Israel Medical Association Journal

Background: National crises can significantly impact healthcare utilization patterns yet analyses of different types of crises are limited. While the effects of the coronavirus disease 2019 (COVID-19) pandemic on emergency department (ED) utilization have been well-documented, the healthcare impact of the Israel–Hamas war, which began 7 October 2023, remains unexplored.

Objectives: To compare ED utilization patterns for non-traumatic low back pain (LBP) during two distinct national crises.

Methods: We conducted a retrospective observational study analyzing ED visits for non-traumatic LBP at our medical center. We compared ED utilization patterns, visual analog scale (VAS) pain scores, and surgical rates during 60 days before and after two distinct dates: 7 October 2023 and 19 March 2020 (the start of the COVID-19 lockdown). Statistical analysis included independent t-tests for continuous variables and chi-square tests for categorical variables.

Results: Following 7 October, ED visits decreased by 28.6% (504 to 360). Mean VAS scores and surgery rates showed a non-significant increase from 5.5 ± 2.6 to 5.8 ± 2.4, and from 3.0% to 4.2%, respectively. During the COVID-19 lockdown, ED visits declined by 44.2%, with non-significant changes in pain scores (6.0 ± 3.0 to 5.5 ± 2.9) and surgical rates (3.5% to 2.5%).

Conclusions: Both events led to significant reductions in ED utilization for non-traumatic LBP, despite the heightened risk factors. Surgical rates remained stable, yet many symptomatic patients may have foregone adequate care. These findings underscore the need for resilient, crisis-specific emergency preparedness strategies to ensure continued access to care.

Background: Coronavirus disease 2019 (COVID-19) causes severe complications in 15% of patients, many of whom are pregnant. Most infected women continue their pregnancies until term even though severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) replicates in the decidua.

Objectives: To assess the impact of SARS-CoV-2 infection remote from delivery on obstetric outcomes.

Methods: Women diagnosed with SARS-CoV-2 infection confirmed by polymerase chain reaction at least 14 days prior to delivery were enrolled prospectively and followed monthly until delivery. Their obstetric outcomes were compared to those of women who gave birth at our center during the year preceding the pandemic. The primary endpoint was a composite of hypertensive disorders of pregnancy, oligohydramnios, and fetal distress or meconium-stained amniotic fluid during labor. Other demographic and obstetric variables were also recorded.

Results: The obstetric outcomes of 143 patients were compared to those of 3565 patients who gave birth during the year preceding the pandemic. The composite rate of placental complications was significantly higher in the study group (58 [41%] vs. 593 [17%], respectively), with an odds ratio of 3.4 (95% confidence interval 2.4–4.7). There was also an increased rate of labor induction or advancing the elective cesarean date in the study group (37 [26%] vs. 601 [17%]). No significant differences were found in the Apgar score, cord pH or gestational age at infection.

Conclusions: The risk of placental complications remains greater in pregnant women infected with SARS-CoV-2 after acute illness resolution. Those patients should be monitored closely until delivery.

Background: Electrocardiogram (ECG) may detect atrial fibrillation (AF), but the true rate of ECG performance is unknown.

Objectives: To explore the performance rate of ECG testing in patient populations at high risk for AF in a real-world cohort and to explore the incidence of newly diagnosed AF.

Methods: This retrospective observational cohort study included de-identified data of members of Maccabi Health Services older than 65 years, excluding patients with prior AF and other cardiac diseases. Patients were followed between 1 January 2016 and 30 September 2020. The number of ECGs performed in an outpatient setting for each patient was reported.

Results: In total, 211,515 patients (59.8% female) were included. The mean age was 70.3 ± 6.6 years, with a mean CHA₂DS₂-VASc score of 2.6 ± 1.0. During the study period, over half of the patients (n=112,340; 53.1%) did not undergo any ECG tests, 51,644 patients (24.4%) had one ECG, 24,914 patients (11.8%) had two, while 22,617 patients (10.7%) had more than three. Of the patients referred for an ECG, 67,433 (81.1%) underwent ECG testing within 2 months following the referral. The median time from ECG referral to ECG testing was 5 days.

Conclusions: Most patients older than 65 years had no ECG tests within a 5-year period. However, when referred to an ECG test, most patients complied within a median of 5 days.

Background: Postoperative atrial fibrillation (POAF) is well recognized after cardiac surgery; however, its incidence and clinical course following non-cardiac surgery (NCS) remain unclear.

Objectives: To evaluate the association between POAF after NCS, patient co-morbidities, and type of surgery.

Methods: In this retrospective cohort study, patients who underwent NCS at a private hospital network between 2016 and 2023 were included. Patients with a history of atrial fibrillation (AF) were excluded. Patients who developed POAF within 24-48 hours were compared with those who did not. To address baseline differences, propensity score matching (1:10) and inverse probability weighting combined with Firth’s penalized logistic regression were applied. Odds ratios with 95% confidence intervals were calculated.

Results: POAF developed in 174 patients within 24–48 hours postoperatively, compared with 391,329 controls. Older age, ischemic heart disease, diabetes, and prior stroke were associated with increased odds of POAF, although significance diminished after multivariable adjustment. Weighted regression confirmed these findings with narrower confidence intervals. Higher POAF risk was observed after laparoscopic pancreatectomy, hepatectomy, rectopexy, synovectomy, and gastrectomy. Total knee replacement was the most common procedure among POAF cases, representing 22% of cases and a fourfold increased risk.

Conclusions: Advanced age and cardiovascular co-morbidities were associated with increased POAF risk after NCS, although attenuated after adjustment. Consistent findings across statistical models support the robustness of the results. Targeted monitoring in high-risk patients may improve postoperative outcomes.

In this review article, we evaluated experimental evidence supporting the pathogenic role of autoantibodies in rheumatic diseases and selected non-rheumatic autoimmune disorders. We conducted a narrative mechanistic review focusing on experimental studies, which employed passive transfer of patient-derived immunoglobulins or active immunization with defined autoantigens capable of reproducing disease-relevant phenotypes in vivo or ex vivo. Strong experimental evidence supports direct pathogenicity for several rheumatologic autoantibodies, including anti-citrullinated protein antibodies (ACPA), anti-myeloperoxidase (MPO) ANCA, anti-β2-glycoprotein I, anti-Ro/SSA, and anti-ribosomal P antibodies. These autoantibodies induce tissue-specific injury through mechanisms involving complement activation, Fcγ receptor engagement, inflammatory amplification, and antigen accessibility. Representative non-rheumatic autoimmune models, including pemphigus vulgaris, neuromyelitis optica spectrum disorder, and myasthenia gravis, further reinforce the generalizability of antibody-mediated tissue injury across autoimmune medicine. Passive transfer and active immunization studies provide compelling evidence that selected autoantibodies are not merely biomarkers, but active mediators of tissue injury under permissive biological conditions. These findings support the development of targeted therapies directed against pathogenic antibodies, complement pathways, and Fc-mediated effector mechanisms across rheumatic and autoimmune diseases.

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.