Israel Medical Association Journal

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.

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.

Chronic Q fever, caused by Coxiella burnetii, is a persistent infection that primarily affects individuals with underlying valvular or vascular abnormalities. The standard treatment regimen consists of prolonged dual therapy with doxycycline and hydroxychloroquine, typically administered for a minimum of 18 months [1]. This combination targets both the intracellular pathogen and the acidic vacuolar environment in which it resides. A key indicator of therapeutic response is the progressive decline in phase I IgG antibody titers, which is generally observed within the first few months of treatment [2].

However, in rare instances, antibody titers may remain persistently elevated despite prolonged therapy, raising concerns about treatment failure, resistance, or host-related factors. The following case highlights an unusual drug interaction that interfered with treatment efficacy, ultimately preventing complete clinical resolution.

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.

Uremic cardiomyopathy (U-CMP), also known as chronic kidney disease cardiomyopathy (CKD-CMP), is a phenotype of non-ischemic cardiomyopathy frequently seen among patients with chronic kidney disease. Left ventricular (LV) systolic dysfunction is seen in approximately 13% of patients, and LV ejection fraction (LVEF) below 40% has been reported in 5.8% of patients [1]. Severe LV dysfunction may be considered a relative contraindication to renal transplantation. We present a case of complete recovery of ventricular function following renal transplantation in a patient with severe U-CMP.