Israel Medical Association Journal

Background: Co-infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) affects approximately 2.2 million people globally and is associated with accelerated liver disease progression, increased morbidity, and reduced quality of life (QoL). While direct-acting antivirals (DAAs) have revolutionized HCV treatment with high cure rates, evidence of their long-term impact on liver-related QoL and associated metabolic or immunologic shifts in HIV/HCV co-infected populations remains limited.

Objectives: To evaluate the effect of achieving sustained virologic response (SVR) with DAAs on long-term QoL in HIV/HCV co-infected patients and to examine associated changes in CD4 count, kidney function, and glucose levels.

Methods: This retrospective observational study was conducted at the Rambam Health Care Campus, between 2015 and 2019. We collected demographic, clinical, and laboratory data from all patients with HIV/HCV co-infection. QoL was evaluated for at least 6 months after the end of treatment. Metabolic variables were collected before and after treatment to test the effects of treatment.

Results: All 70 patients in the cohort achieved SVR. Successful treatment with DAAs resulted in a significant decrease in liver enzymes and globulin levels, and a substantial increase in CD4. A significant improvement in QoL after treatment was noticed in both sexes, regardless of liver fibrosis stage. FIB-4 calculations 6 months and 1 year after the end of therapy showed improved fibrosis levels after SVR.

Conclusions: The use of DAAs in HCV/HIV co-infected patients has improved the long-term QoL, metabolic factors, and fibrosis stage.

Polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma-cell disorder, and skin changes (POEMS syndrome) is a rare multisystem paraneoplastic disorder driven by a plasma-cell dyscrasia and cytokine overproduction. It is often misdiagnosed as chronic inflammatory demyelinating polyneuropathy (CIDP) due to overlapping neuropathy [1]. Although thrombocytosis is typical, immune thrombocytopenia is a rare and underrecognized presentation. We describe a patient with longstanding immune thrombocytopenic purpura (ITP) that evolved to POEMS, developed sinusoidal obstruction syndrome (SOS) after an autologous stem-cell transplantation (ASCT), and remained cytopenic due to hypersplenism, highlighting diagnostic and therapeutic challenges.

A persistently irregular wide complex tachycardia is usually related to atrial fibrillation with aberrant conduction but it rarely has a ventricular origin. We present a case of irregular ventricular tachycardia (VT) associated with reversible cardiomyopathy.

Achilles tendinitis commonly occurs in runners due to overuse of the tendon. Sometimes it may be caused by inflammatory diseases like rheumatoid arthritis and psoriasis or by medications such as steroids and fluoroquinolones. It has never been mentioned in association with gait disturbances caused by abnormal foot pronation and standing due to radicular neuropathy. We reported a case of Achilles tendinitis that developed in a patient with spinal stenosis, radicular injury, and accompanying drop foot.

Surgical aortic valve replacement (SAVR) is the treatment of choice for patients with severe aortic stenosis (sAS). Balloon aortic valvuloplasty (BAV) was developed 40 years ago, and it was an alternative to conventional SAVR in elderly and frail patients for whom there were no other effective therapeutic options [1].

Transcatheter aortic valve intervention (TAVI) has expanded its indications during the last 20 years, from prohibitively high surgical risk of mortality to intermediate risk patients [2].

We reported a case of BAV that was used as a bridge to TAVI in an elderly patient with sAS, congestive heart failure (CHF), and ischemic hepatitis (IH).

Freshwater injuries often pose diagnostic challenges due to occult entry wounds and the risk of infection from environmental pathogens. We report a rare case of an embedded live-derived (biologic) foreign body, Theodoxus jordani, in the hand after rafting trauma on the Jordan River, emphasizing early imaging, prompt extraction, and environment-appropriate antimicrobial coverage.

Polycythemia vera (PV) is a chronic, Philadelphia chromosome-negative myeloproliferative neoplasm primarily driven by the Janus kinase 2 (JAK2) V617F mutation. PV leads to clonal erythrocytosis and is frequently accompanied in laboratory blood tests with leukocytosis and thrombocytosis. The diagnostic approach to PV is based on increased red cell volume and the presence of a JAK2 mutation [1]. PV should not be defined solely by hemoglobin or hematocrit values. In a large study of the genomic landscape of myeloproliferative neoplasms, approximately 65% of patients with PV had at least one additional mutation in addition to the driver mutation, most commonly in TET2, DNMT3A, and ASXL1 genes [2].

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.

Patient Safety and Risk Management in Medicine: From Theory to Practice by Yaron Niv and Yossi Tal, published in 2023 by Springer Nature, is a comprehensive and timely resource dedicated to the theory and practical aspects of patient safety and risk management and focusing on the systemic approach to minimizing harm in healthcare settings.

In 1999, the U.S. Institute of Medicine (IOM) declared that rather than assigning blame for medical errors, professional investigations should be conducted to identify what caused them and how to prevent similar events from occurring in the future. The focus was on systemic factors. It is estimated that in the United States alone, there are between 250,000 and 400,000 preventable deaths annually due to medical errors, costing over US$15 billion per year.

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.