Israel Medical Association Journal

Background: Exertional heat stroke (EHS) is common among individuals engaged in high-intensity physical activity. It can lead to long-term organ damage and be a life-threatening condition when diagnosed and treated incorrectly.

Objectives: To track the changes in biomarkers among EHS patients, to suggest a standardized protocol of clinically relevant biomarkers to be followed during hospitalization

Methods: We conducted a retrospective analysis on biomarker changes in seven EHS patients (aged 18–25 years) who were hospitalized for a minimum of 84 hours. Diagnosis of heat stroke was based on extreme body temperature and neurological deficits. Biomarkers indicative of kidney function, liver function, coagulation, muscle breakdown, and systemic inflammation during their hospitalization were analyzed.

Results: The initial average rectal temperature (T_re) was 41.1°C. Patients were cooled to approximately 38.5°C before being transferred to the emergency department (ED). Within the first 24–36 hours of hospitalization, biomarker levels reach peak levels depending on EHS severity. Renal biomarkers rose to 1.5–3 times normal values, while transaminases increased 7–15 times. Creatine phosphokinase, indicating muscle injury, reached an average of 100 times its reference range. Within 24–72 hours. all biomarker levels were normalized.

Conclusions: There is often a gap between the initial temperature of an EHS patient and the temperature recorded at ED admission after cooling. Accurate assessment is context-specific and requires precise biomarker follow-up. Clinical evaluation should continue for at least 48 hours to track organ damage and guide prognosis.

Background: Blast injuries impair hearing through several mechanisms that are distinct from other causes of acute acoustic trauma (AAT).

Objectives: To compare blast injured patients to those exposed to noise alone in their auditory response to hyperbaric oxygen (HBO) therapy with oral steroids.

Methods: Adult patients with evidence of a previously undocumented ≥ 30 dB pure-tone threshold within 30 days of AAT were treated with a combination of one 2.5 atm HBO therapy session for 90 minutes daily with oral prednisone. Exposure was classified by history as blast (for explosion-induced AAT) or noise. The change in high pure tone average (HPTA) was the primary outcome.

Results: Of 598 ears (387 patients) included in the final analysis, 259 were exposed to blast and 339 to noise. Before treatment, the blast injured patients had significantly more abnormal findings on otoscopy (87% vs. 95%, P = 0.003), higher pure-tone average (18 ± 11 dB vs 12 ± 9 dB; P < 0.001), and higher speech reception thresholds (16 ± 14 dB vs 10 ± 8 dB, P < 0.001). Following treatment, these patients exhibited a significantly smaller improvement in HPTA (6 ± 17 dB vs 10 ± 14 dB P = 0.022) with pure tone thresholds remaining significantly worse across all frequencies in the blast exposed group (mean difference ranging from 3.2 to 6.8 dB, all P < 0.05).

Conclusions: Blast injuries result in unique auditory characteristics and responses to HBO therapy compared to other causes of AAT.

Background: Post-traumatic stress disorder (PTSD) remains a significant and often refractory mental health condition. Hyperbaric oxygen (HBO) therapy has demonstrated promise in alleviating symptoms of PTSD but optimal dosing and treatment duration remain unclear.

Objectives: To evaluate the clinical efficacy and dosing effects of two HBO protocols in patients with PTSD.

Methods: We conducted a randomized controlled trial comparing two HBO protocols: 60 daily sessions of 90 minutes at either 2.0 atmospheres absolute (ATA) or 2.5 ATA (HBO15). Adults with severe PTSD (Clinician Administered PTSD Score [CAPS]-5 ≥ 33) were randomized to treatment arms. CAPS-5 scores were recorded every 2 weeks. Secondary outcomes include measures of depression, sleep, executive function, and safety. Preliminary results are presented for the first nine patients who completed therapy (HBO10: n=5; HBO15: n=4).

Results: Participants in HBO15 were younger (mean age 39 vs. 59 years, P = 0.2). Baseline PTSD severity (CAPS-5) was higher in HBO15 (median 61.5 vs. 48.0, P = 0.4). Other baseline psychological scores were similar between groups. Mean CAPS-5 improvement (ΔCAPS) was greater in HBO15 (-14.0 ± 21.2) vs. HBO10 (-5.3 ± 19.6), although not statistically significant (P = 0.8). Both groups demonstrated the largest symptom reduction by weeks 6–8, with a plateau observed thereafter despite continued treatment through week 12.

Conclusions: Preliminary data suggest both HBO protocols are associated with symptomatic improvement in PTSD, with a trend toward greater effect in the higher-pressure group (2.5 ATA). Improvements appear to peak around 6–8 weeks, potentially indicating a shorter optimal treatment duration.

Operational forces increasingly face concurrent sleep restrictions and thermal strain, yet mission planning lacks field-relevant guidance on their combined cognitive effects and management. This critical narrative review synthesizes laboratory, field, and military-relevant evidence on how sleep loss and heat stress affect sustained attention, drowsiness, reaction time, executive control, and feedback-guided decision making. Sleep deprivation produces dose-responsive vigilance instability across total sleep deprivation and chronic partial restriction, with lapses and response-time variability providing sensitive monitoring endpoints. Heat stress produces task-dependent cognitive costs. Simple reaction time may remain relatively preserved during modest strain, whereas executive control, working memory, inhibition, and cognitive flexibility appear more vulnerable as physiological reserve narrows, particularly during dehydration, exertion, and protective equipment use.

Military multistressor studies show broad cognitive deterioration when sleep restriction co-occurs with heat, dehydration, undernutrition, and sustained workload. However, bundled designs cannot determine whether sleep and heat act additively, synergistically, or through threshold-dependent interactions. Key gaps include factorial sleep × heat trials, standardized cognitive batteries, mechanistic telemetry, and prospective modeling of moderators such as trait-like sleep-loss vulnerability, baseline sleep debt, chronotype, heat acclimation, hydration practices, protective-equipment burden, and sex. Commanders and medical planners should treat concurrent sleep restriction and thermal strain as a compounded operational risk state and apply layered controls, including protected sleep, scheduling, cooling, hydration, work-rest cycles, objective vigilance screening, task rotation, and supervisory cross-checks for high-consequence decisions.

Peripheral facial nerve palsy is an infrequent but well-recognized clinical presentation encountered by primary care and emergency department physicians. Risk factors include diabetes mellitus (DM) and hypertension, both of which are also associated with an increased risk of cerebrovascular accident, which is a critical consideration in the differential diagnosis [1]. Prompt and accurate differentiation between central and peripheral etiologies is crucial in the initial evaluation of facial palsy. Notably, approximately 5% of cases may be secondary to neoplastic processes, whether benign or malignant [1].

Small cell carcinoma of cervix (SCCC) is a rare and aggressive high-grade neuroendocrine tumor [2]. Neurologic manifestations due to brain metastases from neuroendocrine cancers of the cervix are extremely rare, with no prior reports involving the facial nerve [3].

We report a unique case in which peripheral facial nerve palsy was the initial clinical manifestation of SCCC. This case highlights the importance of maintaining a broad differential diagnosis and underscores the pivotal role of a comprehensive history and physical examination as part of a systematic and holistic approach when evaluating patients presenting with facial nerve palsy.

A 32-year-old man with Down syndrome (DS), nonverbal due to severe cognitive impairment, presented to the emergency department after sustaining a fall from standing, causing trauma to his left hip. He had no known chronic medication use. His previous medical history included hospitalizations for severe COVID-2019 in 2021 and herpes simplex virus stomatitis in 2017. Following the fall, he was unable to bear weight on the affected limb. On physical examination, his left leg was externally rotated with preserved neurovascular status. Given the mechanism of injury and clinical presentation, non-contrast computed tomography (NCCT) was obtained to assess fractures and underlying pathology [Figure 1A].

We report the first successful implantation of the CARMAT Aeson® total artificial heart (TAH) in Israel, performed as a bridge to transplantation in a patient with advanced biventricular heart failure and severe right ventricular dysfunction precluding left ventricular assist device (LVAD) therapy. The CARMAT Aeson® TAH is a next generation bioprosthetic device equipped with biological valves, hemocompatible membranes, and an integrated sensor array that enables autoregulation of stroke volume to balance left and right circulation, thereby reducing thrombogenicity and improving physiological adaptation. Following implantation, the patient demonstrated rapid hemodynamic stabilization, complete weaning from inotropes, and marked functional recovery. Remarkably, during the index hospitalization he underwent successful elective inguinal hernia repair under general anesthesia, a procedure previously deemed prohibitive due to high cardiovascular risk. This patient is the first CARMAT TAH recipient to undergoing a non-cardiac surgical procedure. Perioperative interruption of anticoagulation was achieved safely without thromboembolic complications, underscoring the device’s biocompatibility and reduced thrombogenicity compared with continuous-flow VADs. The patient was discharged home on postoperative day 61 in an ambulatory state, clinically stable, and remains actively listed for heart transplantation. This case highlights the feasibility and safety of the CARMAT Aeson® TAH in patients with end-stage biventricular failure, with potential advantages over continuous-flow devices, including pulsatile physiology, autoregulation, and reduced risk of bleeding or thrombotic complications. These advantages strengthen its role as an important bridging strategy to heart transplantation.

A 65-year-old man had a long history of gout attacks, beginning at the age of 35 years. The disease was never well controlled. The patient did not follow diets, nor did he adhere to medication recommendations. He presented with systemic arterial hypertension, overweight (body mass index 29 kg/m²), and metabolic syndrome.

The Holocaust represents an extreme failure of medical ethics, with physicians actively involved in crimes against humanity. Rheumatology is directly affected through eponyms that honor Nazi perpetrators and through persistent musculoskeletal consequences observed in Holocaust survivors. In this article, we critically analyzed symbolic (nomenclature) and biological (trauma-related disability) legacies of Nazism in rheumatology. Narrative reviews of PubMed/MEDLINE, Scopus, and Israel Medical Association Journal (IMAJ) as well as key historiographic analyses and clinical studies of musculoskeletal outcomes among Holocaust survivors were included. Ethical codes emerging post-Holocaust (Nuremberg Code and Declaration of Helsinki) were integrated. Renaming Reiter’s syndrome as reactive arthritis and Wegener’s granulomatosis as granulomatosis with polyangiitis represents ethical correction. Clinical evidence shows Holocaust survivors experience such as reduced functional recovery after hip fracture, lower perceived health despite similar objective measures, and greater cardiovascular burden impairing rehabilitation tolerance. Rheumatology must align nomenclature with ethical responsibility and recognize trauma-associated musculoskeletal vulnerability. Historical memory should guide clinical decisions, language, and education

Background: Gait disturbances are common in patients undergoing hemodialysis and are associated with increased fall risk, mobility decline, and adverse health outcomes. Prior research suggests that hemodialysis may impact gait parameters such as speed, stride length, and variability; however, findings are inconsistent.

Objectives: To evaluate acute changes in gait metrics before and after hemodialysis using an artificial intelligence (AI) based video gait analysis system.

Methods: We initially enrolled 38 hemodialysis patients, two were excluded due to clothing interference with video analysis (27.8% female, 72.2% male). AI-driven gait analysis was performed immediately before and after dialysis. The system extracted spatiotemporal gait and joint range of motion. Statistical analyses included the Shapiro-Wilk test for normality, Wilcoxon signed-rank tests for non-normally distributed data, and paired t-tests for normally distributed data (P < 0.05).

Results: Gait speed (0.59 m/sec pre-dialysis) remained unchanged post-dialysis (P = 0.876), as did cycle length and time. However, step length significantly decreased post-dialysis (P = 0.001), suggesting a more conservative gait pattern. Knee flexion and extension increased slightly but did not reach statistical significance.

Conclusions: Dialysis does not acutely affect overall gait speed but significantly reduces stride length. Post-dialysis fatigue or hemodynamic shifts may alter walking patterns, highlighting the need for fall prevention strategies and physical rehabilitation interventions in dialysis care. AI-based gait analysis may provide a practical tool for monitoring mobility changes in hemodialysis patients.

Background: Patient satisfaction is a key indicator of healthcare quality, influencing treatment adherence, clinical outcomes, and hospital reputation. The relationship between length of hospital stay (LOS) and patient satisfaction in neurological inpatients remains understudied, particularly regarding sex differences and neurological diagnosis types.

Objectives: To understand how LOS influences satisfaction and patient experience. To evaluate care strategies and improve communication in neurological settings.

Methods: We conducted a retrospective observational study of 181 patients admitted to the neurology department at Sheba Medical Center between January 2023 and January 2025. Patient satisfaction was assessed using a standardized survey covering overall experience, communication with medical staff, and the discharge process. We used partial correlation analyses and multivariate ANOVA to explore associations of LOS, sex, diagnosis, and satisfaction.

Results: A significant negative correlation was found between LOS and patient satisfaction (r = -0.19, P = 0.012), as well as with perceptions of competency (r = -0.22, P = 0.004), physician communication, and involvement in treatment decisions. Females reported lower satisfaction than males, particularly regarding hospitalization conditions, the discharge process, and staff communication. Diagnosis-specific differences also emerged, with females diagnosed with headache consistently reporting the lowest satisfaction ratings.

Conclusions: Longer hospital stays were associated with lower patient satisfaction. Female sex and diagnosis of headaches influenced patient satisfaction the most. These findings highlight the need for improved communication and enhanced discharge planning to optimize patient satisfaction in neurological settings. Addressing these factors may contribute to more patient-centered care and better overall experiences for hospitalized neurological patients.

Artificial intelligence (AI) has become the emblem of progress. We are told it learns faster, sees patterns invisible to the human eye, and will soon outthink us in every domain, from finance to philosophy, from language to life. In medicine, where decisions carry the weight of saving lives, this narrative has gained traction. Algorithms promise precision without fatigue, accuracy without bias, and reproducibility without emotion. Yet, sometimes, the data tell a quieter story.

The fourth edition of Recurrent Pregnancy Loss: Causes, Controversies and Treatment summarizes the controversies and discuss the scientific basis for the various causes of recurrent pregnancy loss in depth and to clarify the various treatment modalities. The book shows a radical departure from the format of the previous three editions and succeeds profoundly in satisfying its objective. This book, first published in 2007, the second edition in 2014, and the third edition in 2020 became the foremost and most comprehensive work on recurrent pregnancy loss. In the fourth edition there are new chapters on the epigenetics of recurrent pregnancy loss, biochemical pregnancies, inflammatory placental disorders, artificial intelligence, and the role of hydroxychloroquine. This edition also discusses whether the decline in male infertility is reflected in recurrent pregnancy loss.

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.

It begins with a siren, a deep, pulsating wail tearing through the night over Tel Aviv. It is 3:42 in the morning. A university student jolts awake and rushes to a reinforced room. A young couple gathers their infant and runs for the stairwell. An elderly man descends slowly toward a neighborhood shelter. They each have 90 seconds or less to get to safety. Since 7 October 2023, Israel’s Home Front Command has issued over 60,000 rocket alerts and more than 7000 UAV alerts nationwide. For much of the population, this interval, often shorter near border regions, marks the boundary between safety and danger. Beyond acute threat, these alerts impose a repeated physiological stressor that intrudes into one of the most vulnerable human states: sleep.