Israel Medical Association Journal

The Israel Defense Forces Medical Corps (IDF-MC) is often associated with battlefield trauma and emergency care. While these domains remain central to the IDF mission, they represent only a fraction of a much broader professional landscape. The IDF-MC serves as a unique and multifaceted platform for clinical research, which is characterized by diverse occupational environments, specialized populations, and acute operational challenges.

Background: Noise-induced hearing loss (NIHL) is a prevalent hearing impairment, second only to age-related hearing loss. A change in the listening habits of adolescents may have contributed to the documented increase of hearing impairments in that age group.

Objectives: To examine the prevalence of NIHL among healthy young adults.

Methods: We conducted a retrospective study to examine audiograms of healthy candidates for the Israeli Air Force flight academy between 2018 and 2023. Hearing tests were performed by an expert audiologist using an audiometer.

Results: A total of 1940 audiograms were analyzed. The age range of the patients was 17–19 years. Using the British Society of Audiology classification, 174 (8.97%) audiograms and 313 frequencies were classified as impaired. The 8 kHz was the most affected frequency, accounting for 116 cases (37%).

Conclusions: Hearing impairment prevalence increased from 1% at entry into the education system to 8.45% at the end, respectively. Detecting hearing impairments early may minimize future disability and may reduce future disability and rehabilitation costs. Hearing screens for young adults due to the change in listening habits of adolescents may prove useful.

Background: Decompression sickness (DCS) is a clinical syndrome caused by a substantial reduction in barometric pressure. DCS is more common among divers but may also occur during flight or altitude chamber (hypobaric chamber) training. DCS is classified according to symptoms as either Type 1 (musculoskeletal and skin involvement) or Type 2 (neurological and pulmonary involvement). DCS may be life threatening and often necessitates treatment with hyperbaric oxygen therapy (HBOT).

Objectives: To examine the risk for altitude decompression sickness (ADCS) in altitude chamber training and to compare ADCS symptoms and treatment to those of DCS in divers (DDCS).

Methods: We conducted a retrospective cohort study that included all cases of ADCS in the Israeli Air Force between 2015 to 2022. We collected demographic, flight platform, altitude chamber training, clinical manifestations, and treatment data. Data regarding DDCS was obtained via a literature review.

Results: There were 2279 altitude chamber trainees and aviation physiology instructors. Of these, 11 presented ADCS, leading to a calculated ADCS risk of 0.5%. An additional four cases were reported following combat flights. Musculoskeletal involvement was the most common symptom in both DDCS and ADCS. A shorter HBOT protocol was used in 53% of the ADCS cases but only in 30% of the DDCS cases.

Conclusions: Overall, ADCS is a rare event, occurring in less than 1% of altitude chamber trainees. The common manifestation is of musculoskeletal involvement, and the mainstay of treatment remains HBOT.

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: Asthma poses unique challenges in aviation medicine. While strict criteria typically dictate waiver approvals in military aviators with asthma, the Israeli Air Force (IAF) applies a more individualized approach. Still, evidence to guide correct management is scarce.

Objectives: To assess the characteristics and long-term outcomes of military aircrew diagnosed with asthma.

Methods: This retrospective study included active and reserve aircrew who were diagnosed with asthma during annual assessments at the Israeli Aeromedical Unit between 1998 and 2024. Baseline characteristics, treatment regimes, pulmonary function tests (PFTs), and asthma exacerbations were analyzed.

Results: Thirty-two aircrew personnel (median age 30 years at diagnosis) were included in the study, with 44% serving at high-performance platforms. Six participants (19%) were classified as Global Initiative for Asthma step 4 or 5. Over an average follow-up period of 18.5 years, seven exacerbations were documented (4.0 per 100 patient-years), with no safety incidents reported. Participants' pulmonary function remained stable. Forced expiratory volume in 1 second (FEV₁) and FEV₁/forced vital capacity (FVC) declined around asthma diagnosis (median of 82% predicted and 0.73, respectively) but recovered remarkably while on treatment (median 91% predicted and 0.78, respectively). Aircrew who experienced exacerbations had no statistically significant differences in demographics, disease severity or baseline PFTs.

Conclusions: With individualized management and regular monitoring, a new diagnosis of asthma in military aircrew was not associated with a significant impact on service. Our study supports a flexible, individualized approach to aeromedical management of aircrew with asthma.

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.

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: Combat-related penetrating neck injuries (PNI) present distinct challenges in surgical settings. Accurate identification and removal of metallic fragments are crucial for minimizing complications. Although computed tomography (CT) remains the gold standard for preoperative assessment, use of intraoperative metal detectors may offer supplementary advantages by enhancing surgical accuracy and efficiency.

Objectives: To assess the technical feasibility of intraoperative metal detector assistance vs. a CT-guided primary approach.

Methods: Cadaver heads were implanted with metallic fragments from verified military-grade ordnance and subsequently underwent a CT scan. Two extraction approaches were evaluated: intraoperative metal detector assistance vs. CT-guided primary approach. Key metrics included incision length, dissection time, incision extension, and surgeon workload as assessed by the Surgery Task Load Index questionnaire.

Results: Metal detector-assisted extraction resulted in reduced initial incision lengths (3.50 cm vs. 4.87 cm) and smaller incision extensions (0.33 cm vs. 0.67 cm), indicating improved precision. However, the average dissection time was longer in the metal detector group (15:00 vs. 12:20 minutes), likely due to learning curves and additional scanning requirements. Surgeons reported lower situational stress (2.25 vs. 4.5) and reduced task complexity (4.0 vs. 4.5) when using a metal detector, despite noting increased mental demand associated with interpreting device signals during surgery.

Conclusions: Intraoperative metal detection technology shows significant potential as an adjunctive modality for shrapnel localization in combat-associated PNIs. It facilitates minimized incisions and improved surgical precision. While further optimization and clinical adaptation are necessary, this method holds promise for improving outcomes in both military and civilian trauma scenarios.

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: Mucopolysaccharidosis type II (Hunter syndrome [MPS II]) is a rare, progressive, lysosomal storage disorder, often diagnosed late due to nonspecific early features and limited clinical awareness.

Objectives: To highlight the role of pediatric surgeons in early recognition based on clinical and surgical presentations.

Methods: We retrospectively reviewed patients diagnosed with MPS II at our institution focusing on presenting symptoms, timing of diagnosis, and factors leading to diagnostic suspicion and treatment.

Results: Four boys were diagnosed between 2012 and 2021. Three were diagnosed at 2.5–4 years of age following typical systemic manifestations. The fourth patient was suspected earlier by a pediatric surgeon, whose prior familiarity with similar reported cases enabled recognition of the clinical pattern and led to an earlier diagnosis.

Conclusions: Increased awareness and clinical familiarity among pediatric surgeons are essential for early recognition of MPS II. Recognition of early surgical patterns, such as hernias and recurrent procedures in early childhood, highlights the role of pediatric surgeons in raising diagnostic suspicion, facilitating earlier diagnosis, and enabling earlier initiation of enzyme replacement therapy before disease progression, ultimately improving clinical outcomes.

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: Ultra-short-echo magnetic resonance imaging (MRI) sequences improve visualization of bone cortex and enable the generation of an MRI-based computed tomography (CT)-like (CT-l) images.

Objectives: To compare the agreement between CT-l images derived from merged fast-field echo (MFFE) sequence with conventional CT (cCT) for detecting sacroiliitis-associated structural lesions.

Methods: Consecutive MRI and conventional CT examinations (maximum one-year interval) of the sacroiliac joints (SIJ) of patients with suspected sacroiliitis, performed between 2022 and 2023 were retrospectively evaluated by a musculoskeletal radiologist and a third-year resident who evaluated half of the study’s images for the presence of erosions, sclerosis, and ankylosis on semicoronal CT-l and cCT-SIJ images. Cohen’s kappa was used to compare the results between the two modalities. The diagnostic performance of the CT-l was analyzed using cCT as the reference standard. Inter-reader reliability was assessed using intraclass correlation coefficients (ICCs) between the two readers.

Results: Sacroiliitis was detected in 11 patients (21%). Erosions, sclerosis, and ankylosis were detected in 44%/31%, 48%/42%, 4%/4% on CT-l/cCT, respectively. Statistical analysis regarding ankylosis was not feasible due to its low prevalence. Cohen's kappa agreement between modalities was substantial for erosions (0.68) and almost perfect for sclerosis (0.92). Sensitivity and specificity of CT-l were 0.90 and 0.69 for erosions and 0.72 and 0.91 for sclerosis, respectively. The ICC on CT-l/cCT for detecting erosions was 0.72/0.68 and 0.84/0.91 for sclerosis.

Conclusions: CT-l MRI sequence is a promising, radiation-free alternative to conventional CT for detecting structural lesions in SIJs, with high diagnostic performance and inter-reader agreement.

Background: Indwelling catheters are commonly used in non-intensive care internal medicine patients. They are associated with significant side effects.

Objectives: To determine the proportion of warranted indwelling catheters and factors associated with inappropriate use.

Methods: We included consecutive patients hospitalized in three internal medicine departments from 2020 to 2021. We determined the proportion of urinary catheters inserted in the emergency department that were retained inappropriately for monitoring urine outputs. The area under the curve (AUC) was used to determine the ability of the logistic regression model to predict inappropriate use of urinary catheterizations.

Results: Of 11,542 patients, 625 (5.4%) were excluded because they were admitted with a permanent catheter. The urinary indwelling catheterization rate was 13.3% (1454/10,917), which was appropriate in 4.9% (n=533). Patients with an unjustified indwelling catheter had a 3.75-fold (95% confidence interval 3.2–4.4) increase of prolonged hospitalization. Approximately 13 cases of a catheter associated urinary tract infection and 9% (83/921) of those with an unjustified indwelling catheter were discharged with the catheter in place. Older age, female sex, nursing assessments of patient frailty, urinary tract diseases, congestive heart failure, respiratory tract, and infectious diseases were independently associated with inappropriate use (AUC 0.847, 95% confidence interval 0.841–0.854).

Conclusion: Indwelling urinary catheters are justified in less than 5% of non-intensive care internal medicine patients and associated with significant side effects. Efforts to reduce inappropriate catheterizations might focus on frail elderly patients with infections and those presenting with urinary tract diseases, congestive heart failure, respiratory tract, and other infectious diseases.