Israel Medical Association Journal

Background: Age is a well-established prognostic factor in civilian trauma, where adverse outcomes increase with ages. Whether this pattern holds true in military trauma, where populations, injury mechanisms, and systems of care differ fundamentally, remains uncertain. A large-scale mobilization of Israeli Defense Forces (IDF) reservists provided an opportunity to examine this association.

Objectives: To clarify whether older service members experienced less favorable outcomes compared with younger counterparts.

Methods: This retrospective cohort study included IDF casualties recorded in the IDF Trauma Registry and the Israel National Trauma Registry between 27 October 2023 and 19 January 2025. Participants were categorized by age: 18–21 years, 22–39 years, and ≥ 40 years. Primary outcomes included 24-hour and 30-day mortality, intensive care unit admission (ICU), and hospitalization ≥ 7 days.

Results: Of 4905 casualties, 40.4% were 18–21 years of age, 54.2% were 22–39, and 5.4% were ≥ 40. Injury severity, evacuation times, pre-hospital interventions, and admission vital signs were similar across groups. Adjusted analyses showed no significant age-related differences in mortality, ICU admission, or prolonged hospitalization. Subgroup analysis of casualties with injury severity score ≥ 16 yielded comparable results.

Conclusions: In this large military trauma cohort, no significant association was found between age and mortality, ICU admission, or prolonged hospitalization. These findings were observed in a generally healthy military population receiving organized trauma care and suggest that, within this context, chronological age alone may not be an appropriate criterion for determining reserve service eligibility.

Background: Inflammatory bowel disease (IBD) is a chronic relapsing condition affecting millions worldwide, often diagnosed during young adulthood and associated with significant functional impairment. The Israel Defense Forces (IDF) allows citizens with IBD and 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.

Objectives: To evaluate the association between IBD and military service-related outcomes, including service completion and occupational stability, among IDF medical volunteers.

Methods: In this retrospective study, we examined 734 volunteer soldiers with IBD who served in the IDF between 2019 and 2024. Data were collected from computerized medical records and included demographic, occupational, and medical information.

Results: Among 734 IBD volunteers, 96.7% successfully completed their military service. Male sex (odds ratio 3.73) and lower sick leave utilization (odds ratio 3.13) were key predictors of service completion in multivariable analysis.

Conclusions: The findings suggest that the vast majority of IBD volunteers successfully completed military service, with male sex and lower sick leave utilization as predictors of completion. Given these outcomes, consideration should be given to including carefully selected IBD patients within the standard medical classification system, based on individualized assessment of disease stability and functional capacity, with a non-combat profile, rather than through the volunteer program.

Background: The management of symptomatic abdominal aortic aneurysms (AAA) remains a surgical challenge.

Objectives: To compare the outcomes of endovascular aneurysm repair (EVAR) versus open surgical repair (OSR) in patients with symptomatic AAA.

Methods: Patients treated for symptomatic AAA between April 2020 and April 2025 were retrospectively analyzed, comparing perioperative mortality and major adverse events between EVAR and OSR.

Results: A total of 494 AAA patients were identified, 49 (9.9%) were symptomatic (40 [81.6%] EVAR group, 9 [18.4%] OSR group). Patients undergoing OSR had a higher rate of juxtarenal involvement (OSR 6/9 [66.7%] vs. EVAR 3/40 [7.5%]; P < 0.001). Any signs of rupture were more prevalent in the EVAR group (27/40 [67.5%] vs. OSR 2/9 [22.2%]; P = 0.013). Technical success was achieved in 83.7% (n=41/49). In-hospital mortality was 22.4% (n=11/49), with no difference between groups (EVAR 9/40 [22.5%] vs. OSR 2/9 [22.2%]; P = 0.986). At logistic regression analysis, open repair was associated with a significantly higher risk of major complications (odds ratio [OR] 16.9, 95% confidence interval [95%CI] 1.79–158.3, P = 0.013), and a shock index > 0.9 remained an independent predictor of intra-hospital mortality (OR 372.5, 95%CI 1.58-87889.4, P = 0.034). During a mean follow-up of 28.8 ± 18.6 months, late mortality was 18.4% (n=7/38). Estimated survival analysis over 60 months did not demonstrate a significant difference between groups (log-rank test, P = 0.317).

Conclusions: Both EVAR and OSR yield satisfactory technical outcomes. Hemodynamic instability at presentation remains a critical predictor of mortality.

Background: Crohn’s disease is a chronic inflammatory condition of the gastrointestinal tract. Biological therapy has transformed disease management; however, its association with postoperative outcomes remains debated.

Objectives: To evaluate the association between preoperative biological therapy and postoperative outcomes following ileocolic resection for Crohn’s disease, and to identify additional factors associated with postoperative complications.

Methods: We conducted a single-center retrospective observational study of Crohn’s disease patients who underwent ileocolic resection between 2021 and 2023. Patients were stratified according to preoperative exposure to biological therapy.

Results: Of 208 screened patients, 150 met inclusion criteria. Postoperative complications were more common in patients receiving biological therapy compared with controls (56% vs. 36.4%, P = 0.017), which was primarily driven by minor complications (48% vs. 30%, P = 0.022). Rates of major complications and length of hospital stay did not differ between the groups. Patients who developed major complications had significantly lower preoperative serum albumin levels (3.08 vs. 3.7 g/dl, P = 0.021).

Conclusions: Preoperative biological therapy was associated with a higher rate of postoperative complications, predominantly minor in severity. Low preoperative serum albumin was associated with major postoperative complications, highlighting the importance of preoperative nutritional assessment and optimization.

Background: Tunneled hemodialysis catheters are frequently used and are a major source of catheter-related bloodstream infections (CRBSI), which result in significant morbidity.

Objectives: To examine the adverse outcomes associated with CRBSIs, including hospitalization, recurrence, 1-year mortality, and catheter outcomes in a hemodialysis setting that uses modern preventive catheter-care practices.

Methods: We conducted a retrospective cohort study of adults with jugular tunneled hemodialysis catheters who met criteria for CRBSI from 1 January 2015 to 31 December 2020 at a tertiary referral center.

Results: Of 380 hemodialysis patients, 75 experienced CRBSI events. The average rate was 1.55 CRBSIs per 100 patient months. The median time from catheter insertion to CRBSI was 179 days; and 68% required inpatient management. Gram-positive bacteria accounted for 53% of isolates, with Gram-negative organisms also being common. Recurrence occurred in 16% of cases and was independently associated with ferritin levels over 500 ng/ml (P = 0.02), albumin levels below 3.5 g/dl (P = 0.011), and uric acid levels under 2.5 mg/dl (P = 0.04). Catheters were removed in 61.3%, exchanged over a guidewire in 24%, and salvaged in 18.6%. The 1-year mortality rate was 28% and was associated with lower weight, catheter salvage, neutrophilia, hypoalbuminemia, and hypokalemia. Using chlorhexidine exit-site dressings was associated with fewer hospital admissions.

Conclusions: Among hemodialysis patients with CRBSI, recurrence and mortality might be linked to a patient's nutritional and inflammatory status. Current preventive measures might reduce hospitalization rates, but in this cohort, they were not associated with lower recurrence or mortality rate.

Background: Acute myocarditis (AM) is an inflammatory cardiac condition with heterogeneous clinical manifestations that often overlap with other acute cardiac syndromes, making diagnosis challenging.

Objectives: To characterize the prevalence, clinical profile, and outcomes of AM patients with respiratory viral pathogen detection on nasopharyngeal swabs at admission.

Methods: We retrospectively analyzed all patients admitted to the Sheba Medical Center with confirmed AM between January 2005 and December 2020. Diagnosis was based on compatible presentation, elevated cardiac biomarkers, and supportive imaging findings. Nasopharyngeal swab results, when performed, were reviewed for respiratory viral detection.

Results: Among 425 identified AM cases, 146 (34%) underwent swab testing; 11 (8%) tested positive for respiratory viral pathogens, most commonly influenza A (n=5) and adenovirus (n=3). With one exception, all positive cases occurred during winter or early spring (10/77, 13%). Compared with swab-negative patients, swab-positive individuals were older (47 ± 22 vs. 35 ± 14 years, P = 0.03), more frequently female (45% vs. 14%, P = 0.007), and more often presented with dyspnea (55% vs. 25%, P = 0.036) but less commonly with ST-segment elevation (27% vs. 70%, P = 0.003). No differences were observed in inflammatory markers, imaging findings, or hospital stay.

Conclusions: Respiratory viral detection in AM is uncommon and predominantly seasonal. Nasopharyngeal swabbing is a simple, non-invasive tool that may help identify treatable viral pathogens and guide patient management. These data provide a pre-COVID-19 reference for future studies investigating the impact of viral infection on myocardial injury.

Background: Idiopathic pulmonary fibrosis (IPF) is a progressive, fatal lung disease leading to end-stage lung disease (ESLD). Single lung transplantation (SLT) is the primary treatment option for IPF; however, the native lung continues to influence post-transplant outcomes.

Objective: To determine whether the native lung continues to deteriorate under post-transplantation immunosuppression treatment by assessing chest computed tomography (CT) and perfusion scans.

Methods: We conducted a single-center retrospective analysis of patients who underwent SLT for IPF between 2016 and 2023. Serial chest CT scans assessed native lung changes. CT signs of fibrosis were scored for severity according to published criteria for defining pulmonary fibrosis disease progression. Lung volumes and perfusion were calculated.

Results: Among 57 patients (mean age 57 years; 33% female), 42% died during follow-up (median survival 95 months). The most common immunosuppressive regimen (54% of patients) included prednisone, calcineurin inhibitor, and mycophenolate mofetil. CT analysis demonstrated that in 41/57 (72%) patients, fibrosis signs continued to deteriorate. There was also a significant correlation decline in native lung volume and perfusion scans over time (P = 0.0003, P < 0.0001, respectively) (r = 0.82, P = 0.03).

Conclusions: Fibrotic progression in the native lung persists after SLT as demonstrated by both chest CT and nuclear perfusion scan, thus highlighting the importance of ongoing monitoring for accuracy and complications assessment, integrating it into routine surveillance, and ensuring it is consistently considered in post-transplant assessments.

Background: Apparent treatment-resistant hypertension (aTRH) is a high-risk phenotype associated with increased cardiovascular and renal morbidity. Renal denervation (RDN) has emerged as a promising intervention for patients with refractory blood pressure (BP) despite maximal medical therapy.

Objectives: To present the first Israeli prospective cohort evaluating RDN outcomes in aTRH patients.

Methods: The Tel Aviv Renal Denervation registry is a single-center, prospective cohort of 19 patients with aTRH who underwent RDN between 2021 and 2024. Baseline data included demographics, co-morbidities, medication burden, ambulatory BP monitoring (ABPM), and renal function. Outcomes were assessed at 3 and 12 months post-procedure, with repeated measures analyses used to evaluate longitudinal trends.

Results: The cohort (median age 62 years, 42% female) exhibited a high burden of co-morbidities including ischemic heart disease (37%), diabetes (26%), and chronic kidney disease (21%). Baseline ABPM showed a median 24-hour systolic BP of 152 mmHg. Following RDN, mean systolic BP decreased to 143 mmHg at 3 months and 138 mmHg at 12 months (P = 0.097), with a significant reduction in nighttime systolic BP (P = 0.033). Pill burden decreased from a median of 7 to 4 pills daily (P = 0.037). The number of antihypertensive drug classes declined from 6 to 4 (P = 0.052). Renal function remained stable throughout follow-up.

Conclusions: In this Israeli RDN cohort, patients with aTRH experienced clinically meaningful reductions in BP and medication burden, with preserved renal function and minimal complications. These findings support further expansion of national RDN registries to better guide patient selection and optimize long-term outcomes.

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are established treatments for peritoneal metastasis from colorectal cancer (PM-CRC). The peritoneal carcinomatosis index (PCI) measures disease burden.

Objectives: To evaluate the effect of PCI on short- and long-term outcomes of patients with PM-CRC who underwent CRS-HIPEC.

Methods: We retrospectively analyzed 120 PM-CRC patients who underwent CRS-HIPEC, categorizing them into four PCI groups (PCI ≤ 3, PCI 4–6, PCI 7–11, PCI >11). We evaluated perioperative outcomes and long-term survival.

Results: Higher PCI scores were associated with increased surgical complexity, longer operative times, more organ resections, and higher blood transfusion requirements. Complete cytoreduction was achieved in 100% of the PCI ≤ 3 group, but only in 70.8% of the PCI > 11 group (P = 0.001). Postoperative outcomes showed a trend toward less major morbidity in low PCI patients (16.7% vs. 28%) and significantly shorter hospital stays (10–13 days vs. 19 days, P = 0.006). The 90-day mortality rate was 0% in the PCI ≤ 3 group compared to 11.5% in the PCI > 11 group. Long-term outcomes revealed significantly better disease-free survival (DFS) and overall survival (OS) for the PCI ≤ 3 group (DFS: 22 months vs. 4–6 months; OS: 79.6 months vs. 21–40 months, P < 0.001).

Conclusions: Patients with low PCI scores experience reduced morbidity and improved long-term survival, supporting the use of CRS-HIPEC in this subgroup. Further research is needed to enhance treatment strategies for patients with high PCI scores.

Background: Lung transplantation (LT) is a viable option for end-stage chronic obstructive pulmonary disease (COPD) patients when conventional treatments fail. However, sex disparities in mortality outcomes among COPD patients awaiting LT remain understudied. LT waiting lists are generally shorter in Western countries compared to Israel.

Objectives: To evaluate sex-specific differences in mortality and co-morbidities among COPD patients awaiting lung transplantation, to identify key risk factors influencing survival.

Methods: We assessed associations between sex, co-morbidities, exacerbations, and mortality using Cox regression models, adjusting for confounders. Survival curves for lung transplant candidates were stratified by sex using Fine and Gray models.

Results: We identified 385 COPD patients listed for LT at Rabin Medical Center. Females exhibited higher rates of asthma (P = 0.008), anxiety (P = 0.005), and depression (P = 0.002); males were more frequently diagnosed with ischemic heart disease (26.5% vs. 10.83%, P = 0.001) and had a higher lung transplant rate (24.9% vs. 15%, P = 0.029). Multivariate analysis revealed that female sex (hazard ratio [HR] 1.55, 95% confidence interval [95%CI] 1.06–2.29, P = 0.025), older age (HR 1.02, 95%CI 1.002–1.054, P = 0.035), ischemic heart disease (HR 1.69, 95%CI 1.12–2.48, P = 0.011), and depression (HR 1.81, 95%CI 1.15–2.83, P < 0.01) were significantly associated with increased mortality. Females showed higher 1-year mortality rates than males (40.3% vs. 29.8%, P < 0.001).

Conclusions: Female sex is a significant risk factor for increased mortality among COPD patients awaiting LT, likely due to a higher burden of co-morbidities.

Background: Lung transplantation is an advanced medical therapy reserved for patients with end-stage lung disease. Relative to other solid organ transplants, lung transplantation in children is infrequently performed. The most common etiologies for pediatric lung transplantation worldwide are cystic fibrosis, pulmonary hypertension, and children’s interstitial lung disease.

Objectives: To describe our experience in pediatric lung transplants at Israel's largest transplant center.

Methods: We performed a retrospective review of all pediatric lung transplantations conducted in our center since 1997. We recorded demographic characteristics, indication for transplantation, clinical and laboratory parameters, post-transplant complications, and survival rates.

Results: Of 965 lung transplants, 29 (3.0%) were pediatric patients who underwent lung or heart-lung transplants for end-stage lung disease. Age at transplantation ranged from 2 to 18 years, with a median of 14.0 years (IQR 11–15). Primary etiologies for transplantation were cystic fibrosis (44%), pulmonary hypertension (17%), and children’s interstitial lung disease (10%). Survival at 1, 5, 10, and 15 years post-transplant were 90%, 65%, 55%, and 20%, respectively, which is consistent with data reported by pediatric lung transplantation registries. The primary cause of mortality post-transplant was chronic lung allograft dysfunction. Four patients (13.8%) underwent re-transplant. There was no association between survival and transplant indication, nor between survival and type of procedure (lung vs. heart-lung transplant).

Conclusions: The short- and long-term outcomes from our program are consistent with published registry data. These outcomes may reflect the benefits of a centralized pediatric lung transplant program, supported by a multidisciplinary team trained in high-capacity international centers.

Background: Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to a wide spectrum of clinical severity. The gold standard diagnosis of infection is reverse transcription polymerase chain reaction of nasopharyngeal swabs, which also provides a semiquantitative assessment of viral loads by measuring cycle threshold (CT) values.

Objective: To assess whether CT values at admission can predict mortality and oxygen needs among individuals hospitalized for coronavirus disease 2019 (COVID-19).

Methods: The retrospective study included adults hospitalized for COVID-19 between 1 August 2020 and 30 April 2021 at Barzilai University Medical Center. Patients were categorized according to initial CT values as high (≥ 25) or low (< 25) values. The primary outcome was the association between CT values during admission and overall mortality.

Results: The study group included 636 patients, with a mean age of 67.2 years, 54.4% males. Overall mortality of patients with CT values < 25 was significantly higher (odds ratio for mortality 1.78 vs. patients with CT ≥ 25, P = 0.002). Significantly more patients in the low CT group required oxygen support than in the high CT group, 50% vs. 31.9% (P < 0.001). An inverse association between CT values and mortality rates remained significant in multivariate regression analysis, such that a 1-unit decrease in CT was associated with a 6% increased mortality.

Conclusions: Lower CT values at admission were associated with increased mortality among patients hospitalized for COVID-19. CT values can be used to predict outcomes among such patients.

Background: Hypertensive disorders during pregnancy can lead to significant adverse outcomes. Currently, no established and effective tests have a high predictive value for preeclampsia toxemia (PET) severity and its associated adverse outcomes.

Objectives: To investigate the correlation between the aspartate aminotransferase-to-platelet ratio index (APRI) and the risk of obstetrical and neonatal adverse outcomes in women with PET.

Methods: We conducted a population-based cohort study at a tertiary medical center, which included all women who delivered between the years 2020 and 2022 and were diagnosed with PET. Women with incomplete records, multiple gestations, and fetal malformations were excluded. The median APRI of the cohort was the cut-off point to compare the risk of obstetrical and neonatal complications between low and high APRI scores. A multivariable logistic regression was used to adjust for confounders.

Results: The study included 513 women with PET who met the inclusion criteria. The median APRI score was used as a cut-off value, resulting in 255 women with an APRI score < 0.26 and 258 with a score > 0.26. A higher APRI score was significantly correlated with a small for gestational age (SGA) newborn and preterm delivery before 34 weeks after controlling for parity, previous cesarean delivery (CD), and maternal age (adjusted odds ratio 1.60, 95% confidence interval 1.01–2.55; P = 0.047, adjusted hazard ration 1.75, 95% confidence interval 1.12–3.09, P = 0.047).

Conclusions: In patients with PET, an APRI score > 0.26 was associated with an increased risk for SGA and preterm deliveries.

Background: Despite a significant advance in prevention and treatment of heart failure (HF), patients still struggle with decreased quality of life, high mortality, and recurrent hospitalizations. Several inflammatory cytokines have been widely investigated in the pathogenesis of HF.

Objectives: To investigate the prognostic value of fibrinogen on clinical outcomes of patients admitted with acute HF.

Methods: This retrospective study was based on data of patients hospitalized with acute HF. Demographics, laboratory, and clinical outcomes including length of stay and readmissions were obtained. We compared outcomes of patients with normal (< 430 mg/dl) and high (> 430 mg/dl) fibrinogen levels.

Results: We included 149 patients (mean age 67.6 ± 12.3 years, 73.8% male). In our cohort, 24 (16.1%) had normal fibrinogen (< 430 mg/dl) and 125 (83.9%) had high fibrinogen levels (> 430 mg/dl). Among patients with readmissions for HF, fibrinogen levels were higher (622 ± 136 vs. 470 ± 68, P < 0.001) and were associated with longer hospital stay. Fibrinogen remains an independent risk factor after adjusting to age, diabetes status, and left ventricular ejection fraction.

Conclusions: High fibrinogen levels may predict readmissions in patients with HF.

Background: Limited data exist regarding the association between marital status and outcomes among octogenarian and nonagenarian patients with heart failure (HF).

Objectives: To examine the association between marital status and outcomes of octogenarian and nonagenarian patients with HF.

Methods: We conducted a retrospective analysis of 1371 octogenarians and nonagenarians who were hospitalized with HF and enrolled in the multicenter national survey in Israel between March and April 2003. The patients were followed until December 2014. Patients were classified into married (n=562) and unmarried (n=809). The clinical characteristics of the patients by marital status categories were compared by using Student's t-test for continuous variables and the chi-square test for categorical variables. Kaplan–Meier survival analysis was used to present survival estimates according to the different marital status categories and the subsequent 4-year survival probability. Multivariate stepwise Cox proportional hazard regression modeling was used to assess the independent predictors of mortality among the study population.

Results: Married patients were more likely to be male, to smoke, and to have past myocardial infarction and previous revascularization. They tended to have higher rates of peripheral vascular disease and dyslipidemia. Survival analysis showed that 4-year mortality rates were similar between married and unmarried patients. The main consistent independent predictors of 4-year mortality were age, advanced HF (New York Heart association (NYHA) > 2), advanced renal failure, low hemoglobin, high Charlson Comorbidity Index, and low admission systolic blood pressure.

Conclusions: Among the octogenarian and nonagenarian population with HF, being unmarried does not confer an increased risk of mortality. Nevertheless, unmarried patients had a different clinical profile. Higher risk profile, co-morbidities, and advanced age impact mortality among octogenarian and nonagenarian patients.