alongside the need for preventive measures to reduce psychological distress, which typically target soldiers at risk- actions are needed to enhance well-being among all soldiers. This is crucial because all soldiers undergo an adaptive crisis upon enlistment. The key question is not why some soldiers develop distress, but rather how-despite the many challenges they encounter in military service-the majority of soldiers successfully navigate their service experience.

Background:
The salutogenic model of health, developed by Aaron Antonovsky in the 1970s, poses the question: What helps people move toward health? This stands in contrast to the pathogenic model, which focuses on what causes illness. The core concept of the salutogenic model is Sense of Coherence (SOC), which reflects an orientation to life comprised of (a) Comprehensibility – a cognitive component referring to the extent to which a person perceives life’s challenges as making sense and predictable; (b) Manageability – a behavioral component referring to an individual’s perception that they have the necessary resources to cope with challenges; (c) Meaningfulness – an emotional-motivational component reflecting the extent to which a person feels that facing challenges is worthwhile. Thousands of studies worldwide have found that SOC is a strong predictor of physical and mental well-being and serves as a buffer against negative psychological conditions such as burnout, depression, PTSD, and suicidal ideation (SI). In military contexts, SOC has also been positively associated with operational performance. Consequently, various interventions have been developed to strengthen SOC among soldiers, with a particular emphasis on social cohesion, a key coping resource in military settings. In our study, we aimed to determine whether SOC is directly related to SI, or whether its effect is mediated by PTSD symptoms.
Method:
In a cross-sectional design, 140 male IDF compulsory soldiers (mean age 20.4, 53% combatants) filled out self-report questionnaires. We used the Beck Suicide Ideation Scale (SIS) to measure SI. We used the sense of coherence questionnaire (SOC-13), the PTSD Checklist (PCL-5), and the Unit Cohesion scale to measure the independent variables.
Results:
SOC had a strong negative association with PCL, a moderate negative association with SIS, and a moderate-strong association with unit cohesion. Path analysis revealed that the direct path from SOC to SIS was much stronger than the indirect path through PCL. This suggests that SOC has a more direct impact on suicidality than through its influence on PTSD symptoms.
Conclusion:
SOC has a strong and direct buffering effect on suicidality, reducing the likelihood of suicidal tendencies. This highlights the importance of interventions (such as strengthening unit cohesion) aimed at enhancing soldiers' SOC, which could contribute to mitigating suicidality.

Background and Rationale:
Suicides among military personnel are a significant concern for many armed forces worldwide. However, the impact of warfare on suicide rates is inconsistent, with variations observed across different armies and conflicts. This study aims to present recent data on suicides within the Israeli Defense Forces (IDF), with emphasis on changes observed during the past year and a half of wartime.
Materials and Methods:
A descriptive study was conducted using systematically collected data from the IDF Human Resources Division. Suicide data were gathered and suicide rates calculated relative to the size of the military. Demographic and clinical data were also collected, with separate calculations made for regular and reserve soldiers. The suicide rate for regular soldiers was based on the total number of active-duty soldiers, while the rate for reserve soldiers was based on annual reserve duty days.
Results:
In 2024, 21 soldiers in the IDF died by suicide: 7 active-duty soldiers, 2 career soldiers, and 12 reserve soldiers. This represents a high absolute number compared to the past decade. Most had no prior contact with mental health services (18 out of 21), and all were male, with the majority being combat or combat-support soldiers. The suicide rate among regular soldiers in 2024 was lower compared to previous years, while the rate among reserve soldiers showed a slight increase.
Conclusions:
The findings align with other studies indicating a decrease in suicide rates during wartime. Suicides among reserve soldiers may be linked to their abrupt transition into the military environment, where there is limited familiarity with their backgrounds and a lack of clinical information sharing between civilian and military authorities. These results underscore the need for focused preventive efforts for reserve soldiers during times of conflict.

Background and Rationale:
The October 7th war caused significant psychological trauma among soldiers and civilians, leading to a rise in post- traumatic stress disorder (PTSD). Traditional therapy often fails to meet these individuals’ complex needs, particularly where access to mental health resources is limited. Virtual Reality (VR) presents a promising solution, offering immersive, personalized therapy. We explore how VR can be utilized for PTSD treatment, focusing on soldiers and civilians affected by the war.
Research Methodology:
A mixed-method approach, combining tool development with qualitative and quantitative evaluation. The target population includes Israeli soldiers and civilians impacted by war trauma. We are adapting the US BraveMind VR Technology to Israeli scenarios, and developing a new VR tool focused on place attachment. A focus group of seven experienced therapists (1 psychiatrist, 2 psychologists, 2 clinical social workers, 1 drama therapist, and 1 medical clown) tested our prototypes and answered a standard Presence questionnaire and customized user experience questionnaires. A 60-minute group discussion provided insights into tools’ effectiveness and adaptations needed.
Findings:
We will present the current version of our tools. Initial evaluation results indicated that therapists responded positively to both VR tools. Participants reported a strong sense of presence during sessions and were optimistic about using these tools for PTSD treatment. Therapists suggested cultural and geographical adaptations to reflect local trauma experiences. The group discussions and questionnaires revealed enthusiasm for VR as a viable treatment option and we are adapting our prototypes accordingly.
Conclusions:
The initial phase shows that therapists accept VR for PTSD treatment and recognize its potential for combat PTSD and trauma related to place attachment and bereavement. Given the extensive validation of Bravemind in the US and these early findings, VR is concluded to potentially enhance emotional processing and offer scalable mental health interventions for soldiers and civilians in Israel.

One in three women will experience sexual violence during her lifetime. The data paint a worrying picture of Israeli and global reality.
Self-defense programs are offered as a strategy for reducing women’s vulnerability to sexual violence. Self-defense programs for women are based on the premise that violence against women is a "special type" of violence, and the ways in which women respond to violence directed against them are a product of gender education about women's roles.
These programs teach the participants new methods for self- defense that take a more assertive and reactive approach. These are expressed in body language, speech, use of emotion, and patterns of thinking and action. Participants undergo a process of empowerment and self-efficacy. To date, most of the research in the field of empowering self-defense workshops has been conducted among female students on campuses in the United States.
This is the first study of its kind in Israel. The self-efficacy and mental health of female soldiers have been proven to be significant for the success of military service. Our research offers a practical tool for reducing sexual violence against women, both in a general and military context. The program is scientifically proven and is simple, effective and short.
In the long term, its results may lead to the development of an innovative systemic intervention program that will be regularly implemented to help prevent sexual violence in the IDF.

Background:
Suicide is the second leading cause of death in young people nationwide and the first among soldiers in times of peace. In times of war suicide rates are usually lower in the general population. Suicide prevention is a major challenge in developed countries. Using a systematic review of evidence, we found four major evidence-based strategies for suicide prevention (Zalsman et al., Lancet Psychiatry 2016). COVID-19 didn't raise suicide rates in Israel and our data show no raise in 33 countries (Pirkis el al, Lancet 2022). Changes in suicide rates after a nationwide trauma may be different from changes in psychiatric symptoms or general distress after such events. However, very few studies have examined short-term suicide- related reactions after such an event.
Objective:
To evaluate the short-term outcome of the events in Israel on October 7, 2023, a large-scale terror attack and unfolding war, on changes in suicidality as reflected in percentages of suicide-related calls in relation to all calls to a national mental health first aid helpline, the Israeli Association for Emotional First Aid (ERAN).
Methods:
The data included all interactions via the various ERAN helpline services between January 1, 2022, and December 31, 2023.
Exposures: The October 7, 2023, terror attack on Israel.
Mean outcomes and measures: Changes in the numbers of overall calls and suicide-related calls to the ERAN helpline using an interrupted time-series analysis.
Results:
A total of 602 323 calls were received by the ERAN helpline. The number of calls reflecting psychological distress in the 3 months before October 7, 2023, was 67 555 compared with 89 445 calls in the 3 months after. Analysis indicated that overall calls increased significantly on October 7 (β = 2089.16; 95% CI, 1918.97-2259.35). In addition, the daily trajectory of all calls changed significantly after October 7 (β = -22.77; 95% CI, -33.37 to -12.16), such that there was a decrease in the number of calls per day (β = -11.34; SE = 1.213; t = -9.35; P < .001). The number of suicide-related calls in the 3 months before October 7 was 1887, whereas 1663 suicide-related calls were registered in the 3 months after. Analysis showed that there were no changes in the daily number of suicide-related calls from before October 7 (β = -0.001; 95% CI, -0.005 to 0.03) or on October 7 (β = -0.22; 95% CI, -3.69 to 3.25). Therefore, the percentage of suicide- related calls decreased significantly on October 7 (β = -1.42; 95% CI, -1.92 to -0.92) and gradually increased in the following period (β = 0.016; 95% CI, 0.006-0.026).
Conclusions and relevance:
The findings of this cohort study suggest that although short- term emotional distress increased after national trauma, the percentage of suicide-related calls decreased. These results support previous studies suggesting that suicidality is not one of the immediate reactions to such trauma

Background and Rationale:
Remotely Piloted Aircraft (RPA) operators play a crucial role in modern warfare, particularly in high-intensity conflicts. During the Iron Swords War, Israeli Air Force RPA operators conducted an unprecedented number of missions, underscoring their strategic significance. However, their role entails unique psychological stressors, including prolonged exposure to combat imagery, moral dilemmas, and cognitive overload. Previous research has linked RPA operations to PTSD, depression, burnout, and moral injury. This study aims to identify risk and protective factors affecting RPA operators’ mental health during wartime.
Methods:
The study will employ a multi-phase approach using existing data and self-report surveys:
Phase 1: Analyze mental health and medical service referral rates before and during wartime, given prior research linking psychological distress to physical complaints.
Phase 2: Examine demographic factors (e.g., age, experience, marital status) and their association with referral rates.
Phase 3: Compare psychological distress and help-seeking behaviors among RPA operators, Air Force pilots, and elite special forces.
Phase 4: Conduct anonymous surveys assessing PTSD (PCL), depression (BDI), substance use, and moral injury— variable not yet studied among Israeli RPA operators.
Expected Results:
Findings will highlight distress patterns, high-risk subgroups, and protective factors to address key research questions:
• The impact of operational intensity on the mental health
of RPA operators.
• Differences in mental health outcomes among RPA
operators, pilots, and special forces.
• The role of moral injury in the psychological distress of
RPA operators.
Conclusions & Implementation:
This study will provide critical insights into the mental health challenges of RPA operators. Insights will enhance mental health interventions, resilience training, and support strategies, helping sustain operational effectiveness while safeguarding psychological well-being.

Background and Rationale:
Prolonged disaster response scenarios present significant challenges to first responders yet remain under-examined with respect to resilience training and mental health interventions. The Champlain Towers collapse in Surfside, Florida, required extensive search and rescue efforts involving international collaboration between U.S. domestic and local teams and Israeli first responders, representing the first time there was international collaboration on U.S. soil. As such, this context offers a unique window into understanding the emotional and psychological impact of such operations for first responders. Our research is aimed at understanding how to best support first responders emotionally in prolonged disaster scenarios, with a focus on cross-cultural nuances in emotional support mechanisms.
Research Methodology:
This work employs a phenomenological qualitative approach to examine the lived experiences of first responders deployed to Surfside. We will conduct semi-structured interviews with members from both U.S. domestic teams and the Israeli Defense Forces (IDF) Search & Rescue unit (Target N = Approx. 35) to explore first responders’ subjective experiences of emotional debriefing protocols, stress management strategies, and coping mechanisms during this prolonged response effort.
Findings:
Expected findings include information pertaining to the value of semi-structured emotional debriefing sessions, as used by the IDF team, to buffer against long-term psychological distress. We expect that, to some degree, less formalized psychological support potentially leads to greater emotional strain. The researchers will employ thematic analysis to identify potential cultural nuances in trauma processing, the potential role and value of peer support, and the need for some form of structured pre-, during, and post-mission support protocols.
Conclusions:
This research highlights the need for a more comprehensive understanding of how to best support first responders emotionally in the context of a prolonged call, with an emphasis on making recommendations that can help optimize first responder effectiveness and well-being. Findings will support a better understanding of how military- style resilience training and emotional support strategies, like those used by the IDF, may benefit civilian responders. The goal of the study is to enhance psychological support systems to improve operational efficiency while mitigating long-term mental health consequences, contributing to better disaster response frameworks.

Background and Rationale:
The few existing studies on civilian abductees revolved around captivity hardships and their lifelong consequences, while how civilians cope with captivity has received limited attention. The current study aims to fill these gaps by analyzing the strategies employed by civilian women of different ages to deal with the hardships of captivity.
Methods:
Our data consists of 17 oral interviews broadcast on Israeli media with nineteen civilian Israeli women aged 18 to 85 abducted by Hamas terrorists on October 7th, 2023, and released after 50-54 days in captivity. The interviews were transcribed and analyzed using inductive content analysis. Findings:
The participants described various coping strategies, which were divided into three types: emotional – hope and psychological disengagement; cognitive – externally-oriented: time orientation and obtaining information about the world outside; internally-oriented: self-talk, thinking about loved ones at home, imagining the release and life afterward, and identifying advantages in captivity; and behavioral – writing, survival-oriented actions, socializing with other hostages, and caregiving. The participants described the various strategies as deliberately applied and requiring constant effort. Conclusions:
To cope with the extreme adversities of captivity, the participants simultaneously applied emotion-focused, problem-focused, and avoidance strategies featuring emotional, cognitive, and behavioral aspects. Some strategies, particularly caregiving, seem gender-characteristic, and others were used differently by younger and older abductees. Given the long-term psychological consequences of captivity, our findings can inform the rehabilitation process of released captives, especially civilian women.

Background and Rationale:
Previous research by our group integrated data from assessments conducted by the Israeli draft board with records of psychiatric hospitalizations both during and after military service. This extensive dataset enabled the characterization of adolescents assessed at age 17 who were later hospitalized for severe mental illness. Our findings indicated that 17-year- old individuals later diagnosed with schizophrenia were more likely to exhibit cognitive impairment (0.4 standard deviations), lower levels of social activity, and an increased likelihood of non-psychotic psychiatric disorders compared to age, sex, and socioeconomic status-matched controls. However, the differences between cases and controls were not large enough to provide meaningful predictive accuracy. In soldiers hospitalized during their military service who had been previously examined by a mental health professional, the positive predictive value of delusions or hallucinations was too low for accurate early identification of at-risk individuals. Research Methodology:
We are currently in the process of obtaining approval to relink these datasets. This expansion will allow us to track approximately three million adolescents over a follow-up period of up to 40 years.
Findings and Conclusions:
Utilizing modern artificial intelligence, data mining, and machine learning techniques—unavailable during our initial studies—we aim to develop more accurate predictive models. A separate, unrelated study will examine PTSD risk among soldiers exposed to combat stress or injury, using data from the October 7th attacks and subsequent months. By linking PTSD assessments with draft board data, we aim to identify baseline factors differentiating soldiers who develop post- traumatic symptoms from those who do not.

Background and Rationale:
Combat soldiers face a wide variety of mental challenges on the battlefield. Despite the broad common denominator of combat activity, it is worth identifying and mapping distinctive mental challenges which characterize specific combat units in unique missions. In these mixed methods study we sought after the mental challenges of individual augmentees (soldiers who individually join organic units per specific missions). As far as we know, this subject has not received sufficient research attention so far.
Method:
The study was conducted in the first half of 2021, in three units: "OKETZ" (dog handlers), "YAHALOM" (special engineering unit) and the Combat Documentation Squad (photographers). Data were collected from 109 combat soldiers, using seven questionnaires (self-efficacy, professional ability, fear of mistakes, sense of coherence, burnout, situational anxiety, and well-being). In addition, focus groups were conducted to examine the functional aspects of their military activities. Results:
A qualitative content analysis of the focus group findings revealed 4 main themes relating to individual augmentees' operational functioning: (a) before carrying out the mission, (b) while performing the mission, (c) after completing the mission, (4) a sense of meaning versus a sense of burden. A general finding that overarches the four themes was the feeling of loneliness. Quantitative results from the questionnaires point to differences between the three units which are in line with the qualitative analysis.
Conclusions:
The most demanding mental challenge that the individual augmentee combat soldier faces is the sense of loneliness that accompanies the act of teaming. This general conclusion expresses the importance of satisfying the basic human need for social belonging, a need that intensifies in life-threatening situations, such as those experienced by members of individual augmentee units. In light of the findings, we propose a few changes in the combat preparation programs of individual augmentee units, as well as in officer training courses for commanders of organic combat units.

Background and Rationale:
As Israel continues to face the challenges of prolonged warfare, the experiences of first responders reveal parallels between wartime emergency response and disaster-related deployments. This study explores the psychological and operational frameworks shared by these contexts, with a focus on cross-cultural differences in emotional processing and psychological support. Insights from this study aim to improve resilience training and mental health interventions for first responders.
Research Methodology:
This qualitative study involved in-depth interviews with Israeli Defense Forces (IDF) first responders who participated in the Champlain Towers collapse in Surfside, Florida, June 2021, alongside American first responders. The overall sample included participants with diverse roles within both teams, emphasizing their psychological and operational experiences during prolonged crisis response. Using a phenomenological approach, data for the Israeli team has been collected through semi-structured interviews and will be analyzed through preliminary thematic analysis to identify relevant themes that map onto concrete recommendations for prolonged disaster response and other ongoing response efforts such as the current war.
Preliminary Findings:
The initial analysis of the Israeli interviews highlighted key themes: (1) the emotional and mental toll of sustained operations, including stress, fatigue, and the cumulative impact of prolonged exposure to distressing situations; (2) the importance of structured psychological support mechanisms, with daily debriefing sessions used by the IDF team to mitigate trauma relative to other protocols utilized by other teams who were present, and (3) the challenges of preserving team cohesion under prolonged stress, balancing individual coping strategies with collective performance; and (4) participation in a prolonged response call prepared first responders to certain aspects of the current war. These preliminary themes pertain to maintaining well-being and operational effectiveness. Conclusions:
This portion of the overall study suggests that best practices from prolonged disaster response have the potential to enhance resilience and performance in both military and civilian emergency operations. Initial insights from Surfside highlight the value of comprehensive psychological support, proactive leadership, and culturally tailored debriefing processes. As U.S. and Israeli military collaboration deepens, these preliminary findings provide a foundation for integrating cross-cultural disaster response knowledge into broader crisis preparedness strategies, promoting both individual well- being and team effectiveness.

Background and Rationale:
The RPA operator community has demonstrated remarkable resilience, regularly managing what can sometimes feel like apocalyptic scenarios. However, the Iron Swords War, combined with the unique yet routine psychological challenges of our profession, has pushed operators to their limits. Based on my experience as an RPA operator I distilled several contributing factors, some of which in my humble opinion are unique to remote warfare:
Distant Battlefield:
Our missions take place tens to hundreds of kilometers away: we are not physically threatened.in addition, sensory input is predominantly visual, albeit limited, with some auditory information available, while tactile and olfactory perception, are absent.
Target Intimacy:
The operator team remains above the battlefield longer than any other element. We maintain a broad and detailed situational awareness, and today’s sensors provide profound insights into target characteristics - age, gender, body language, illness, etc. We maintain a 360-degree perspective, observing the target for prolonged periods before ultimately eliminating it.
Transitions:
The physical distance between an operator’s peaceful home to the control station - where they engage in high-intensity combat - is minimal. The psychological shift required to navigate this transition is immense. Likewise, transitioning back to normal life after being immersed in warfare presents significant challenges.
Vigilance Fluctuations:
During a four-hour shift, RPA operators may execute low- intensity mission objectives, only to be suddenly redirected to high-stakes operations requiring extreme vigilance. These fluctuations can happen multiple times within a single shift, shifting rapidly between calm and crisis.
Accumulated Engagements:
For an RPA operator, the number of enemy engagements and confirmed kills over a 12-month period of intense combat is unprecedented. No sniper or Special Forces operative comes close to these figures.
Conclusions:
When these factors are combined into daily operations, RPA teams bear a significant mental burden. Being a remote warrior requires psychological skills that in my opinion have been largely overlooked and the operator's ability to endure this constant pressure relies almost entirely on innate skills.

Background:
The emergence of neuromodulator interventions has revolutionized the management of neuropsychiatric conditions in military settings. This lecture presents the integration of “Prism,” an innovative device developed by Grey Matters, into the Taatzumot clinic. Prism is designed to provide targeted neuromodulator feedback, leveraging principles of neuroplasticity to restore functional neural circuits implicated in stress-related disorders, cognitive deficits, and other neurobehavioral conditions frequently encountered among soldiers.
Rationale:
The rationale for using Prism stems from a growing body of evidence suggesting that precise modulation of neural activity can enhance traditional therapeutic approaches. By delivering individualized stimulation protocols, Prism aims to recalibrate dysregulated brain networks, thereby accelerating recovery and improving resilience in high-stress environments. This technology not only complements existing treatment regiments but also offers a novel, non-invasive method to address complex psychiatric and neurological challenges. Population:
Our target population primarily includes military personnel who have been exposed to combat situations, particularly combatants, who are experiencing stress-induced neuropsychiatric conditions, cognitive deficits, and trauma- related disorders.
The Pilot:
As part of our pilot initiative at the Taatzumot clinic, a structured integration plan has been developed. This includes comprehensive baseline assessments using neuropsychological evaluations to quantify the device’s impact. Future research will focus on a comparative study involving two groups of soldiers: one receiving conventional treatment and the other receiving Prism as an adjunct. Early observations indicate promising improvements in treatment response rates and cognitive function among those utilizing Prism.
This presentation will discuss the background, integration strategy, and preliminary findings, setting the stage for further investigations into the efficacy of Prism. Ultimately, our goal is to enhance clinical outcomes and offer a scalable solution for neuropsychiatric care in military and other high-stress populations.

Aim:
This study aimed to evaluate the effectiveness of the "Band of Brothers" (BoB) intervention, a cost-effective program designed to enhance social networks and support among soldiers during introductory military training, and to explore its impact on salutary measures.
Method:
A quasi-experimental design was employed. Sample A consisted of 360 male combat trainees, randomly assigned to either the intervention (n=240) or control (n=120) groups. The BoB intervention involved structured dyadic interactions over six weeks. Participants completed self-report questionnaires at baseline and post-intervention, measuring perceived social support, self-efficacy, sense of coherence (SOC), sense of community coherence (SOCC), and well-being. Sample B (n=60) participated in focus groups post-intervention to gather qualitative data.
Results:
Quantitative analysis revealed a greater increase in perceived social network size in the intervention group compared to the control group. However, changes in other measured salutary measures were minimal. Qualitative data from both samples indicated positive perceptions of the intervention, with thematic analysis highlighting enhanced social ties, emotional ventilation, empowerment, and improved morale. Conclusions:
The BoB intervention demonstrates potential for strengthening social support and cohesion in early military training, particularly in challenging environments. While quantitative measures of salutary effects were limited, qualitative data strongly support the intervention's positive impact on social integration and perceived support. Further research with longitudinal designs and diverse populations is recommended to explore the long-term effects and broader applications of BoB intervention.

Guilt is a common phenomenon among people who have experienced traumatic events, despite being victims themselves. Combatants who have experienced traumatic events during combat often feel guilty regarding various aspects of the event: their functioning or disfunction in the events, their emotional response, or the very fact that they are alive. Studies have shown that trauma-related guilt is especially common among soldiers seeking treatment, and in some studies, it was found that 41% of soldiers reported feeling guilty in the month preceding the measurement. That guilt – even when it's not part of PTSD – can be experienced for years as a rigid, torturous experience and perception that the combatant deserves punishment and suffering.
In the lecture, I will review the theoretical background for trauma-related guilt, in psychoanalytic thinking as well as from the perspective of cognitive psychology, and valid therapeutic models. I will refer to the unique features of trauma-related-guilt in combatants, and I will propose a new conceptualization - 'combat guilt'.
Through a case study from group intervention with combatants, I will present an application of these unique features of combat-guilt for therapeutic practice, by recognition and processing of the combatant relationship with the affiliation group (squad, platoon etc.).
In addition, I will refer to aspects of countertransference of guilt among combat-trauma therapists, and its effect on the therapeutic process.

On October 7, the Rear Rehabilitation Unit received (MALSHA) orders to commence operations. This reserve unit is activated in emergencies (war), and its mission is to treat soldiers no longer in the front lines suffering from Acute Stress Reactions (ASR) or Disorder (ASD) following operational activities. The first time activated since 1982, in the weeks and months following October 7, the unit faced a series of challenges: the number of patients was five times greater than the planned maximum capacity; the principles of Closeness, Immediacy, and Expectancy (CPI), which are the military’s basis for treating ASR and ASD, did not fit the unit’s treatment framework; the patients and families experienced a lack of trust and a feeling of abandonment; and there was a need to implement an overall uniform therapeutic approach among a diverse population of veteran therapists, all of whom were reservists. In this talk, I will describe how we addressed these challenges during the unit’s operational period focusing on: 1. Alternatives CPI, balancing regression with the option to return to active duty if at all possible; 2. Addressing the soldiers’ need for security and containment while simultaneously exposing them to the ongoing military reality; 3. Providing a uniform approach for treatment without undermining the therapeutic identity of the therapists and their professional freedom, acknowledging that therapeutic flexibility is essential in treating the ASD phase.
I will conclude by referring to the uniqueness of the Rear Rehabilitation Unit as a military therapeutic body that treats soldiers suffering from trauma within the military system, and the inherent tension between the need to encourage the traumatized soldiers for regression and return to functioning. The statistic that more than 80% of the soldiers returned to service supports the assumption that encouragement toward regression did not significantly harm the soldiers' return to military service.

Background:
The IDF operates in extreme heat, where exertional heat injuries (EHI) are a persistent risk. Training enforces strict safety guidelines to prevent EHI, yet injury rates remain high. Paradoxically, during the "Swords of Iron" war—despite the absence of such guidelines in combat—EHI cases were unexpectedly low, even in Israel’s hot summer.
Purpose:
This study examines the contrast between EHI incidence in training versus combat, exploring risk factors, mitigation strategies, and operational conditions.
Methods:
Data on heat injuries from both training and combat scenarios were analyzed, supplemented by a survey of medical officers and commanders. A retrospective review examined exertional heat injury (EHI) cases from the war, while qualitative insights explored exertion levels, hydration, and cooling measures in combat settings.
Results:
Contrary to concerns, only seven EHI cases occurred during combat,comparedto35intraining.Surveysshowed70%of soldiers rated combat exertion as moderate, attributing lower EHI rates to adaptive pacing, mission-driven exertion, and natural cooling opportunities. Despite the absence of formal prevention protocols, commanders pragmatically integrated hydration and cooling strategies.
Conclusion:
The paradox between training and combat suggests adaptive exertion, passive cooling, and mission pacing help reduce EHI risk. Unlike training’s rigid protocols, combat conditions fostered a flexible yet effective approach. Logistical support— hydration, cooling, and environmental adaptations—proved essential, highlighting the need for adaptive, mission-driven heat mitigation strategies in military planning.

Background:
Exertional heat illness (EHI) is a major concern for military personnel operating in hot environments. In the Israeli Defense Forces (IDF), all service members with EHI undergo evaluation at the Institute of Military Physiology before return-to-duty (RTD) decisions. The IMP database records demographics, clinical presentation, risk factors, lab results, and RTD outcomes. From 2014 to 2021, RTD decisions were based on heat tolerance testing, whereas from 2022 onward, they have been physician-based.
Methods & Data Overview:
As of 2024, our database includes 686 evaluations: 474 from 2014–2021 and 212 from 2022–2024. This registry enables the identification of potential risk factors, risk markers, and biomarkers for heat intolerance (HI).
Findings:
We identified the lactate dehydrogenase to creatine phosphokinase (LDH/CPK) ratio as a potential risk marker for HI, with a higher ratio significantly associated with increased odds of HI (OR=3.35, 95% CI 1.74–7.95). Additionally, our analysis revealed an ethnicity-dependent association between creatine phosphokinase (CPK) levels and HI among the IDF Jewish population. Higher CPK levels were linked to increased odds of HI in Ashkenazi Jewish soldiers (OR=1.18, 95% CI 1.04–1.40) but were associated with decreased odds in non-Ashkenazi individuals (OR=0.33, 95% CI 0.04–0.82). Beyond biomarkers, we explored how the IDF Heat Illness Registry aids return-to-duty decisions after exertional heat stroke, optimizing safety and readiness. We also examined how registry data improves heat intolerance prediction, enabling early risk identification and prevention.
Conclusion & Future Directions:
The IDF Heat Illness Registry is a vital tool for identifying novel risk markers and improving our understanding of HI in military personnel. While CPK and LDH/CPK show promise as biomarkers, validation in larger cohorts is needed. Expanding research and collaborating with international military institutions, such as in the U.S., could refine these findings and enhance heat illness prevention strategies.

As climate change reshapes the battlefield, military operations are increasingly conducted in extreme environments, placing significant physiological demands on soldiers. This session features a TED-style panel with three medical officers from the battalion and brigade levels, sharing firsthand experiences from the IRON SWORD war. They will discuss how heat and cold exposure, sleep deprivation, nutrition, and physical exertion impact operational performance.
Heat stress is a critical factor in both dismounted ground forces and armored vehicle crews. Soldiers operating in high temperatures face dehydration, heat exhaustion, and reduced cognitive function, while armored crews in enclosed vehicles struggle with excessive heat buildup, leading to hyperthermia and impaired decision-making. Conversely, cold environments increase the risk of hypothermia, frostbite, and reduced dexterity, affecting combat effectiveness. Extreme weather events also disrupt logistics, delay medical evacuations, and impact sleep quality-leading to decreased situational awareness and performance.
Beyond the physiological burden on soldiers, the panel will address the medical officers’ challenges in balancing operational needs with health risks. They will discuss their role in guiding commanders on mitigating environmental stress while maintaining combat readiness.
By bridging battlefield experience with scientific inquiry, this panel will provide insights into improving soldier resilience and performance in the era of climatic change and highlight the need for future military collaboration.

Background:
Rising global temperatures pose significant challenges for outdoor physical activities, including military training, athletics, and manual labor. Heat stress increases the risk of exertional heat illnesses, necessitating accurate assessment tools to mitigate these risks. Traditional heat stress indices, such as the Wet Bulb Globe Temperature (WBGT), rely on outdated parameters and have limitations, particularly in high-altitude environments where black globe and wet bulb temperatures become unreliable. Additionally, current indices do not incorporate advancements in fast-response digital sensor technology and the role of ultraviolet (UV) radiation in thermal load assessment.
Purpose:
This study aims to develop a universally applicable and validated heat load index that incorporates real-time meteorological variables, including ambient temperature (Ta), relative humidity (RH), solar radiation (SR), and ultraviolet (UV) exposure. The new index seeks to provide precise, real- time guidelines for various exercise intensities, helping to prevent heat injuries and enhance operational safety for military personnel.
Methods:
The research follows a four-phase methodology. Phase I involves collecting meteorological data from three locations in Israel (-400m, sea level, and 2,000m) over six months, with measurements taken every 10 minutes. Phase II analyzes these data to construct a predictive heat load model. Phase III validates the model with additional data from locations in Israel and five in the United States, spanning various altitudes. Finally, Phase IV is a request for information (RFI) to develop a handheld device integrating the new index for field use. Conclusions/Possible Implementations:
The proposed heat load index will utilize fast-response digital microsensor technology to improve real-time heat stress assessment. Implementing this index can extend safely extend training hours. Military operations and other high-exertion activities will benefit from improved safety guidelines, reducing heat-related injuries and optimizing performance.

Background:
Exercise-associated hyponatremia (EAH) is a life-threatening medical emergency caused by excessive fluid intake exceeding fluid loss, inadequate sodium intake, and inappropriate ADH secretion. In the military, awareness of EAH is limited, as intense physical exertion-especially under environmental heat stress is more commonly associated with dehydration and exertional heat illness.
Purpose:
To highlight the danger of EAH among soldiers during military training in the era of climatic change.
Methods:
A retrospective follow-up was conducted on three young soldiers (ages 20–21), early in their service (<1 year), who collapsed with neurological symptoms after a field march. A week after collapse, a physician and dietitian interviewed them to document their medical history, including food and water intake.
Results:
The cases occurred during field marches (50 km, 15 km, and 19 km) under moderate to severe heat stress amid a heat wave in late July 2023. Soldiers were advised to "drink a lot," but food intake was limited, leading to low sodium consumption. Fluid and salt intake are summarized in the following table: (view in PDF only)
At the time of collapse, all three soldiers experienced headaches, dizziness, vomiting, and tonic-clonic seizures. Though initially suspected of exertional heat illness, their rectal temperatures were below 38°C. They were hospitalized for 2–5 days.
Conclusions:
The high awareness of possible dehydration and heat stroke while exercising in the heat has encouraged excessive fluid intake (water), which can lead to EAH. Improved educational measures should be implemented to increase awareness of EAH, emphasizing the importance of adequate carbohydrates, salt, and fluid intake before and during prolonged physical activities. This is particularly crucial in the context of climate change and global warming.

Soldiers operating in combat environments are exposed to intense physical, cognitive, and environmental stressors that challenge their endurance, resilience, and overall performance. Proper nutrition is essential for maintaining operational readiness, preventing performance decline, and reducing health risks such as dehydration, hyponatremia, and hypoglycemia.
This presentation will provide a structured approach to combat nutrition, detailing its implementation from training to battlefield operations, with key insights from the Iron Swords War. The discussion will cover essential nutritional strategies for both short-term, high-intensity missions (1–3 days) and extended operations. Emphasis will be placed on the role of strategic nutrient intake in sustaining physical and cognitive performance.
The lecture will also examine the operational nutrition protocol currently integrated into IDF combat units, focusing on its practical application, including pre-mission fueling, sustained energy intake during operations, and recovery nutrition post-mission. A core theme of this session is the "Train as You Fight" principle, underscoring the importance of nutritional preparedness during training to enhance soldiers’ adaptability in real combat scenarios.
Case studies from the Iron Swords War will highlight real- world challenges, such as inadequate food planning during prolonged marches, and demonstrate the necessity of structured dietary protocols. By bridging research-based insights with operational demands, this presentation aims to advance combat nutrition strategies that enhance soldier health, endurance, and performance in complex battlefield conditions.

In recent years, the IDF has expanded combat roles for female recruits, including positions in infantry and elite units. Given well-documented physiological differences between males and females—such as anthropometric traits, muscle and bone composition, and overall strength—the challenge lies in enabling female soldiers to successfully complete training while minimizing the risk of injuries. As part of the integration process of female soldiers into new infantry units, two pilot programs were initiated. We conducted a scientific study to accompany these pilots, closely monitoring soldiers using smartwatches and other physiological measurements throughout training. Physical and cognitive tests were performed at key time points, and physiological data were continuously tracked. Findings indicate that female soldiers demonstrated significant improvements in strength and fitness over a relatively short period, though they remained at a physical disadvantage compared to their male counterparts. Additionally, excessive marching distances and insufficient sleep appeared to contribute to a high incidence of overuse injuries.
In this talk, we will present the ongoing study, share interim results and key insights, and highlight emerging challenges. We will also explore potential opportunities for collaboration to enhance training methodologies and optimize female soldier integration in combat roles.

Introduction:
Female soldiers increasingly serve in physically demanding roles, yet military-issued equipment, including sports bras, is often designed without considering their specific physiological needs. Improper bra fit has been linked to breast discomfort, musculoskeletal strain, and potential impairment in operational performance. While extensive research exists on sports bra biomechanics in athletes, limited studies have addressed this issue in military populations. This study investigates the relationship between bra fit, breast discomfort, and performance limitations among female soldiers, with the goal of informing military procurement policies for improved support garments. This research aims to (1) assess the prevalence of breast discomfort and improper bra fit among female soldiers, (2) evaluate the impact of bra fit on physical performance and well-being, and (3) explore potential solutions to enhance comfort and readiness through optimized sports bra design.
Methods:
The study utilizes a mixed-methods approach, combining questionnaires assessing bra fit, discomfort levels, and perceived performance impact with anthropometric measurements of reported vs. actual bra sizes. Statistical analyses examine associations between bra fit accuracy, breast-related complaints, and operational performance indicators. Qualitative feedback provides insights into soldiers’ experiences and recommendations for improvement. Results:
Findings on the relationship between bra fit, reported discomfort, and physical performance limitations will be presented. Preliminary data indicate a significant mismatch between reported and measured bra sizes, with many soldiers experiencing avoidable discomfort affecting their daily tasks.

Introduction:
Women’s involvement in male-dominated environments has expanded worldwide over the last decades. Nevertheless, the basic needs of females in these environments are still overlooked. Female Advanced Life Support providers (FALSp) are among the first women to occupy combat positions in front-line troops. This study investigates the unique experiences and needs of FALS providers in maneuvering units of the Israel Defense Forces.
Methods:
Sixty female and forty male ALSp serving in combat units in Gaza between October 2023 and March 2024 enrolled in the study and were surveyed. Data on demographics, operational assignments, hygiene habits, gear suitability, health concerns, and emotional well-being were collected and analyzed. Results:
Nearly 75% of the FALSp that were mobilized to Gaza during the study period were surveyed. Female participants reported substantial challenges with hygiene and physiological needs, including 80% avoiding urination and 70% reducing fluid intake. Inadequately fitting protective gear was cited by most of women. women were less likely to distribute weight within their units. Emotional impacts included stress over familial responsibilities and reintegration into professional roles post-deployment. Despite these burdens, 88% of women felt secure among male colleagues.
Conclusion:
The findings underscore an urgent need for holistic strategies to support FALSp in austere, male-dominated combat settings. Key recommendations include developing gender-tailored protective gear, ensuring ready access to feminine hygiene products and appropriate medications, and implementing robust emotional and family support programs. These insights have broad relevance for other militaries and organizations where women increasingly serve in high-stakes operational environments

Background:
The day-to-day of physical and occupational therapy department of the IDF-MC is within military outpatient clinics and military bases throughout Israel. During wartime, firstly done on Operation Cast Lead, the physical therapy department treats patients in assembly areas alongside the day-to-day practice, this practice was also used during Iron Swords war, with constant improvement of treatment methods and modalities and on a significantly larger scale than before. During the war, physical therapists crossed into an active combat zone for the first time to provide treatment for troops.
Purpose:
The purpose of this study is to examine the work conducted during the first six months of war and to share findings and insights.
Methods:
A review of actions and decisions taken during the first months of the war and a retrospective study of computerized medical records throughout this period.
Results:
During those months, 13 thousand treatments were provided by 44 physiotherapists in all fronts, while maintaining day-to- day care.
Quick adaptation, continuous changes, and a solid framework for handling requests enabled the team to provide effective care. Factoring in limited information about the operators’ future activities, considered both placebo and nocebo effects, and maintained a clear indicator for returning to the mission- assessing whether they could operate with their MSK injury. Conclusions/ possible implementations:
The physical therapy department is a core component in the IDF-MC. There is a need for constant re-assessment and improvement of triage and treatment modalities, and operating with multiple entities to schedule treatment is redundant. Implementing a clear chain of command is essential.

Background:
Musculoskeletal (MSK) overuse injuries notably impact military readiness, with up to 75% affecting the lower extremities, primarily due to repetitive stress from weight-bearing activities. Anterior knee pain (AKP) and exercise-induced leg pain (EILP) affect up to 15% and 35% of army recruits, yet their etiology remains unclear. Diagnosis relies heavily on medical history, clinical evaluation, and exclusion of other conditions. Purpose:
This research aims to enhance military readiness by improving the diagnosis and prevention of knee and leg MSK overuse injuries.
Methods:
A retrospective study at the Combatant Health Center analyzed knee and leg overuse injuries in 7,611 soldiers, assessing physical, anthropometric, gait, and postural factors, with six- month follow-up on injury incidence and risk associations. Results:
Among 4,002 soldiers, AKP (14.3%, n=573) and EILP (10.5%, n=421) were highly prevalent during training, significantly linked to reduced performance, altered postural sway, and higher pain scores, straining military healthcare. Logistic regression identified predictors for AKP, including weight (OR=0.99, p=0.032) and grip strength differences (OR=1.03, p=0.042), and for EILP, bilateral anterior-posterior sway (OR=0.61, p=0.003) and bilateral medial-lateral sway (OR=1.82, p=0.004). However, the models explained only 0.6% and 1.0% of the variance.
Conclusions:
This study highlights the high prevalence of knee and leg injuries among soldiers, affecting a quarter of participants and posing significant medical and operational challenges. These injuries were associated with performance deficits, pain, and alterations in gait and balance. However, the predictive models demonstrated limited reliability, suggesting that additional, unexamined factors contribute to injury risk.

Background:
Musculoskeletal (MSK) injuries are common in the Israel Defense Forces (IDF), which places a significant burden on orthopedic clinics. However, most MSK injuries do not require consultation with an orthopedic surgeon, which can lead to excessive referrals for imaging, medications and more. To address these challenges, IDF Medical Corps has established a MSK clinic as an alternative to orthopedic clinics in order to provide more precise and higher-quality medical care for cases that do not require consultation with an orthopedic surgeon. This clinic is staffed by physiotherapists with specialized training and extended authorizations.
Purpose:
To compare the effectiveness of the MSK clinic with orthopedic clinics.
Methods:
We compared the number of sick-days, imaging referrals, medication recommendations, activity-limitation-days, and satisfaction survey between the general orthopedic clinic and the MSK clinic by examining the medical records of 450 and 297 sessions, respectively.
Results:
The referral rate for imaging was 36% in the general orthopedic clinic and 3% in the MSK clinic. The recommendation rate for medication was 29% and 3% respectively. The average sick-days were 0.93 days per visit and 0.03 days per visit, respectively, and the average activity-limitation-days were 6.67 days per visit and 1.65 days per visit, respectively. The satisfaction survey showed satisfaction rate regarding the factors attitude (73% and 76%), professional (57% and 76%) and recommendation (69% and 72%) between general orthopedic clinic and MSK clinic respectively.
Conclusions:
Musculoskeletal clinics enable higher operational readiness and cost savings for the IDF, as well as better medical service for its servicemen.

Introduction:
Wearable sensors offer valuable insights into physical behaviors, enabling personalized training loads and early detection of musculoskeletal injury (MSKI) risk. This study aims to integrate wearable devices for long-term monitoring of training loads in a military context and develop a predictive model for MSKI.
Methods:
This ongoing 5-year study involves 263 soldiers across five military training courses (paratroopers, n=42; infantry, n=83; navy, n=134 in three courses), each lasting 17-28 weeks. Continuous data were collected on heart rate, sleep patterns, distance covered, and stress levels. A machine learning algorithm was created to predict injury risk, with the model tested and refined three times across different courses. Results:
MSKI rates were high (~70%) across all courses, with soldiers regularly exceeding planned distances. Heart rate (HR) predominantly stayed in low zones, and sleep duration was insufficient across all courses. The predictive model achieved 83% accuracy in forecasting injuries one week in advance for the Navy SF 1st course (precision: 0.82, recall: 0.79, F1 score: 0.81). Injured soldiers showed significant differences, including lower normalized daily distance (p<0.001), more low-activity periods (p<0.001), shorter high-intensity activity duration (p<0.001), reduced sleep duration (p=0.02), more sleep interruptions (p=0.02), less REM sleep (p=0.02), and higher stress levels (p<0.01).
Conclusion:
Wearable sensors were successfully deployed in a military setting for continuous monitoring of training loads. The predictive model identified injury risk up to one week in advance, highlighting potential for injury prevention and optimized training. Further refinement is needed to improve model accuracy, with future studies focusing on load management and enhanced interdepartmental collaboration for soldier health and readiness.

Background:
Tunnel warfare has been one of the most complicated forms of combat while each tunnel presents unique challenges and potential surprises. Yahalom, a special engineering combat soldier unit, was established to fill the gap for subterranean warfare; however, understanding the psycho-physiological changes associated with the subterranean environment is yet limited.
Purpose:
To investigate the psychophysiological strain associated with performing military tasks in the SubT environments. Methods:
Twenty-six active duty Yahalom soldiers signed an informed consent form after the study protocol was approved by the IDF Medical Crops IRB Committee. The soldiers entered either a "linear-type" or a "metro-like" training SubT facility. Environmental conditions were monitored for O2, CO2, temperature, and humidity. Before entering the SubT and after exiting the SubT, they underwent cognitive tests using the Flanker task, and collected the subjective measures of anxiety (VAS, visual analog scale), and rate of perceived exertion (RPE). Physiological measures included blood lactate levels, continuous heart rate (HR) monitoring, and gas exchange (VO2, VE) using the K5 device (COSMED).
Results:
HR was significantly increased from 115±8 b/min to 162±10 b/min during the SubT activity, VE was 67±9 l/min, and VO2 2201±479 ml/min which is equivalent to 31 ml/kg/min. Anxiety, VAS scale and Flanker test were not significantly changed. Blood lactate, however, was 7.2±3.5 mmol during the SubT, and remained at 4.8±1.9 even 10 minutes after exiting the SubT.
Conclusions:
Both objective (HR, VO2, VE) and subjective (RPE, VAS) measures of exertion reflect low aerobic strain under a training SubT compound. However, lactate levels were significantly elevated and remained high even during 10 minutes of recovery. No substantial differences were observed between the linear tunnel and the metro one. Additional experiments are warranted to elucidate the anaerobic strain during SubT activities.

Background and purpose:
On October 7, 2023, the terrorist organization Hamas launched a deadly attack on Israel. These attacks marked the start of the Swords of Iron War (SOI), which included a southern ground maneuver beginning on October 27, 2023, and a northern maneuver on October 1, 2024. The southern front involved heavy vehicle activity (tanks and APCs), while the northern front was primarily infantry-based. This study reports injury patterns and medical interventions of both fronts.
Methods:
This retrospective, registry-based analysis examined casualties from the SOI War (October 2023 – December 2024). Prehospital data were obtained from the IDF Trauma Registry, and in-hospital data from the Israeli National Trauma Registry. Southern and northern front characteristics were compared using chi-square or Fisher’s exact test for categorical data and Student's t-test or Mann-Whitney test for continuous data. Results:
4,626 casualties were recorded, with 4,000 from the southern front and 626 from the northern front. Extremity injuries were the most common, with similar rates on both fronts (63% southern; 64% northern; p=0.5), followed by torso injuries (24% southern; 24% northern; p=0.9). Explosions with shrapnel were the primary injury mechanism (78% southern; 83% northern), followed by gunshot wounds (22% southern; 17% northern; p=0.024). Tourniquet application was the most common life-saving intervention (14% southern; 13% northern; p=0.7), followed by whole blood transfusions (6.1% southern; 4.6% northern; p=0.2). Chest decompression (1.2% southern; 0% northern; p=0.007) and endotracheal intubation (2.4% southern; 0.5% northern; p=0.002) were infrequent. Conclusion and Discussion:
Despite differences in combat environments, injury patterns and life-saving interventions were similar between both fronts in SOI War. The predominance of extremity and torso injuries, particularly from shrapnel, suggests a continued need for medical focus on hemorrhage control. Tourniquets and blood transfusions were the most frequently performed life-saving interventions, emphasizing the importance of hemorrhage control strategies in modern combat medicine.

Background and Purpose:
Recent evidence supports prioritizing blood product resuscitation over early airway and chest interventions in trauma care. In response, on April 30, 2024, the Israel Defense Forces (IDF) Medical Corps released new clinical practice guidelines that limit the indications for definitive airway management and chest decompression. This study evaluates the implementation and impact of these protocol changes during the recent ground operation in Gaza.
Materials and Methods:
This retrospective, registry-based study analyzed all IDF casualties injured during the Swords of Iron War ground maneuver (October 27, 2023 – November 30, 2024). Data were extracted from the IDF Trauma Registry and the Israeli National Trauma Registry. To evaluate trends in airway management and chest decompression procedures following the guideline update, prehospital interventions were compared across four time periods: October 27, 2023, to January 31, 2024 (Period 1); February 1, 2024, to April 30, 2024 (Period 2); May 1 to August 31, 2024 (Period 3); and September 1 to November 30, 2024 (Period 4).
Results:
A total of 3,984 casualties were analyzed across four periods. Of them, 2,328, 459, 819, and 378 in periods 1 to 4, respectively. Injury characteristics and mortality rates remained stable (p>0.05). Still, the proportion of casualties undergoing endotracheal intubations or cricothyroidotomy decreased progressively: 3.8%, 2.8%, 1.2%, and 0.8%, respectively (p<0.001). Similarly, needle or chest tube decompressions were performed in 2.8%, 3.1%, 0.9%, and 0.0% of casualties, respectively (p<0.001). Blood product administration rates remained unchanged at 7.8% (p=0.8).
Conclusion:
The marked reduction in prehospital airway and chest decompression interventions demonstrates the feasibility of implementing clinical protocol changes during wartime. These findings underscore the potential for evidence-based guidelines to optimize trauma care even in the challenging conditions of active conflict.

Introduction:
Accurate triage of trauma casualties is one of the most significant challenges faced by pre-hospital providers. The allocation of resources, as well as tactical decisions regarding the use of aerial and ground evacuation forces, depend on the clinical status of the casualty—an assessment that is not always straightforward. Failure to correctly identify casualties in need of life-saving interventions can lead to poor clinical outcomes and, in battlefield settings, may result in preventable deaths.
Methods:
This retrospective, registry-based analysis examined casualties injured during the Swords of Iron War (October 2023 – December 2024). Prehospital data were extracted from the Israel Defense Forces Trauma Registry, while in-hospital data were obtained from the Israeli National Trauma Registry. The study included casualties who exhibited no clinical signs of hemodynamic compromise in the prehospital setting, had no significant head injury, and were not treated with blood products. Patients with favorable outcomes were compared to those with unfavorable outcomes, defined as requiring a blood transfusion in the emergency department, undergoing urgent surgical intervention, having an Injury Severity Score (ISS) greater than 16, or dying.
Results:
A total of 4,295 casualties met the inclusion criteria—showing no clinical signs of shock, not receiving blood product transfusions, and not suffering significant head injuries. Among them, 182 experienced unfavorable outcomes and, in retrospect, should have received more aggressive treatment in the field.
Casualties with unfavorable outcomes were twice as likely to have sustained firearm injuries (22% vs. 11%, p<0.001), torso injuries (35% vs. 16%, p<0.001), or pelvic injuries (15% vs. 6.2%, p<0.001).
Discussion:
Current clinical practice guidelines for combat casualty care in the Israel Defense Forces (IDF) rely primarily on vital signs and other surrogates of hemodynamic compromise. While these indicators have a relatively strong positive predictive value, their negative predictive value—particularly when measured shortly after injury—is debatable.
A data-driven reassessment of clinical practice guidelines, incorporating injury mechanism and field assessment of injury location, may improve patient selection for life-saving interventions and optimize resource allocation.

Background and Purpose:
After controlling hemorrhage, volume resuscitation is the most critical component in managing bleeding casualties. The IDF Medical Corps (IDF-MC) has utilized Freeze-Dried Plasma (FDP) as its primary resuscitation fluid since 2013. During the Swords of Iron (SOI) War, Low Titer O Whole Blood (LTOWB) was introduced across all ground and aerial evacuation platforms, making it the most widely used resuscitation product. While blood products are superior to crystalloids, limited data compare LTOWB to FDP alone. This study evaluates the impact of LTOWB compared to FDP on survival outcomes in combat casualties.
Methods:
This retrospective analysis included combat casualties from October 2023 to December 2024 who received prehospital blood product resuscitation. Data were extracted from the IDF-MC Trauma Registry and the Israeli National Trauma Registry. Casualties were categorized by blood product received: LTOWB alone, FDP alone, or both. A multivariable regression analysis assessed the association between blood product type and mortality.
Results:
A total of 380 casualties received prehospital blood products. Among them, 233 casualties (61%) received LTOWB, 77 casualties (20%) received FDP, and 70 casualties (18%) received both. Casualties treated with LTOWB were more likely to exhibit signs of shock prior to treatment compared to those treated with FDP (58% vs. 47%, p=0.2) and were more likely to have severe injuries (ISS ≥16, 69% vs. 47%, p=0.024). Despite greater injury severity, casualties treated with LTOWB had lower mortality than those treated with FDP (22% vs. 34%, p=0.045). In multivariate regression analysis, adjusting for prehospital shock, LTOWB was independently associated with a lower mortality rate than FDP (OR=0.31, 95% CI=0.15-0.63). Conclusions and Discussion:
Introducing prehospital whole blood represents a major advancement in combat casualty care. This study provides combat-setting evidence that LTOWB improves survival compared to FDP, even in more severely injured casualties. These findings reinforce whole blood as the optimal resuscitation fluid for battlefield trauma, highlighting the need to overcome logistical barriers to its widespread implementation.

Battlefield injuries pose a significant challenge. These injuries often involve extremely high energy, making them more likely to be life-threatening and necessitating aggressive treatment and rapid casualty evacuation. While they create significant clinical challenges, they also present tactical difficulties. Several of these challenges will be discussed.
First, to push advanced medical care as close as possible to the point of injury, the Israeli Defense Forces Medical Corps has assigned advanced life support providers at the company level. While this allows for rapid, advanced medical care, careful consideration is required regarding mobilization, tactical training, and the positioning of these providers. Second, evacuation platforms vary considerably, ranging from fast, wheeled, non-protected vehicles to heavily tracked, well- protected armored personnel carriers capable of reaching casualties under fire. Assigning the appropriate platform based on the tactical scenario while ensuring high-quality medical care end route presents another significant challenge. Third, decisions regarding the use of static facilities-such as a Role 1 battalion aid station or a Role 2 facility, including a forward surgical team-demand careful consideration.
Fourth, accurate casualty assessment and the allocation of appropriate resources, as well as evaluating the risk to both ground and aerial casualty evacuation teams, are critical decision points for medical and tactical commanders. These decisions often require data that may not always be available. Finally, the use of whole blood as a key component in combat casualty care requires a carefully maintained and effective cooling chain, which can also create tactical dilemmas.

Background and Purpose:
Traumatic brain injury (TBI) is the hallmark injury of modern warfare and a leading cause of morbidity and mortality among military personnel. Understanding evolving combat trends and their impact on injury severity is essential for informing prevention and management strategies. This study examines the epidemiology, injury characteristics, and treatment of hospitalized IDF soldiers with head injuries during the Swords of Iron (SOI) conflict.
Methods:
This registry-based study analyzed data from the IDF Trauma Registry and the Israel National Trauma Registry. The cohort included all military personnel hospitalized with head injuries (Abbreviated Injury Scale [AIS] ≥1) during the SOI conflict (October 2023–January 2024). The study examined injury patterns, severity (Injury Severity Score [ISS]), prehospital interventions, and short-term outcomes.
Results:
Among 385 hospitalized soldiers (median age: 22 years, 99% male), 72% suffered blast injuries, 9% had gunshot wounds, and 81% experienced penetrating trauma. A total of 116 (30%) had an ISS of 25 or higher, and 70 (18%) had an ISS between 16 and 24. In the prehospital setting, 17% received whole blood or freeze-dried plasma, and 23% were administered TXA. Upon hospital admission, 77% had a Glasgow Coma Scale (GCS) score of 15, while 18% had a GCS of 8 or less. Severe head injuries (AIS ≥3) were documented in 216 (56%) patients, of whom 112 (52%) had isolated head trauma. Thoracic (28%) and facial (23%) injuries represented the most common severe associated injuries. Profound shock was noted in 25% of these cases. Among those with severe head injuries, 53% were discharged home, 37% to rehabilitation, and all in-hospital mortality cases (n=27, 13%) occurred within this group. Conclusions and Discussion:
The predominance of blast-related head injuries aligns well with epidemiological trends observed in recent U.S. military conflicts. While a considerable proportion of patients received whole blood, FDP, or TXA in the prehospital setting, these interventions were primarily administered to those with severe systemic and head injuries, limiting our ability to assess their potential link to patient outcomes. Further research is required to determine the effectiveness of early blood product administration and the role of advanced battlefield protective gear and evolving combat tactics in mitigating TBI.

Background and Purpose:
Medical documentation in battlefield conditions remains challenging for military medical teams. Past conflicts, including U.S. Army operations in Afghanistan and Iraq, saw prehospital documentation rates at only 18-25%, while the IDF’s 2014 Gaza operation recorded rates as low as 11%. During the Swords of Iron War, the IDF Medical Corps implemented a new digital documentation system, which has been significantly refined and continues to evolve. This study examines the system’s achievements and its upcoming next-generation platform. Methods:
This registry-based study analyzes data from the IDF Trauma Registry between October 2023 and October 2024. Data include casualty demographics, event characteristics, medical treatments, and evacuation details. Prehospital documentation was categorized into digital vs. non-digital. Results:
In one year of intense warfare, the IDF recorded 5,058 casualties, with 1,627 (32%) having pre-hospital digital records. Of these, 1,175 were cross-referenced with the IDF Trauma Registry. Most (99.3%) were male soldiers from conscript (48.4%), reserve (42.3%), and career (9.3%) units. Injury patterns reflected broader casualty trends, with explosions (60%) as the leading cause and injuries mainly to the extremities (37% upper, 35% lower), face (27%), and torso (24%). For those with digital records, 15% involved three or more body regions, and 58% were urgent. Digital documentation correlated with higher battlefield interventions, like tourniquet application (15% vs. 13%), blood product administration (11.3% vs. 8%), and air evacuation (55% vs. 32%) compared to non-digital cases.
Conclusion:
The Swords of Iron War marked a significant advancement in battlefield medical documentation, leading to improved continuity of care, enhanced medical handoffs, and better post-event analysis. While digitally documented casualties closely resemble the general injured population, they are more likely to receive treatment on the battlefield and undergo air evacuation. The next-generation digital documentation system will integrate continuous vital sign monitoring and real-time data transmission, transforming battlefield medical decision-making and evacuation triage.

Introduction:
Rapid and accurate physiological monitoring is critical for battlefield trauma care, yet current systems rely on intermittent assessments rather than continuous real-time data. Wearable sensor technologies offer a potential solution, but their adaptation to field conditions remains challenging. This study evaluates a novel sensor system initially designed for telemedicine, focusing on its adaptability, usability, and real-world performance in military trauma scenarios. Materials and Methods:
Military medical teams received structured training on the sensor system and prospectively evaluated it during simulated and real-world casualty evacuations. A comparative analysis was conducted against standard monitoring devices, measuring key physiological parameters like blood pressure, heart rate, and oxygen saturation. Usability and operational feasibility were assessed using quantitative performance metrics and structured feedback from field personnel. Key failure points, including connectivity, stability, and interface usability, were scrutinized to identify barriers to deployment. Results:
The wearable sensor was used by nine medical teams, in various simulated (80%) and real-world operational (20%) scenarios, yielding over 70 cases with confirmed physiological readings. Continuous monitoring in field environments was achieved in 44.7% of the cases, whereas single reads were achieved in 82.9% of the cases. The sensor’s blood pressure, heart rate, and oxygen saturation measurements were consistent with standard monitoring devices. However, operational challenges included signal disconnections in high-motion settings and discrepancies in user interface expectations between telemedicine and battlefield medical workflows. Field personnel identified three main areas for improvement: signal robustness, hands-free operation, and integration with existing combat medic workflows. Conclusions:
This study shows that wearable sensor technology is feasible for trauma monitoring in military settings, but modifications are needed to ensure seamless data accessibility and integration. Future efforts should emphasize enhancing real- time data transmission, improving ruggedness for extreme conditions, and incorporating artificial intelligence-driven early warning systems to optimize decision-making in battlefield trauma care.

Background:
On October 7th, Israel endured an unprecedented attack, marked as the deadliest day in its history, resulting in 1145 deaths (most of them civilians), over 1941 injuries and 253 individuals kidnapped to Gaza. The orchestrated attack unfolded simultaneously across over 60 locations. The escalating number of injuries, continuous rocket fire, and pervasive terrorist presence especially when tactically blocking evacuation routes and perilous conditions necessitated urgent, adaptable approaches to manage the crisis effectively. In response to the heinous attack, Military and civilian forces arrived independently or as organized units to the combat zones. There, they coalesced and established casualty collection points to provide initial lifesaving treatment and facilitate their evacuation to hospitals. Objective:
To characterize the key principles contributing to mass casualty incident (MCI) management
Methods:
A retrospective review with senior medical providers and medical scene commanders who managed and treated casualties at MCI, to identify the unique command factors that facilitated effective incident.
Results:
The most important principle is unified and clear command, with standardized protocols for all forces. When dealing with non-organic forces working together, conducting detailed briefings enables synchronized and efficient work by the entire medical team.
Additionally, formulating accurate situational awareness, including understanding the battle zone, anticipating casualties, evacuation capabilities, and existing medical equipment, are critical for proper utilization of resources during MCI management.
The location of the casualty collection point has great importance and should consider the distance from the combat zone, convenient and relatively safe evacuation route and the possibility of establishing a temporary landing pad. Choosing the right location can improve both treatment and evacuation.
Conclusion:
October 7th terrible events highlighted the essence of MCI management. The main principles in commending MCI are uniformity and synchronization between all the medical and operational forces, continuous briefing, formulating situational awareness and choosing the correct location for casualty collection point.

Introduction:
During the Swords of Iron War, the Israel Defense Forces (IDF) faced complex and high-threat environments, resulting in a significant number of mass-casualty events (MCEs). Understanding the injury patterns and medical response during MCEs is critical for optimizing battlefield trauma care and resource allocation. This study characterizes MCEs and examines the treatment provided in combat settings. Methods:
This retrospective registry-based analysis included casualties injured during the Swords of Iron War between October 2023 and November 2024. Data extracted from the IDF Trauma Registry and the National Trauma Registry included population, injury, event characteristics, prehospital treatment, and data regarding mortality. Casualties were grouped by the number of casualties involved in an event (Group A: single casualty, Group B: two to three, or Group C: greater than three casualties), and injury patterns were compared accordingly.
IDF Advanced Life Support (ALS) providers are positioned at Role 1, responding within 1-4 minutes of an event.
Results:
A total of 5,474 casualties from military events were analyzed. Of these, 1,931 (35%) were single-casualty events, while 2,349 (43%) were involved in MCEs with four or more casualties. MCEs were significantly more likely to result from explosions (69% vs. 29% in single-casualty incidents, p<0.001) and had higher rates of multi-region injuries (29% vs. 5.6%, p<0.001). Casualties in MCEs had significantly higher injury severity (ISS>15 in 26% vs. 16.4%, p<0.001) and higher mortality rates (15% vs. 4.1%, p<0.001). Hemorrhagic shock was three times more common in MCE casualties (18% vs. 6.1%, p<0.001). Yet, blood product administration rates declined as the number of casualties per event increased (47% in single-casualty incidents, 37.6% in 2-3 casualty events, and 26.3% in MCEs, p<0.001). A similar trend was observed for TXA administration (35% in single-casualty incidents, 34% in 2-3 casualty events, and 24% in MCEs, p<0.001).
Conclusion:
MCE in the Swords of Iron War saw high explosive-related injuries, increased battlefield mortality, and more severely injured casualties. Blood product and TXA administration rates dropped as casualties rose, indicating resource limitations and triage challenges. These findings highlight the need for better battlefield medical strategies, improved resource allocation, and optimized hemorrhage control protocols to enhance survival in MCEs.

Introduction:
On October 7, 2023, Hamas and several other Palestinian terrorist groups launched coordinated armed incursions from the Gaza Strip into southern Israel, attacking both civilian and soldiers population. The 51st battalion was assigned in Kissufim base that day, and its soldiers were the first to fight against the terrorists. Dr Gilor, as the battalion surgeon, accompanied by his wife Dr Gutman- Gilor, also a battalion surgeon, treated dozens of military casualties in the operation center of the base, becoming one of the mass casualty incidents of that day.
Methods:
The medical personnel during the mass casualty incident were two physicians and three combat medics. The operation center was used as an improvised casualty collection point, and it was divided into two separate parts (soldiers who required resuscitative measures and the other for the rest). The team had the standard equipment for an infantry medical team, including 2 endotracheal intubation kits, 1 cricothyroidotomy kit, 2 chest tube kits and 2 dried plasms bottles. The casualties presented different types of injuries: penetrating head injury, penetrating chest and abdomen injury, shrapnel wounds, blast injuries and combat stress reaction. Evacuation wasn’t possible for more than two hours due to presence of terrorists on the main roads. When it became possible, the evacuation was performed using non-medical armored vehicles and without any medical escort, except one intubated patient who was escorted by a combat medic.
Results:
All the casualties were evacuated successfully, only one died later at the hospital ER.
Out of the casualties, only one wasn’t physically injured and had only a temporary combat stress reaction. Many of the casualties who suffered from massive external limb hemorrhage treated themselves with CAT tourniquet applications. Two soldiers had penetrating head injury and one of them was intubated and ventilated. Three soldiers had a penetrating chest injury and one of them had a chest tube. Two soldiers were in a deep hemorrhagic shock and one of them received one plasma bottle.
Conclusion:
Managing mass casualty incidents with limited resources can lead to extreme workload on the medical team. In this case, the presence of two physicians allowed every casualty better treatment. Moreover, the soldiers’ tourniquet applications skills had a major role in treating bleeding casualties who were not able to reach the casualty collection point.

Introduction:
Understanding the causes of death among military personnel is critical for improving battlefield medical care, forensic identification, and future preparedness. The events of the "Swords of Iron" war presented unique challenges, requiring adjustments in forensic procedures and casualty management. This review outlines IDF fatality processing across three key periods: routine evaluations before October 7th, the mass casualty incident on October 7th, and the fatalities sustained during the "Swords of Iron" war. Pre-October 7th: Routine Forensic Evaluations:
Before the war, fallen IDF personnel underwent structured forensic examinations at the "Shura" victim identification facility. The standard process included external examination, forensic pathologist and dental assessments, and documentation for official identification.
The October 7th Mass Fatality Incident:
The Hamas attack on October 7th resulted in the deaths of over 300 IDF soldiers and many hundred civilians, overwhelming Israel’s forensic capabilities. In response, the IDF’s technological and logistics directorate assembled emergency forensic teams, including physicians, dentists, radiology and DNA technicians, and other specialists dedicated for IDF fatalities. These teams processed 414 victims in the first week, conducting postmortem CT scans on 308, collecting dental imaging for 300, DNA samples for 356, and fingerprint records for 326. Despite the absence of professional forensic pathologists, rapid identification efforts were crucial in managing the unprecedented scale of fatalities.
The “Swords of Iron” War Fatality Analysis:
From October 27, 2023 (beginning of ground maneuver), IDF fatalities were examined at “Shura”. Each case underwent external examination, forensic documentation, and postmortem imaging, with findings integrated into the IDF Trauma Registry. An expert review assessed causes of death, preventability, and survivability, contributing to ongoing improvements in combat casualty care.
Conclusion:
The evolving nature of military conflict necessitated adaptations in forensic procedures and casualty management. Lessons learned from these events will help refine future battlefield medical and forensic capabilities.

Introduction:
Understanding combat fatalities is crucial for enhancing battlefield survivability and minimizing preventable deaths. This study examined the causes of death and potential survival opportunities among Israel Defense Forces (IDF) personnel during the Swords of Iron War.
Materials and Methods:
All IDF fatalities from October 27, 2023, to September 17, 2024, were processed at the Victim Identification Center. Cases underwent external examinations, written and visual documentation, and post-mortem computed tomography. The data were integrated into the IDF Trauma Registry, and a multidisciplinary expert review panel evaluated the causes of death, preventability, and survivability. Based on injury patterns and the medical interventions available at the time of injury, fatalities were categorized as either non-survivable/ non-preventable or potentially survivable/preventable. Results:
A total of 310 fatalities were analyzed, with 227 (73.2%) cases fully examined and 83 (26.8%) pending review. The vast majority of cases, 295 (95%), were classified as KIA, while 15 (4.8%) were categorized as DOA. Among the examined cases, 216 (95%) were deemed non-survivable or non-preventable, while 11 (4.8%) were identified as potentially survivable or preventable. Explosive trauma accounted for 64% of cases, followed by firearm injuries at 30%. The injury severity was high, with 199 fatalities (71%) having an Injury Severity Score (ISS) of 25 or higher. The leading causes of death were devastating head injuries (44%), total disintegration or severe burns (21%), and major thoracic vascular injuries (15%). Although rare, potentially preventable causes include airway injuries and tension hemopneumothorax, with one case identified in each category.
Conclusions:
In the past decade, the IDF Medical Corps has implemented a strategic force buildup plan that reduced preventable death rates from 25% to 4.8%. This is shown by decreased battlefield mortality and case fatality rates (CFR), highlighting effective combat medical interventions and strategies. While these gains have saved lives, more can be done to reduce preventable deaths. Key focus areas are refining trauma protocols, improving medical training in hemorrhage control, airway management, and resuscitation, and enhancing protective equipment against trauma. This study underlines the need for ongoing research, data-driven policy updates, and operational enhancements to improve battlefield survivability care.

Introduction:
The multi-arena conflict resulted in multiple casualties evacuated by aeromedical platforms to civilian level 1 trauma centers. To avoid specific center from being over-whelmed, the Israeli Defense Force Medical Corps (IDF-MC) regulates evacuation destination to balance casualty clinical status, evacuation times and trauma center burden. Near Front Line Medical Centers (NFMCs) are reserved for high-risk casualties rather than default destinations. This study evaluates the impact of this strategy on quality of care and patient outcome. Methods:
This retrospective analysis included all helicopter-evacuated casualties during the Swords of Iron War (October 27, 2023 – January 22, 2025). Prehospital data were extracted from the IDF-Trauma Registry, and in-hospital data from the Israeli National Trauma Registry (INTR). Destination accuracy (Default vs. NFMC) was assessed using prehospital and injury attributes (signs of shock: systolic blood pressure [BP] < 90 mmHg or non-palpable radial pulse or depressed consciousness without traumatic brain injury, injury severity score [ISS], prehospital interventions) and trauma bay indices (BP, heart rate, transfusion, surgery).
Results:
Overall, 1,714 casualties were evacuated: 595 (34.7%) to NFMCs and 1,119 (65.3%) to default centers. In both groups, the predominant mechanism of injury was penetrating trauma (83%). NFMC casualties had higher proportion of critical injuries (ISS ≥ 25: 29% vs. 9.5%, p<0.001), signs of profound shock (29% vs 8.9%, p<0.001), more likely to receive blood products and prehospital interventions. In the ED, NFMC casualties had higher rates of hypotension (7.3% vs. 2%, p<0.001), blood product usage (32% vs. 10%, p<0.001) and surgery in the first hour (laparotomy/thoracotomy: 12% vs. 4.3%, neurosurgery: 3.4% vs. 0.4%, both p < 0.001). Overall mortality was higher in NFMCs (11% vs. 2.9%, p<0.001). Conclusions:
The increased severity of prehospital and trauma bay indices among casualties evacuated to NFMCs is consistent with an aeromedical evacuation strategy that successfully prioritized high-risk casualties, ensuring that less critically injured patients were appropriately triaged to default trauma centers. This strategy likely reduced hemodynamic compromise upon admission, optimized trauma bay resource utilization, and maintained quality of care without overwhelming individual hospitals. This offers a well-balanced aeromedical evacuation strategy applicable to future conflicts.

The lecture will give a glance from above at the different considerations dictating the identification procedures of casualties in the IDF in the Iron Swords war.
It will discuss the operational, scientific religious, cultural and historical influences on identification, and the main goals of the process. The lecture will also give examples of problems in the process and what steps needed to be taken in order to solve them in field.

The IDF’s Forensic medicine and identification unit played a crucial role in the “Iron Swords” war, managing a significant number of casualties under exceptionally challenging conditions.
Throughout the conflict, the unit faced an unprecedented scale of fatalities, many with severe and complex injuries that posed significant challenges to forensic identification and the determination of mechanisms of death. Prior to the war, training scenarios had been based on handling up to 30 casualties per day; the realities of “Iron Swords” far exceeded these expectations.
This lecture will provide an in-depth examination of the unit’s deployment since October 7th, tracing its evolving responsibilities over time. It will explore key identification efforts conducted both within Israel and beyond enemy lines to recover missing personnel, as well as forensic operations related to casualties from military maneuvers in Gaza and along the northern borders.
The lecture will also address the establishment of a second forensic identification center in northern Israel and the operational challenges of managing two facilities with the same limited resources.
Additionally, the lecture will highlight strategies for maintaining mental resilience and professional efficacy after 15 months of sustained, high-intensity forensic work.

The lecture will detail the dental identification techniques used during the Iron Swords War, including:
• Identification through conventional methods: PA X-rays
and full-mouth status radiographs.
• CT scans performed in forensic centers, converted into 2D
panoramic images and compared to existing panoramic
or status X-rays in 2D.
• Comparison of 3D CT scans to 3D images taken during
life, for casualties who experienced significant dental
changes.
• Development and utilization of independent comparison
software leveraging AI during combat, adapted to various imaging types – PA, panoramic, and CT.

Background:
The Center of Biometric Technology and Innovation is the sole responsible for the identification of the military personnel using biometric means.
The Center of Biometric Technology and Innovation was in the forefront of the identification of the deceased from the events of the terror attack during October 7th, identifying both the military personnel and civilians.
Purpose:
This presentation will be focusing on the history of the Center, use cases we had been involved with (including October 7th), the difficulties of identifying the deceased and the future of the Center.
Methods:
The methods explored in the presentation will be mainly fingerprint identification through different conditions such as burnt, rigor mortis and rotting.
Results:
We’ll present the results of our work and methods to extract latent fingerprints through the different conditions and the identification process that helped us keep the remarkable over 97 percent identification rate of the IDF’s deceased and the 99 percent identification of the October 7th terror attack victims.
Conclusions:
Will conclude the presentation going more in detail into the identification of the victims of October 7th. Taking it as a case for the use of biometrics for military identification even under the hardest of conditions the victims and the environment (desert, urban, combat)

The lecture will highlight the activities of the Genomic Center for Casualties Identification under the Chaplaincy Corps, focusing on its operations on October 7th, 2023, and in the sequential period. It will explore the challenges of DNA identification detailing the grim progression from analyzing fresh samples to decomposed samples, then to fresh bones and teeth and ultimately to highly degraded bone samples. Additionally, the lecture will address the centers’ role in the effort to locate missing persons inside and outside the borders of the country, the significant amount of evidence retrieved from hostile homes in the Gaza Strip and war tunnels.
Mass casualty events during the war, such as the explosion of a demolition truck, highlighted the urgent need for extremely quick and accurate identification. In one instance, the task was to identify six presumably missing soldiers from various small remains as quickly as possible, ensuring no soldiers were missing and enabling the army to notify families and deliver the devastating news. In this case, the genomic center successfully generated profiles from several samples in just three hours, providing definite proof of death for all six presumably missing soldiers. Following this, the team processed more than 200 samples in 24 hours, enabling timely burial, with each coffin containing the appropriate remains. Another scenario, at the Shifa Hospital, is an example of large-scale corpse sampling and identification in an effort to locate missing Israeli citizens – a true ‘needle in the haystack’ challenge. Similarly, the “Yemen Field” operation involved sampling more than 1500 terrorist bodies in advanced stages of decomposition, driven by the hope of finding even one missing individual. The Genomic Center demonstrated remarkable technological advancement during the war, including the acquisition of wartime validation of rapid identification systems such as ANDE and RapidHIT. These systems enabled the rapid identification of challenging samples under critical conditions. On the Northern front, the Genomic Center established the Tsiporit Rapid DNA Identification outpost during the war. Equipped with two RapidHIT machines, this facility was capable of handling smaller scale events locally, eliminating the need to transfer bodies or samples to the main Genomic Center in Shura.

Forensic DNA analysis faces critical challenges in handling low-quality and degraded samples, limiting the reliability of traditional short tandem repeat (STR) profiling. Here we present an innovative approach leveraging Nanopore sequencing for single nucleotide polymorphism (SNP) profiling, combined with STR, addressing these limitations. Our project integrates advanced bioinformatics, wet- lab experimentation, and engineering to develop a comprehensive system for DNA extraction, quantification, and profiling. Nanopore sequencing enables real-time analysis of DNA fragments, preserving critical genetic information from degraded samples and enhancing accuracy. We are also developing a microfluidic device for streamlined sample preparation, aiming for rapid, robust, and field-deployable solutions. This multidisciplinary effort lays the groundwork for a transformative forensic workflow, capable of achieving precise individual identification from challenging biological evidence, expediting forensic investigations, and paving the way for future advancements in forensic genomics.

This lecture will explore the intricate collaboration efforts within Unit 6017, the Unit for Identification and Investigation of Mortality Circumstances, which have been crucial for the effective execution of IDF casualty identification processes throughout the various stages of the Iron Swords War.
The presentation will begin by examining the coordination required for the identification of casualties from October 7th. Key collaborative efforts included coordination with the Missing Persons Unit, the ITAN Unit, the IDF Rabbinical Corps, the Israel Police, as well as the Israel Dental Association. Next, the lecture will discuss the processes involved in the identification tasks at the Shura and Zipporit mortuary facilities. These tasks required a highly coordinated workflow with multiple entities, including the IDF Rabbinical Corps, the Israel Police, the Operations Directorate, the National Institute of Forensic Medicine, the Casualties Branch, and the Operational Medicine Branch. In scenarios of complex cases or high-intensity casualty influxes, ongoing synchronization and fine-tuning of collaborative frameworks were essential to ensure precise and high-quality identification.
The lecture will also cover additional collaboration efforts, including the partnership with the IDF Spokesperson's Unit, which was instrumental in conveying the horrific massacre to the world. In addition, collaboration with mental health professionals focused on ensuring the resilience and well- being of the unit’s personnel.

The Iron Swords War presented unprecedented challenges in the organization and operation of forensic examination teams tasked with the dignified and accurate handling of fallen soldiers. This lecture will delve into the logistical, ethical, and operational hurdles encountered during the forensic external examination and postmortem computed tomography (CT) interpretation of Israel Defense Forces (IDF) casualties. Attendees will gain insights into the multidisciplinary coordination required, the integration of advanced imaging technologies, and the protocols established to ensure both medical precision and respect for the deceased. By reflecting on these experiences, the session aims to provide valuable lessons for medical officers involved in military and disaster forensic operations.

The "Iron Swords" war began with a Hamas attack on Israel, leading to significant civilian casualties and over 900 military fatalities. This conflict necessitated the full activation of Unit 6017, the Israeli Defense Forces casualty identification unit of the medical corps, together with the casualty unit of the military rabbinate, responsible for both casualty identification and operational investigation. While existing literature predominantly focuses on the ethical aspects of casualty identification in civilian contexts or mass disasters, this lecture uniquely explores the ethical considerations specific to Unit 6017’s operations during the "Iron Swords" war, including the integration of operational investigation with standard bioethical concerns and Jewish laws.
The lecture reviews the medical, ethical, and operational principles guiding the casualty identification process and the investigation of death circumstances, using Unit 6017's role in the "Iron Swords" war as a case study.
Unit 6017 operates under medical ethics, religious ethics principles, such as respect for the deceased and the family's rights, while also adhering to IDF values, necessitating operational investigations that may delay funerals and pose risks to the unit in complex situations.
The unit's work requires balancing ethical principles with military obligations, especially in challenging scenarios involving medical investigations, informed consent, staff safety, and timely burial.
This lecture examines how Unit 6017 navigated the ethical complexities of its dual role, balancing bioethical considerations with military demands during the "Iron Swords" war.

This lecture will address the unique characteristics of the Iron Swords War, focusing on the operational and national imperative to recover hostages, including those who are no longer alive.
We will present the need that arose during the conflict to rule out the presence of Israeli casualties among bodies located in enemy territory.
The discussion will explore several alternative methods for casualty identification outside the walls of the national/ military casualty identification center, emphasizing the advantages and limitations of each approach.
We will introduce the operational concept and, consequently, the system developed during the war for dental identification in enemy territory—a simple, fast, and efficient system designed for frontline identification, even under hostile conditions.

Institute for Research in Military Medicine (IRMM), Advisor to the IDF Surgeon General for Victim Identification, Brandman Foundation Professor of Cardiac and Pulmonary Diseases, Faculty of Medicine, The Hebrew University of Jerusalem and IDF Medical Corps.
In the surprise attack on Saturday, October 7, 2023, the Jewish holiday of Simchat Torah, the terrorist organization Hamas invaded Southern Israel, killing over 1100 Israelis and foreign nationals, of which over 400 were soldiers, police officers, and security service personnel, and abducted 251 to Gaza. Since then the number has risen to over 1800 of which over 900 are soldiers and other security personnel.
The Forensic Identification unit of the IDF Medical Corps, with the guidance of the National Institute of Forensic Medicine, is responsible for determining the identity and cause of death of all fallen soldiers. Included in its responsibilities are also evaluation of treatment, effectiveness of protective gear, and identification of types of weapons and munitions.
In this talk we will elaborate on the unique challenges posed by the current conflict for execution of these tasks. These challenges include the logistical complexities created by the unprecedented numbers of victims at the same time, difficulties of evaluation of victims recovered during active combat, difficulties in triage of civilian vs military personnel, large numbers of decomposed, incinerated or detached remains, and the particularly difficult cases of commingled remains. To this it is necessary to point out the added burden and complexity surrounding the simultaneous identification and assessment of casualties among the enemy forces. These challenges, their qualifications, and the solutions employed will be discussed.

The Identification of Casualties in Extreme Scenarios: Lessons from the "Iron Swords" War -
The "Iron Swords" War is one of Israel’s most difficult conflicts, beginning with a surprise attack on October 7 resulting in ~1,200 casualties. The high number of casualties, severe body conditions, and difficulty distinguishing between Israeli victims and terrorists made identification especially challenging.
Unlike small-scale incidents, this mass-casualty event involved civilians, soldiers, and foreign workers in chaotic combat conditions. Identification required collaboration between forensic experts, criminal investigators, military and civilian rabbinates, and legal authorities. The Military Rabbinate and Medical Corps worked extensively to identify both military and civilian casualties.
There are four well-established methods for identifying casualties: personal recognition, fingerprint analysis, dental comparison, and DNA matching. However, in extreme scenarios—such as severe burns, significant bodily trauma, or mass-casualty events—these methods may not always be helpful.
This lecture covers three such cases.
Burned Military Command Center – A fire reaching 1,000°C prevented conventional identification of 15 fallen soldiers. A combination of skeletal reconstruction, advanced dental analysis, and survivor testimonies enabled full identification. Mass-Casualty Event – Such events, involving a large number of body fragments—sometimes numbering in the hundreds or thousands—that required identification and classification. Deep anatomical knowledge is crucial in prioritizing remains for DNA testing facilitate identification and even to establish the legal declaration of death.
Burned Skeleton in a Kibbutz –Despite multiple attempts, no viable DNA could be extracted. Following an extensive investigation, an additional body part was recovered, which was conclusively identified as belonging to the same individual. This organ provided viable DNA, leading to a definitive identification.
These cases highlight the need for teamwork, forensic expertise, and creative problem-solving in large-scale disaster victim identification.

Severe infections usually require a multimodal treatment, typically consisting of a pharmacological and surgical approach. Hyperbaric Oxygen has an important role as an adjuvant treatment in cases of severe infections. It is well established that HBOT not only saturates tissues in oxygen enabling better recovery in cases of ischemia, edema and hypoxia, but also represses the proliferation of pathogens such as bacteria and fungi. We will cover the literature regarding indications for HBOT in severe infections, the mechanism by which HBOT helps combat these infections and the benefits and limitations of this approach.

Casualty care events are not very common in the navy, but when they do occur, their severity is considerable due to the kinetics and the mechanism of the injury. During Iron Swords War we experienced a few serious events, and many practical lessons were learned and have since been implemented in our medical teams and among the naval warriors.
From our experience, in addition to the trauma protocol, we learned to pay attention to other areas that are less intuitive. These areas include the location of the medical equipment on vessels, the location of stretchers, the route of evacuation, the appropriate medical staff needed for missions we have not experienced before, and issues of command and control.

Ancient and ubiquitous in seafaring, coping with the natural phenomenon known as seasickness is an ongoing challenge. Over the past decade, women are increasingly filling the ranks in the IDF Navy fleet. Women are commonly conceived as more susceptible to seasickness than men, with studies looking to the plainest factor: hormones. Though estrogens and their ever-fluctuating levels play an integral role in almost all human physiology, their contribution to seasickness and motion sickness is not definitively understood. Recent and not-so-recent studies reveal possible mechanisms that could uphold a non-traditional view on the effect of estrogen on seasickness. Neurophysiological in-vitro studies have shown interesting evidence of the effects estrogens may have on the vestibular system. Additionally, mono- and multi-phasic formulations of combined oral contraceptives have developed over the years. By taking this into account and analyzing the current state of knowledge, new possibilities for leveraging the female hormonal system are identified.

The gut microbiome is composed of bacteria, archaea, fungi, protozoa, and viruses that colonize the intestines of all mammals. Studies in humans suggest microbiome involvement in a variety of physiological processes including energy homeostasis, metabolism, immune activity, neuro- behavioral development and diseases. Recent studies have demonstrated that microbiota transplantation is a beneficial treatment for epilepsy in mice, by inducing changes in gene expression in the hippocampus, which appears to protect mice from seizures. In humans this treatment has also been established for Clostridium difficile infection and fibromyalgia. In the current research, we aim to characterize the modulations in the microbiome and epigenome following repetitive hyperbaric oxygen exposures, in order to lay the foundations for harnessing these changes to enhance oxidative stress endurance in combat divers.
Stool, saliva, buccal epithelia and blood samples were collected from participants during consecutive weeks of oxygen dives. DNA was extracted from stool and saliva samples and sequenced to identify the bacterial composition of the gut and lungs, respectively. Epithelia and blood data is lacking due to Iron Swords operation and other training stand down. We observed changes in bacterial composition and a decrease in species diversity, as well as 16/220 species in stool samples and 100/230 species in saliva samples with significant average abundance changes following repetitive oxygen dives.
These findings suggest that exposure to hyperbaric oxygen a few times a week during several consecutive weeks, leads to modulations in gut and lung bacterial microbiome composition, some of these changes returned to baseline non- diving activity, while others remained unchanged. Further samples collection and analysis are required to validate these results and to identify pertinent bacteria that could potentially enhance endurance to oxidative stress.

Acute acoustic trauma (AAT) is sensorineural hearing loss resulting from exposure to loud noise. In 2019 a clinical guideline was established for diagnosis and treatment of military personnel in the Israeli Defense Forces (IDF).
With the onset of “Iron Swords” war in October 2023, the volume of AAT patients increased drastically, while Uniformed Medical Officers (UMOs) were engaged in combat themselves. Due to these circumstances the process of diagnosis and treatment were refined, and a new medical unit was formed to provide prompt and effective treatment. From October 7, 2023, to this day 422 patients were treated at the INMI for AAT with a combination of HBOT and steroids.
In this session these adaptations will be discussed, as well as treatment protocol. Wartime findings support previous knowledge regarding the importance of beginning treatment as soon as possible, optimally within seven days from exposure. Age was negatively correlated with recovery of hearing.

Hyperbaric oxygen therapy (HBOT) has long been a critical component of naval medicine, primarily used to treat decompression sickness in divers. However, its potential applications extend far beyond its traditional role, offering significant benefits in the context of naval training and operational readiness. By delivering 100% oxygen at elevated pressures, hyperbaric oxygen chambers can accelerate recovery from intense physical training, reduce inflammation, and enhance wound healing, thereby optimizing the physical performance and resilience of naval personnel. Additionally, HBOT has shown promise in mitigating injuries associated with high-stress environments and improving cognitive function by promoting neural repair and reducing oxidative stress. This lecture will explore the integration of hyperbaric oxygen chambers into naval training programs, focusing on their role in recovery protocols, injury prevention strategies, and overall performance enhancement. By leveraging these advanced medical technologies, naval forces can ensure their personnel are better prepared to meet the physical and mental demands of modern maritime operations.

Background:
Central nervous system oxygen toxicity (CNS-OT) is a critical concern for Navy divers using closed-circuit rebreathers who are subjected to prolonged exposure to hyperbaric oxygen levels. We explored the potential of specific dietary supplements, caffeine, and astaxanthin, to delay the onset of CNS-OT.
Methods:
Experiments were conducted using male C57BL/6 mice exposed to pure oxygen at 507 kPa, with latency to tonic- clonic seizures recorded. Mice were orally administered caffeine (1.25, 2.5, or 5 mg/kg), astaxanthin (8 mg/kg), or a vehicle (water).
Results:
Caffeine and astaxanthin significantly extended the latency period to seizure onset (P<0.03). Notably, combining caffeine and astaxanthin (P<0.001 vs. control) provided better protection against CNS-OT than either substance alone. Conclusions:
Our results suggest that administering caffeine and astaxanthin before hyperbaric oxygen exposure delays hyperoxia-induced seizures. We aim to translate this work to a human model, with a focus on expanding oxygen dive profiles for combat divers by extending depth, duration, and range

Background:
Post-Traumatic Stress Disorder (PTSD) affects over 6% of the general population with a lifetime prevalence as high as 33% in high-risk populations - including veterans, combat zone residents and areas affected by natural disasters. Defined as the administration of breathing oxygen at partial pressures exceeding 1 atm, hyperbaric oxygen (HBO) therapy has been attempted in various neurological and psychiatric impairments. Hyperoxemia, with PaO2 as high as 1800mmHg under 3.0 ATA of pure O2, is the most important mechanistic path by which HBO alters physiology. A recent pooled estimate of 4 RCTs totaling 252 patients found no significant effect of HBO therapy compared with sham (PCL Md of 0.61, 95% CI [−7.75, 8.96], p = 0.38). (1)
Goals:
Our primary goal is to examine the effect of HBO therapy on PTSD symptoms.
Materials and Methods:
In this double blinded, prospectively randomized, sham controlled, pragmatic cross over study patients referred by our VA are randomized to either one of two treatment protocols (2.0 ATA and 2.5 ATA) or placebo (a sham protocol) for 60 daily sessions. To be included, patients must be 18-80 years old with a PTSD (as per DSM-5 criteria) severe enough to warrant a military discharge. Excluded are patients with known or suspected psychosis or suicidality and any contraindication to HBO. The Clinician-Administered PTSD Scale (CAPS)-5 score at the end of the treatment series compared to the baseline score is the primary outcome with various questionnaires and biometric sleep recording serving as secondary and exploratory outcomes, respectively.
Discussion points:
We hypothesize that symptoms of PTSD will reach peak improvement following 40-60 HBO treatments compared to sham pressurized controls, with better overall improvement in higher doses of PO2, in patients with shorter duration of symptoms and when TBI is present. An interim analysis is scheduled for September 2025.

Fatigue impairs various cognitive functions, but currently, no objective, validated measure exists to quantify it. In the last two decades, studies have used speech analysis to detect and monitor medical, physiological, and mental conditions. The objective of this study is to develop an algorithm based on acoustic measurements to evaluate the fatigue level of aircrew under sleep deprivation (SD) conditions. This study included recordings of 40 aircrews and UAV operators, each recorded in four different SD stages: slight fatigue, severe fatigue, accumulated fatigue, and recovery. The recording protocol included various speech signals, such as syllables, counting, reading, speech under cognitive load, and free speech. A qualitative perceptual analysis was conducted by a speech therapist to compare and interpret the results. The analysis involved computing the distance between acoustic features in the states of alertness and slight fatigue, as well as between alertness and maximal fatigue. Both speaker- dependent (comparison of recordings from the same subject) and speaker-independent (comparison of recordings from all participants) analyses were performed. In the speaker- dependent analysis, some features showed a greater distance between alertness and maximal fatigue compared to the distance between alertness and slight fatigue. These features included all d-LPC derivations (with 70-80% identification), PARCOR (77%), LPC (76%), pitch (F0) (76%), and MFCC (75%). The speaker-independent analysis did not yield significant results, and a larger cohort is required for further analysis. This study demonstrated a high correlation between fatigue and vocal characteristics. This connection could be measured by analyzing the distance between acoustic features in the state of fatigue and those in the state of alertness for each individual. These results suggest the potential for developing a user-dependent fatigue sensor.

The most effective method for fatigue monitoring is EEG, but its use is limited to laboratory or clinical settings. We identified that EEG components related to error monitoring influence corrective sub-movements—subtle micro-motions triggered by error detection—offering a novel fatigue assessment approach. We hypothesized that changes in these sub- movements reflect fatigue levels.
Our model was based on a two-hour driving simulator, where fatigue levels were determined using EEG, KSS ratings (driver and external evaluator), and driving performance. Fatigue level was determined when the driver's self-reported KSS matched an identical indication from at least one other measure. AI analysis identified sub-movement features distinguishing KSS threshold of ≥8 indicating unfitness for activity.
The Israeli Air Force validated the model in two phases. In a Flight simulator study (52 cadet pilots), it detected KSS ≥8 with 79% true alerts and 3% false alerts (all at KSS 7) and identified KSS ≥8 flight patterns with 82% true alerts and 8% false alerts. In UAV operations, it matched instructor evaluations for KSS ≥8 with 78% true alerts and 1% false alerts. The model, initially designed for steering analysis, was minimally adapted for the Air Force test. With dedicated training, it can achieve rapid detection (about 1 min) and very high accuracy, allowing assessment of flight crew fatigue before or during operations.

Background:
SD is a significant contributor to aviation mishaps, often resulting from misinterpreted sensory cues, leading to an incorrect understanding of the aircraft’s position, attitude, or motion. Understanding eye-scanning behaviors associated with SD can improve training and reduce incidents.
Purpose:
To analyze eye-tracking patterns contributing to or mitigating spatial disorientation (SD) during flight, providing insights to reduce its impact.
Methods:
Eye movements of 45 participants (30 aircrew members, 15 cadets) were recorded using Tobii Pro Glasses 2 during SD- inducing flight simulations in the Gyro-IPT SD simulator. Metrics such as fixations, saccades, and visits were compared between SD and non-SD groups, and statistical analyses were performed to identify differences.
Results:
Among 284 flight profiles, 136 SD events were recorded across 30 aircrew and 15 cadets. Some illusions targeted navigators, F-15 aircrew, or active aircrew instead of cadets. SD events during visual illusions were more likely with frequent instrument panel checks. In contrast, vestibular illusions showed the opposite effect and had a higher probability of causing an SD event among participants who examined the HUD in greater frequencies.
Conclusions/ possible implementations:
Efficient SD mitigation requires task-specific eye-scanning strategies: visual illusions demand greater instrument focus, while vestibular illusions benefit from HUD engagement. Implementing the knowledge and training based on the current results can improve performance in flight profiles with high SD risk. There is potential to develop a real-time alert system installed on aircraft during real flights, helping to mitigate or entirely eliminate the fatal results of SD events.

Ocular dominance is a key factor in visual processing and performance, particularly in high-demand operational environments such as military aviation. While traditionally considered stable in adulthood, recent findings suggest that long-term exposure to asymmetric visual input—such as that experienced by helicopter pilots using Helmet-Mounted Displays (HMDs)—may influence the progression of visual acuity and potentially induce shifts in ocular dominance. This retrospective longitudinal study examines the relationship between ocular dominance and changes in visual acuity parameters over time in Israeli Air Force (IAF) helicopter pilots. The study analyzes a cohort of 300 pilots who underwent annual optometric assessments at the IAF Aeromedical Center, spanning multiple years of service. The primary objective is to determine whether ocular dominance is associated with differential changes in myopia, hyperopia, and astigmatism, and whether these changes vary based on pilot age, service duration, and flight platform. Data were analyzed using repeated-measures ANOVA and linear mixed-effects models to assess trends in visual acuity degradation and its correlation with ocular dominance over time.
Preliminary findings indicate that pilots with prolonged exposure to HMDs exhibit distinct patterns of visual acuity progression compared to non-HMD users, with notable differences in the dominant versus non-dominant eye. These results suggest that the operational demands of aviation may contribute to ocular dominance shifts and asymmetrical visual deterioration, warranting further investigation into adaptive visual training and early intervention strategies.
The implications of this research extend to pilot selection, training methodologies, and the ergonomic design of visual display systems in military aviation. By understanding the long-term effects of asymmetric visual exposure, this study provides valuable insights into optimizing flight safety, vision screening protocols, and personalized corrective measures for pilots operating under demanding visual conditions.

Introduction:
Spinal pain is a significant challenge in air forces, as Neck Pain (NP) or Lower Back Pain (LBP) can impair pilots’ functioning. Although studies on the general population showed no strong correlation between MRI findings and NP or LBP, data on aircrews is limited. This study aims to assess the association between clinical and MRI findings among aircrews with spinal pain.
Method:
Data from Israeli Air Force aircrew members experiencing NP or LBP and who underwent MRI between 2019–2025 were analyzed. Collected data included demographics such as age and sex, basic anthropometrics, occupational data such as aircraft and position, clinical findings assed by a doctor and/ or physiotherapist and MRI findings. MRI severity was graded by a blinded, experienced orthopedic surgeon.
Results:
51 aircrew members (mean age 31.93 ± 6.18 years) were included in our study. 64% were jet pilots, 18% helicopter pilots, and 18% transport aircraft operators. LBP pain affected 70% and NP affected 62% of the participants. Axial pain was reported by 46%, referred pain by 40%, and combined symptoms by 14%. MRI findings showed disc pathology in 78%, mainly bulges (30%) and herniations (28%), which significantly correlated with neurological symptoms (p = 0.043) and positive Spurling tests (p = 0.021). Cord compression was associated with pain location (p = 0.018), particularly in cases of isolated cervical pain, where 50% showed signs of canal stenosis or cord compression. Higher MRI severity correlated with limited range of motion (ROM) (p = 0.031).
Discussion:
Most aviators with severe spinal pathology requiring further imaging were fighter pilots, consistent with prior research by our institute. The predominant clinical and imaging findings were axial pain and disc bulging, similar to the non-aviators population. In most of the cases, in addition to pain there were accompanying neurological symptoms.
Our Analysis showed that spinal cord compression was highly associated with isolated cervical pain but not with limb weakness or gait disturbances, differing from the general population. Additionally, decreased ROM was strongly associated with the extent of MRI findings, highlighting the importance of thorough physical examination in order to predict those with severe pathology.

Background:
Spinal pain, particularly cervical pain, is a recognized occupational hazard for military pilots, exacerbated by high G-forces and constrained cockpit postures. This can lead to neurological deficits and reduced operational readiness. Existing research highlights the need for preventative strategies.
Purpose and Goals:
This prospective study aims to establish baseline measurements of cervical strength, range of motion (ROM), and anthropometry in Israeli Air Force flight cadets prior to extensive flight exposure. The primary objectives are to; 1) track the longitudinal evolution of these measures throughout the pilot training course; and 2) investigate the association between objective (strength, ROM, anthropometry) and subjective (pain, function) cervical measures.
Methods:
Four hundred flight cadets (aged 18-25) from four consecutive pilot courses will be recruited. Cervical ROM will be assessed using a validated virtual reality system (XRHealth TM Oculus Quest VIVE HTC VR TM). Cervical muscle strength will be evaluated using a Microfet 2 dynamometer (Hoggan Scientific). Anthropometric measurements will include neck circumference and length. Subjective cervical pain and function will be assessed via validated questionnaires. Measurements will be taken at baseline (one year into the course, prior to flight exposure) and at two and three years into the course.
Possible Implementations:
The resulting baseline data will inform the development and implementation of targeted exercise interventions aimed at mitigating cervical pain and improving pilot performance and operational readiness. Longitudinal data will elucidate the evolution of cervical health during pilot training.

Background:
Combat pilots are subjected to quick altitude dynamics and high accelerations and manage complex systems in rapidly changing environments. These conditions might cause perilous physiological events, including spatial disorientation (SD), g-induced loss of consciousness (g- LOC) and hypoxia. The operational conditions might incur sleep deficiency, cognitive overload, and excessive time on task. Together, these physiological and mental factors account for the majority of military aviation safety incidents.
Purpose:
Electrophysiologic data can be useful in identifying physiological events and mental conditions. Electroencephalography (EEG), electrocardiography (ECG), electrooculography (EOG) and electromyography (EMG) have previously been demonstrated to support reliable indicators in research settings. However, their translation to operational environments has been challenged by their size and their wired nature. In this work, we evaluated a novel low-footprint wireless device optimized for extreme environments. Methods and Preliminary Results:
PilotSense (X-trodes inc.) uses printed dry electrode arrays to provide EEG, ECG, EOG and EMG data using small wireless patches. Multiple sensing modalities are integrated into a single patch. The dry electrode technology enables stable signal quality with sweat and movement. The wireless nature and small size enable standalone use in the combat aircraft environment.
Performance in high-acceleration environments has been initially evaluated in centrifuge and motorsport settings. In centrifuge settings, early results demonstrated reduced delta and theta activity related to a g-LOC event. In motorsport settings, Event Related Spectral Perturbation (ERSP) analysis demonstrated increased alpha and beta activity before sharp turns. Usability has been assessed in training combat flights. Discussion:
PilotSense is a novel solution enabling electrophysiologic measurements in extreme environments. The patches are soft, thin and self-applicable. They are FDA approved to provide data quality equivalent to traditional systems. They are compatible with standard protective gear, communication devices and life support systems. PilotSense is currently being evaluated in debriefing use. Next steps will include integration with flight monitoring systems to support real time monitoring and alerts.

Background:
Vision plays a crucial role in daily life and is especially critical in aviation. In this study, we examine how the timing of eye exams influences their results for candidates applying to the Israeli Air Force Flight Academy. Since 2024, eye exams have been scheduled after candidates undergo a 4–5-hour computer-based test. The aim of the study is to assess whether the timing of the eye exam affects test outcomes.
Methods:
The study included candidates who failed their eye exams between 2019 and 2024. The cohort consisted of healthy young adults with no known ocular conditions, all highly motivated to perform well in vision tests. Each candidate underwent a thorough eye exam conducted by trained military optometrists and ophthalmologists. The study tracked disqualification reasons and categorized them accordingly. The eye exams involved tests for visual acuity (near and far), color vision, keratoconus, and a comprehensive binocular evaluation. Results & Conclusions:
There was a significant increase in strabismus cases, with 140 recorded in 2024, compared to 85 in 2023 and 52 in 2022. This trend raises concerns about the impact of the timing of eye exams. The exams, scheduled after lengthy computer sessions, may contribute to visual fatigue, potentially affecting binocular function and increasing disqualification rates. The study suggests that the timing of vision assessments should be reconsidered to ensure accurate results and reduce unnecessary disqualifications. Further research is needed to explore how digital strain affects vision testing protocols in aviation.

Background:
Keratoconus is a progressive eye condition where the cornea thins and forms a cone-shaped protrusion, leading to visual distortions. It is common among young individuals and can severely affect visual acuity. For pilots and aircrew, who rely on sharp vision for their duties, keratoconus presents significant challenges, including difficulty reading instruments, identifying distant objects, and adjusting to changing light conditions, especially during night flights or in low-visibility situations.
This case study aims to evaluate the impact of corneal cross- linking (CXL) treatment on aircrew members diagnosed with keratoconus and assess their readiness to return to flight duties. The goal is to determine the effectiveness of CXL in stabilizing the condition and ensuring that affected aircrew can safely resume their duties.
Methods:
The study involved two Israeli Air Force aircrew members diagnosed with keratoconus. Both underwent corneal cross- linking treatment and were grounded for approximately two months. During this period, they received continuous monitoring and comprehensive medical evaluations, including corneal topography and visual acuity assessments, to determine their recovery and visual stability.
Results:
After undergoing the prescribed recovery period and undergoing rigorous evaluations, both individuals demonstrated significant improvements in corneal structure and visual stability. Following confirmation that their vision met the required standards; both aircrew members were cleared to return to active flight duty.
Keratoconus can be effectively managed with early diagnosis and modern treatments like corneal cross-linking. The study highlights the importance of continuous monitoring and post- treatment evaluations to ensure aircrew members with keratoconus can safely return to flight. The findings contribute to best practices in aviation medicine and offer valuable insights into managing ocular health for military aviators. Further research may refine protocols and improve recovery guidelines for affected personnel.

Background:
Myopia prevalence is rising worldwide, driven partly by progressive axial elongation. While many studies address axial length (AL) changes in children, data are limited for healthy young adults, particularly military pilots and cadets. Purpose:
To investigate AL progression and refractive changes among active pilots and flight cadets undergoing routine aeromedical evaluations.
Methods:
A retrospective study (June 2018-December 2024), including 3,398 Israeli Air Force personnel (mean age 31.2±10.6 years) with at least two AL and refractive measurements ‚>1 year apart, were included. Autorefraction was measured upon each encounter. AL was measured at baseline and upon the last follow-up. Statistical analyses assessed progression-inflicting factors.
Results:
Mean follow-up was 2.73±0.84 years. Overall, AL increased significantly by 0.018±0.126 mm (p<0.001) in the total cohort. Younger adults (<20 years) and baseline myopes showed greater progression (0.043±0.113 mm, p<0.001). Significant correlations were observed between AL elongation and changes in the sphere (p=0.028). Subgroup analyses indicated accelerated AL progression among those who developed new myopia or exhibited worsening myopia.
Conclusions:
Even in healthy young adults, axial elongation persists beyond childhood, with younger individuals and baseline myopes at higher risk. Aeromedical personnel should remain aware of subtle ongoing refractive changes in pilot populations. Discussion:
These findings underscore the importance of routine refractive monitoring in aircrews, particularly among baseline myopic candidates. Recognizing these trends informs aeromedical policy, ensuring long-term visual readiness in military aviation environments and candidate selection

Background:
In many air forces, individuals with asthma are ineligible for flight training. However, waivers may be granted if asthma develops during or after successful training completion. The primary concern is that asthma could impair pulmonary function and increase the risk of sudden incapacitation under extreme conditions, such as high G-forces and hypoxia. Purpose:
This study aimed to evaluate the long-term health and flight performance of asthmatic aircrew and assess the validity of the current Israeli Air Force (IAF) asthma waiver policy. Methods:
This retrospective cohort study analyzed medical records of active and reserve asthmatic air crew who underwent annual medical screenings at the IAF Aero Medical Center (AMC) between 2008 and 2024. Data collected included demographic characteristics, flight platform, role in the aircraft, age at onset, treatment regimen, presence of allergy, eosinophilic count and pulmonary function test (PFT) results.
Results:
A total of 30 aircrew members with asthma met the inclusion criteria, 90% of whom were male. The average age at diagnosis was 32.39±7.66 years, with a maximum follow-up period of 16 years. Nearly half (46.7%) served as high-performance air crew. Most (66.7%) were treated with inhaled bronchodilators. The average forced expiratory volume in one second to forced vital capacity (FEV1/FVC) ratio was 74.02%, with a minimum recorded value of 65%.
Conclusions:
Despite the limited sample size, findings suggest that asthmatic aircrew maintain stable pulmonary function over long-term follow-up, without reported medical or flight safety concerns. These results support the current IAF asthma waiver policy, allowing jet pilots to continue flying while on chronic inhaled bronchodilator therapy.

Background:
On April 4th 2024, a reserve fighter navigator in an operational squadron was diagnosed with active tuberculosis. This led to a unique contact tracing challenge due to the need to understand the structure of the aircraft's ventilation systems and the contagion potential in it. In addition, it was also necessary to understand the bacterial survival within the F-15 aircraft's environment. 78 close contacts, all aircrew, were identified, creating a complex situation given the operational demands on the squadron.
Purpose and Goals:
The primary goal was to effectively rule out latent tuberculosis among the 78 aircrew members while minimizing disruption to their operational duties. The challenge lay in balancing thorough testing with the need to maintain a high level of operational capability within the squadron.
Methods:
The standard protocol for ruling out latent tuberculosis (two Mantoux tests and a chest X-ray) was deemed impractical due to the frequency of required medical
visits. Instead, the less common but more efficient QuantiFERON test (two blood tests a month apart) was chosen. To further streamline the process, special permission was obtained to conduct the tests at IAF Aeromedical Center and the squadron's base clinic, requiring special training for the clinic staff.
Possible Implementations:
The QuantiFERON test, though more expensive and complex, was implemented to reduce the number of medical visits required by the aircrew. Decentralizing the testing to the base clinics, rather than hospitals, further facilitated participation. Despite this accommodation, some aircrew members (9 out of 78) did not complete the full testing regimen. Ultimately, 69 aircrew members completed both tests.

Background:
Combat casualty care has advanced significantly with the implementation of evidence-based protocols designed to lower combat-related mortality. Over the last decade, two major urban conflicts in southern Israel have challenged the evolving military trauma system.
Purpose:
This study aimed to assess differences in prehospital care and compare the outcomes of aeromedical evacuated casualties from the 2014 and 2023 conflicts.
Methods:
A retrospective cohort study analyzed records from the Military Airborne Combat Evacuation Unit (MACEU) and the Israeli National Trauma Registry. Patients aeromedically evacuated between 07.17.14–08.16.14 and 10.27.23–03.17.24 were included. Ground- evacuated casualties were excluded. Demographics, prehospital interventions, and clinical outcomes were compared.
Results:
In 2014, 251 casualties were evacuated alive, compared to 940 in 2023. Both conflicts involved young males injured by explosions, with similar injury distributions. Median injury-to-hospital time decreased from 65min (IQR 47-94) to 60min (IQR 47-180) (d=0.5, p<0.001). The proportion of severely (ISS≥16) and critically injured (ISS≥25) increased from 18.3% to 25.2% (OR 1.5, p=0.03) and 7.6% to 12.8% (OR 1.79, p=0.03), respectively. Advanced airway interventions and thoracostomies declined from 11.6% to 6.0% (OR 0.48, p<0.001) and 7.0% to 2.1% (OR 0.28, p<0.001). Prehospital blood transfusion use rose from 6.6% to 16.4% (OR 2.78, p<0.001). In-hospital mortality remained stable (2.7% vs. 2.5%, OR 1.12, p=0.99), with non-significant reductions among severely.