Israel Medical Association Journal

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: 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: 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: Transgender and gender diverse (TGD) adolescents often experience higher rates of psychiatric co-morbidities, autism spectrum disorder (ASD), and autistic traits. A few studies have described TGD adolescents who were referred to psychiatric clinics. To the best of our knowledge, no study has yet compared clinical characteristics of autistic vs. nonautistic TGD adolescents.

Objectives: To describe the demographic and clinical characteristics of TGD adolescents referred to a tertiary child and adolescent psychiatric clinic, and to compare the characteristics of autistic and nonautistic TGD adolescents.

Methods: We conducted a retrospective study of 28 TDG adolescents who were consecutively referred for psychiatric evaluation in a child and adolescent psychiatric clinic at a tertiary children's hospital between December 2020 and February 2023. Data were collected from electronic medical files.

Results: Of the sample, 67.9% first questioned their gender identity after the onset of secondary sex characteristics (pubertal onset) and 35.7% were identified as gifted. The gifted group had a higher rate of pubertal onset compared to the nongifted group. Our cohort exhibited a higher rate of ASD (39.3%) than the general population. Autistic compared to nonautistic TGD adolescents had a higher rate of giftedness and a lower rate of social transition.

Conclusions: TGD adolescents referred for psychiatric evaluation display distinct features, including high rates of ASD, giftedness, and pubertal onset. Autistic compared to nonautistic TGD are more likely to be gifted and less likely to have undergone social transition.

Cerebral arterial air embolism (CAAE) is a rare, but often fatal, complication of interventional bronchoscopy. Despite its rarity, a high index of suspicion can facilitate early diagnosis and prompt treatment. Standard of care treatment for CAAE is hyperbaric oxygen therapy, despite limited definitive data supporting its efficacy, given the conceptual potential for reversibility of neurological impairment. We describe five cases from our institution, and review the clinical presentation, pathophysiology, diagnosis, and management of suspected CAAE. Based on published case reports involving transbronchial lung biopsies (TBLB), standard of care treatment for CAAE secondary to TBLB is hyperbaric oxygen therapy, although its efficacy in this context has not been unambiguously validated in clinical practice.

Pre-Ramadan fasting planning before the month of Ramadan represents a golden opportunity for better glucose control during the month of Ramadan among patients with type 2 diabetes mellitus (T2DM). Pre-Ramadan begins 1–2 months earlier and represents a crucial period when healthcare practitioners can provide medical instructions, risk assessment, and stratification to minimize the associated risks such as postprandial hyperglycemia and hypoglycemia during Ramadan fasting. This review focuses on two important classes of drugs that are widely used in Israel incretin-based therapy, particularly the glucagon-like peptide-1 receptor (GLP-1Rc) agonists class and the sodium-glucose cotransporter-2 inhibitors (SGLT-2i) class. In addition, we provide data regarding specific populations such as elderly patients and Bedouins living in the Negev area who require specific recommendations for safe Ramadan fasting. Our data are based on previously published guidelines, consensus statements, and our experience.

Background: Breast edema, characterized by fluid accumulation in breast tissue, is a common yet understudied complication following breast-conserving surgery (BCS) and radiotherapy for breast cancer. Its impact on physical and emotional well-being highlights the need for deeper exploration of its prevalence, risk factors, and clinical management.

Objectives: To evaluate the prevalence of breast edema following breast surgery, investigate its association with arm lymphedema, and explore links to surgical interventions.

Methods: We analyzed 105 breast cancer patients treated with BCS and axillary interventions, including sentinel lymph node biopsy (SLNB), lymph node sampling, or axillary lymph node dissection (ALND). Comprehensive evaluations included physical exams, arm circumference measurements, and a thorough review of patient demographics, medical history, and disease progression to assess the presence and severity of breast and arm lymphedema.

Results: Breast edema prevalence was 7.6%, with rates significantly influenced by surgical extent. None of the SLNB patients exhibited breast edema, compared to 23.5% of ALND patients. Significant predictors included arm lymphedema (OR 57.54, P = 0.024), body mass index (OR 0.65, P = 0.016), and tumor grade (OR 51.78, P = 0.040). Co-occurrence of breast and arm lymphedema was observed in 50% of cases.

Conclusions: Breast edema is a significant postoperative complication influenced by surgical extent and lymphatic disruption. Improved diagnostic methods, multidisciplinary care, and innovative surgical strategies are essential for mitigating this condition and enhancing patient outcomes.

Acne vulgaris is a common dermatological condition, affecting up to 85% of adolescents and increasingly observed in adults, particularly women. Its chronic nature and visible manifestations impose significant psychological and social burdens. This review provides an updated examination of acne pathogenesis that explores emerging therapeutic approaches informed by recent molecular, genetic, and microbiome research. Findings from clinical studies, molecular biology, and immunological research published in the past decade are presented in a comprehensive overview of current advancements in acne treatment. Key databases and recent consensus guidelines have been utilized to identify novel mechanisms and therapeutic innovations. Current understanding emphasizes the role of innate immunity (e.g., toll-like receptors, inflammasomes), sebocyte biology via peroxisome proliferator-activated receptors (PPAR) signaling, and strain-specific Cutibacterium acnes dynamics. Environmental and genetic factors, including androgen receptor gene polymorphisms and lifestyle contributors, influence disease expression. Emerging treatments include selective retinoids (trifarotene), PPAR modulators, interleukin-targeting biologics, probiotics, bacteriophages, and hormonal therapies with improved safety profiles. Microbiome modulation and narrow-spectrum antibiotics are gaining attention for precision management. Integrating molecular insights with clinical practice fosters a personalized, multidisciplinary approach to acne care. Future research should prioritize microbiome restoration, novel biologics, and strategies to minimize antimicrobial resistance.

Juvenile polyposis syndrome (JPS) is a rare autosomal dominant disorder characterized by hamartomatous polyps throughout the gastrointestinal tract, with an estimated prevalence of 1 in 100,000 individuals. While most cases follow an autosomal dominant inheritance pattern, some are caused by de novo mutations [1].

The age of onset for JPS is typically during childhood or adolescence, with a mean age at diagnosis of 18.5 years [2]. A major concern in JPS is the increased risk of colorectal cancer (CRC), requiring close lifelong surveillance. The cumulative lifetime risk for CRC ranges from 38% to 68%, with a mean age at diagnosis between 34 and 44 years [3].

Although juvenile polyps were initially considered to have low malignant potential, studies have identified two pathways of carcinogenesis in JPS: progression from hamartomatous polyps to adenoma and then to adenocarcinoma or direct transformation of hamartomatous polyps into adenocarcinoma. The management of JPS is tailored to each patient's specific manifestations and clinical presentation. The primary treatment goal is to prevent morbidity associated with gastrointestinal polyps, such as bleeding and intestinal obstruction.

Background: Uninterrupted antithrombotic treatment (ATT) during cardiac implantable electronic device (CIED) implantation increases bleeding and device-related infections (DRI) risk. The wide-awake-local-anesthesia-no-tourniquet (WALANT) technique, using large-volume local anesthesia and adrenaline, is successful in hand surgeries but its potential to mitigate bleeding risk in CIED implantations remains unknown.

Objectives: To investigate whether WALANT protocol for CIED implantations reduces clinically significant pocket hematoma in patients with a high bleeding risk or is a contraindication for interrupting ATT.

Methods: We conducted a prospective, double-blind, randomized controlled trial with CIED surgery patients on uninterrupted ATT. They received WALANT protocol (lidocaine 1% with adrenaline 1:100,000) or standard protocol (lidocaine 1%). Following implantation, patients were blindly monitored in the ward and pacemaker clinic. Patients were monitored for bleeding outcomes post-implantation.

Results: Forty-six consecutive patients (73.6 ± 9 years, 72% male) were enrolled. In the WALANT group (n=24) no intra-pocket pro-hemostatic agents were needed, compared to 45% in the control group (P = 0.0002). Postoperative pressure dressings were used in 12.5% vs. 68% (P = 0.0002). WALANT patients had smaller hematoma areas (median 3.7 cm² IQR [1–39] vs. 46 cm² [IQR 24–76], P = 0.0004) 1-day postoperative. ATT interruption occurred in 12.5% vs. 18% (P = 0.7). Superficial skin infection rates were 4% vs. 9% (P = 0.6). No DRI occurred. No WALANT-related side effects were observed.

Conclusions: WALANT protocol in CIED implantation with uninterrupted ATT reduced pro-hemostatic agents, pressure-dressing need, and hematoma size. Larger studies are needed to assess its impact on infection rates.

We presented the emergent development of pulmonary hypertension and right ventricular impairment in a 64-year-old woman with metastatic breast cancer undergoing carboplatin–gemcitabine combination therapy. The patient's acute decompensation, characterized by dyspnea and desaturation, occurred 2 days after chemotherapy initiation. Clinical assessments revealed right ventricular dilation and systolic dysfunction, a rare manifestation not previously associated with the administered drugs, but which may be associated with cardiopulmonary toxicity of gemcitabine therapy. Prompt discontinuation of chemotherapy and initiation of diuretic therapy resulted in clinical improvement and resolution of the right ventricular dysfunction within several weeks. While a definitive causal link to gemcitabine remains inconclusive, this report highlights a potential and under-reported side effect, emphasizing the need for increased awareness and further investigation into the cardiopulmonary effects of gemcitabine.

The Nazi regime occupying Europe during World War II built a series of concentration camps for those opposing the regime, political and criminal adversaries, and eventually victims of the racial, Aryan policy. It was the suggestion of Germany's elite physician to the Schutzstaffel (SS), Reichfuehrer H.H. (Heinrich Luitpold Himmler), to use the available workforce in the camps, before their eventual liquidation [2,3]. What was the outcome?

The SS medical services in the Auschwitz concentration camp functioned based on two mutually exclusive principles. On the one hand, medical care was provided for the SS staff, and on the other hand, prisoners with contagious diseases or in the terminal stages of exhaustion were eliminated.

Gaucher disease (GD) is an inherited autosomal recessive genetic disorder caused by mutations in the glucocerebroside (GBA1) gene [1]. These variants result in decreased activity of the lysosomal enzyme β-glucocerebrosidase (GCase), which is essential for breaking down glucocerebroside into glucose and ceramide. Consequently, activated macrophages, known as Gaucher cells, accumulate undegraded glucocerebroside. The phagocytic role and naturally high-level GCase activity of macrophages may partly explain why these cells are particularly affected in GD. The accumulation of glucocerebroside in macrophages causes an expansion in the population of these cells, leading to symptoms like hepatosplenomegaly, thrombocytopenia, anemia, bleeding tendency, growth retardation, and bone issues. Bone marrow infiltration may result in bone infarction, episodes of bone crises, and osteonecrosis, mainly of large joints and less commonly as pathological fractures. These latter skeletal complications are the most critical irreversible consequence of untreated GD, significantly impacting the quality of life of patients, and hence should be avoided by early administration of specific therapy. The accumulation of glucocerebroside in lysosomes has been linked to a pro-inflammatory state [2]. In addition, the misfolding and retention of mutant GCase within the endoplasmic reticulum (ER) has been associated with ER stress and activation of the unfolded protein response, contributing to GD phenotypic heterogeneity, inflammation, and immune dysregulation [3].

On 9 August 1938, prisoners from Dachau concentration camp near Munich were sent to the town of Mauthausen in Austria to begin building a new camp. The site was chosen because of the nearby granite quarry and its proximity to Linz [1,2].

Mauthausen initially served as a prison camp for common criminals, prostitutes, and other categories of incorrigible law offenders. However, on 8 May 1939, it was converted to a labor camp. Later, Mauthausen KL became a Nazi concentration camp on a hill above the market town of Mauthausen, approximately 20 kilometers from Linz. It was complemented with dozens of subcamps in the surrounding areas.