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עמוד בית
Thu, 21.09.23

December 2019 (Issue 44)

Students Studies | Abstracts
Moshe Wojakowski, Idan Nakdimon, Ron Elyashar, Yehuda Zadik
Background: According to Boyle’s law, at a constant
temperature the volume of gas varies in an inverse and
direct ratio to the pressure change surrounding it. In the
human body, the change in gas volume due to changes
in atmospheric pressure, in areas where gas is trapped,
can cause barotrauma. In the head, these can be barotitis,
barosinusitis and baroparesis (in the ear, sinus or nerves,

Objective: In military scenarios these phenomena may
arise during flight or diving, and may harm the health of
the combatant and the safety of the mission. Our aim was
to clinically describe these phenomena in modern military
flight/diving outlines.

Methods: Using the Computerized Patient Record (CPR) of
the Medical Corps, we identified all the medical meetings
during 2006-2017 of professional divers or aircrew in which
the diagnoses included, ear or sinus barotrauma, or facial
neurological disturbance; events not generated during
professional diving or flight were excluded. The selected
cases were clinically characterized, and comparison
analysis was made between divers and aircrew.
Results: A total of 646 cases were included in the analysis
(568 occurred in men and 78 in women). The average
age at the time of the incident was 25.2 ± 7.0 years. Of
these, 322 occurred among divers and 322 occurred in
aircrews. Ear barotrauma was more prevalent than sinus
barotrauma. The ratio between ear- to sinus-barotrauma
was higher among divers in comparison to aircrew. Of the
nine cases of baroparesis, 8 developed during flight and
1 during diving. Upper respiratory infection was reported
in 35% of flight in comparison to 18% of diving-related
barotrauma events (p<0.05).

Conclusions: There are unique clinical features of facial
barotrauma during diving in comparison to flight events.
Baroparesis was more common than previously reported
in scientific literature.

Moshe Wojakowski
[email protected]
O. Shlush, O. Fishman
Background: Contraception and awareness of pregnancy
risk are a major public health issue. Contraception is an
initial preventive level that stands at the top of the health
pyramid and is an important element in determining
health policy. Unwanted pregnancies and adherence to
sexually transmitted disease prevention are issues that
concern the IDF. The army’s population is mostly young,
sexually active women and men. Prevention depends on
culture, religion, sex education, economic status etc.

Objective: To examine whether there are gender differences
in knowledge and awareness of contraceptives among IDF

Methods: A questionnaire was constructed for the
purpose of the study. The questionnaire included three
parts: sociodemographic data, knowledge questions, and
questions about sexual habits (Alpha Cronbach 0.695). The
questionnaire was randomly distributed among soldiers.

Results: The questionnaires were given to 30 men and
30 women. The mean age was 20 years old. 85% of
respondents reported that they are sexually active. The
overall level of knowledge was poor. The knowledge
regarding condom use was normal. There was no
difference in the level of knowledge between men and
women, and both groups expressed poor knowledge.
Women tended to use contraception than men for the
first intercourse (NS), but they recommend that their
friends use contraception, much more than men (p=0.02).
In addition, women are less likely to agree to have sex
than men if their partner refuses to use contraception
(p=0.059). There were significant differences in the use
of condoms (p<0.0001). The entire sample indicated that
the knowledge on sex was not gained from the education
system or from a conversation with the parents.

Conclusions: The level of knowledge on contraception
among soldiers is poor. There is need for intervention
for both men and women, probably by a dedicated team.
An emphasis on passive training through relevant social
networks and in clinics and medical institutions.

Or shlush Oshrat Fishman
[email protected] [email protected]
Lidor Mokata, Orell Michaelov, Rama Zilber
Background: Research dealing with compliance to medical
treatment has often been found to correlate positively
with patient perception of the illness measurements.
Influenza breaks out every winter, and kills half a million
every year globally. While vaccination has been proved
to prevent disease and mortality, individuals not getting
vaccinated increases the risk for others. There are several
reasons known for non-compliance to vaccination: lack of
information, insufficient means and illness perception.

Objective: To explore the correlation between illness
perception regarding Influenza among IDF soldiers and
their compliance to vaccination against the virus.
Methods: The information was gathered by questionnaires
on socio-demographical date, the Brief Illness Perception
Questionnaire (Brief IPQ) knowledge of the disease and
compliance. The sample was of convenience type.

Results: The research sample included 70 soldiers: 36
combatants and 34 non-combatants, mean age: 20.
We found no correlation between the overall illness
perceptions score and compliance. There was a significant
correlation between the level of understanding of the
disease and compliance. The presence of staff able to
educate on Influenza and the vaccine was also correlated
with higher willingness to vaccinate in the future among
combat and non-combat soldiers.

Conclusion: Education may have an important role in
improving compliance to vaccination. It is recommended to
expand the education among soldiers regarding Influenza
and the effectiveness of the vaccine.

Lidor Mokata Orel Michaelov
[email protected] [email protected]
Cole D .Bendor, Aya Bardugo, Inbar Zucker, Tali Cukierman-Yaffe, Miri Lutski, Estela Derazne, Tammy Shohat, Ofri Mosenzon, Dorit Tzur, Ari Sapir, Orit Pinhas-Hamiel, Richard G. Kibbey, Itamar Raz, Arnon Afek, Hertzel C. Gerstein, Amir Tirosh, Gilad Twig
Introduction: The relationship between acute pancreatitis
and incident diabetes is unclear. A sequela of β-cell
damage that is accompanied with an increased risk for
diabetes later in life may be underappreciated.
Objective: We aimed to determine whether a history of
childhood acute pancreatitis with normal pancreatic
function at late adolescence is associated with incident
diabetes later in adulthood.

Methods: A nationwide, population-based study of
1,802,110 Israeli adolescents (mean age 17.4 years [range,
16-20]) who were examined before compulsory military
service between 1979 and 2008, and whose data were
linked to the Israeli National Diabetes Registry. Resolved
pancreatitis was defined as a history of a single event
of acute pancreatitis with normal pancreatic function at
enrollment. Logistic regression analysis was applied.
Results: Incident diabetes developed in 4.6% of subjects
with resolved pancreatitis (13 of 281; none of these cases
was identified as type 1 diabetes) and 2.5% among the
unexposed group (44,463 of 1,801,716). Resolved acute
pancreatitis was associated with incident diabetes with
an odds ratio (OR) of 2.23 (95%CI, 1.25 to 3.98) with
adjustment for age, sex and birth year. Findings persisted
after further adjustments for baseline body mass index
(BMI) and socio-demographic confounders (OR=2.10,
95%CI 1.15 to 3.84). Childhood pancreatitis was associated
with a diagnosis of diabetes at a younger age with 92%
of diabetes cases diagnosed before the age of 40 years
compared to 47% in the unexposed group (p=0.002). The
association accentuated when the study sample was
limited to individuals of unimpaired health or normal BMI
at baseline.

Discussion & Conclusions: A history of acute pancreatitis
in childhood with normal pancreatic function in late
adolescence is a risk factor for incident type 2 diabetes,
especially at young adulthood.

Aya Bardugo
[email protected]
Avi Benov, Irena Shkolnik, Elon Glassberg, Roy Nadler, Sami Gendler, Ben Antebi, Jacob Chen, Noam Fink, Tarif Bader
Introduction: The Israeli Defense Force Medical Corps
(IDF-MC) is routinely collecting prehospital data to
establish a prehospital registry. Since February 2013,
Israel has been providing medical care to Syrian refugees.
This unique humanitarian aid begins in prehospital setting
and typically culminates in Israeli civilian hospitals.

Objective: To describe the accumulated experience that
collected in recent years treating Syrian casualties by
IDF’s front medical teams for on-going improvement of
combat casualty care.

Methods: Care provided by IDF-MC medical teams,
including prehospital casualty care, is regularly documented
and after-action reports are conducted.
Records of casualties arriving at the Israeli-Syrian border
from February 16, 2013, to December 31, 2017, were
extracted from the IDF Trauma Registry. Patients who
did not have a casualty card were excluded. The database
included demographic information, injury signature and
treatment given.

Results: During the study period, 2,785 Syrian casualties
were treated, of whom 2,339 were trauma victims. The
most common mechanism of injury was penetrating
(60.4%). Prehospital lifesaving interventions included
127 endotracheal intubations, 30 cricothyroidotomies, 55
chest decompressions, and 58 tourniquet application for
extremity hemorrhage control. Remote Damage Control
Resuscitation included reconstituted freeze-dried plasma
(n=75) and tranexamic acid (n=222 casualties) with no
adverse effects.

Conclusions: The experience of the IDF-MC teams in caring
for civilian casualties along a hostile international border
is unique. In this capacity, the IDF-MC has demonstrated
effectiveness in providing lifesaving and resuscitative
interventions. In this experience, tourniquets have been
effective in controlling hemorrhage when applied early
and endotracheal intubation and cricothyroidotomy
have provided effective airway options in select patients.
Prehospital combat casualty care presents a significant
challenge both in terms of providing adequate care and
in terms of data collection and analysis. The experience
described in this article is one example of effective,
ongoing prehospital data gathering process.

Irena Shkolnik
[email protected]
Polly Sever, Sara Eyal
Introduction: There are two main barriers which segregate
the peripheral blood system and the central nervous
system (CNS). These barriers are BBB (Blood-Brain
Barrier) and BCSFB (Blood-CSF Barrier). Their main role
is to curb moving of toxic and endobiotic substances to the
brain. At the same time, these barriers also impact drug
entrance to the brain, and thus leading to possible subtreatment
of some brain diseases.

Objective: Research of the differences between the two
barriers of the brain, while emphasizing their influence on
drug uptake to the CNS.

Methods: Literature review, identification of the
latest discoveries and innovations and their possible
implementation in the pharmaceutical field.
Results: Many differences between the BBB and the BCSFB
have been found in terms of molecular arrangement
and the transporters controlling molecular transport in
both directions. Pharmacokinetic differences of small
molecular distribution have also been demonstrated. As an
example, three drugs - Digoxin, Ritonavir and Duloxetine
showed significant difference in their distribution
between the two compartments. These differences might
influence the pharmacodynamic activity of the drugs.

Discussion & Conclusion: Specific pharmacokinetic
parameters of small molecules, differences between
the inter-compartment barriers may restrict the
pharmacodynamic activity in-vivo. These differences
should be taken into consideration while planning target
sites, route of administration and other aspects during
drug research. At the same time, unique properties of
each barrier may be applicable for drug targeting, which
is an advantage in drug development.

Polly Sever
[email protected]
Soly Elmakias-Sarusi, Maayan Manheim, Ronen Bar, Ohad Ronen
Introduction: Hearing loss is a major source of morbidity
in the Western world. Precipitating factors are numerous,
however noise exposure is the main cause of hearing
loss among young adults. According to the WHO, roughly
5.3% of the world’s population suffers from hearing loss,
and 50% (1.1 billion) of young adults (age 12-35), are at
risk of hearing loss due to noise exposure during leisure
activities. In recent years, there has been an increase in
the use of personal music players.

Objective: To examine if there has been an increase in
hearing thresholds in recent years.

Methods: A retrospective, cross-sectional study included
500 Navy recruits, ages 17-20, who underwent an
audiometry examination from 1985-1995 (n=124), 2000-
2005 (n=126) and 2010-2015 (n=250). We analyzed the
audiometric examination and socio-demographic data
collected by analyzing personal questionnaires. For each
period, we calculated the hearing threshold mean, the
prevalence of hearing loss by the threshold mean value,
according to NITS (Noise Induced Threshold Shift) criteria
for the worst ear. Hearing loss was categorized for right
and left ears, for low frequencies (0.5, 1, 2 kHz) and high
frequencies (3, 4, 6, 8 kHz) and the hearing loss values
were defined as a value of 15 dB and above. A socioeconomic
index was drawn from the Central Bureau of
Statistics and adapted by locality of residence.

Results: We found an increase in hearing threshold in
the second period (2000-2005). The differences between
periods and frequencies were significance (p<0.001). The
prevalence of NITS was 5.4% for all periods. In the second
period (2000-2005) the prevalence was twice as high as
the first period (1985-1995), though with no statistical
significance. The prevalence of increased hearing loss
(≥15dB) for high frequencies was 16.3% in the left ear
and 11.5% for low frequencies in the right ear, both in the
second period (2000-2005). The overall risk for hearing
loss was in the low frequency range (0.5, 1, 2 kHz), in the
left ear, in comparison between the second period (2000-
2005) and the first period (1985-1995). In addition, the
prevalence of worse ear for low frequency (0.5, 1, 2 kHz)
was 9% and for high frequency (3, 4, 6, 8 kHz) was 15.9%,
both of which were measured in the second period (2000-
2005), but this was not statistically significance. The sociodemographic
data showed that high socio-economic
status correlated to a higher risk for hearing loss.

Conclusions: We demonstrated that hearing loss began
earlier than 2007 (before the introduction of the iPhone)
in contradiction with our hypothesis that smartphones
had a negative impact on hearing. The increase in hearing
thresholds is continuous and may indicate a trend of
hearing loss beginning in young age. We believe that in
order to prevent hearing loss, there must be an increase
in education, awareness and prevention. Further research
is necessary to determine the precise origins and what
preventative measures might be effective.

Soly Elmakias-Sarusi
[email protected]
Lectures Abstracts
Yehuda-Matan Danino, Alice Bliznyuk, Liav Leiboviz, Valentina Borgil, Mirit Eynan, Rivka Efrat, Adi Biram, Yoram Grossman, Ben Aviner
Introduction: Combat divers using closed-circuit breathing
apparatus, run the risk of developing central nervous
system oxygen toxicity (CNS-OT). This may lead to seizures
underwater, drowning and death. Previous studies have
suggested that CNS-OT is related to the accumulation of
reactive oxygen and nitrogen species, whose production
is promoted by activation of N-Methyl-D-Aspartate
receptors (NMDAR). Magnesium sulfate (MgSO4), an
NMDAR blocker, has been reported to prolong latency to
CNS-OT seizures in rats.

Objective: The purpose of the present study was to
determine the relationship between blood magnesium
levels, latency to the onset of CNS-OT, and the patterns
on the electroencephalogram (EEG) which precede the
appearance of seizures.

Methods: Rats were divided into six groups: sham, control,
high magnesium (MgSO4-treated), low magnesium
(Mg2+-deficient diet), memantine (an NMDAR antagonist)
and low magnesium with memantine. Animals were
implanted with a telemetric EEG transmitter and exposed
to 6 atmospheres absolute breathing oxygen. Latency to
seizures and EEG patterns were recorded.

Results: There was significant prolongation of the latency
to CNS-OT in the MgSO4-treated group, and a significant
reduction in the Mg2+-deficient group. Memantine
mimicked the effect of MgSO4, although to a lesser
degree, and managed to overcome the effect of the Mg2+-
deficient diet. EEG pattern changes were identified during
the minutes preceding seizure onset.

Conclusions: MgSO4 may be used as a protective agent
for CNS-OT, and NMDAR’s may be involved in the
underlying mechanism. A predictive algorithm identifying
modulations in the EEG may be developed to avoid CNSOT

Ben Aviner
[email protected]
Roy Nadler, Avishai M. Tsur, Gadi Lending, Nikolay Haiman, Ran Yanovitch, Diana Levi, Eilat Shinar, Avi Benov, Elon Glassberg, Jacob Chen
Introduction: Walking Blood Bank (WBB), or Buddy
Transfusion, refers to using fellow combatants for
battlefield blood donation. A fundamental prerequisite
for this technique is that the donating soldier will suffer a
minimal physiological and mental impact.

Objective: To assess the effect of blood shedding on
battlefield performance.

Methods: In a double-blind randomized control trial, 40
IDF combatants volunteered. Parameters measure a
baseline and following the intervention included vital signs
(heart rate, blood pressure, Compensatory Reserve Index),
cognitive evaluation (reaction time, fatigue, exertion, and
subtraction test), physical evaluation (standing long jump,
deadlifts, weighted pull-ups, walking lunges, 100-meter
sprint) and a strenuous shooting test. Three weeks after
the baseline examination, subjects were randomized to
either blood donation or the control group. All subjects
underwent venous catheterization for the duration of a
blood donation under the auspices of the Israeli National
Blood Services. Blindfolds were used to prevent subjects
from realizing their assigned group. Vital signs and
function evaluation were then repeated.

Results: Thirty-six patients were available for
randomization. Baseline measurements were similar for
both groups. Mean strenuous shooting score was 80.5 ±
9.5 for the control group and 82 ± 6.6 for the test group
(p=0.58). Mean difference in shooting scores between
baseline day and test day measurements was 3.1 ± 9.24 for
the control group and 3.7 ± 7.7 for the test group (p=0.81).
No clinically or statistically significant differences were
found in tests designed to evaluate cognitive performance
or physical functions. Vital signs taken multiple times
were also similar between the test and control groups.

Conclusions: Executive, cognitive, and physical functions
were well preserved after whole blood donation in healthy
blood donors. This study supports the hypothesis that blood
donation does not decrease donor combat performance
and therefore "Buddy transfusion" may be utilized in
theatre with no risk of compromising the donors.

Roy Nadler
[email protected]
Matan Golan, Yaacov Samet, David Planer
Introduction: Resuscitative endovascular balloon occlusion
of the aorta (REBOA), is gaining worldwide attention as a
minimally invasive technique for initial control of acute
intra-abdominal and pelvic hemorrhage. While most
studies have shown effectiveness and safety for short
term bleeding control, data is lacking regarding prolonged
aortic occlusion.

Objective: The aim of this study is to investigate the safety
and effectiveness of a six hour infra-renal REBOA for
stabilizing a non-compressible pelvic hemorrhage in the
pre hospital setting.

Methods: Pelvic bleeding was induced in swine through a 7F
arterial introducer sheath inserted via the femoral artery.
Basic bleeding rate was measured. After 5 min of bleeding,
a high compliant aortic balloon (CODA, Cook Medical), was
introduced via the contralateral groin, and inflated below
the renal arteries. Treatment time was 6 hours, followed
by 30 minutes of reperfusion. Continuous blood pressure
was measured above and below the balloon. Survival and
reduction in bleeding rate vs. baseline were the primary
safety and effectiveness outcomes, respectively.

Results: Eleven animals were studied. All animals survived
six hours of bleeding followed by 30 min of reperfusion.
Bleeding rate was significantly reduced by 84.9% from
105.9 ml/min pre-intervention to 16 ml/min with REBOA
(p<0.001). Mean potassium levels raised from a baseline
of 3.65 mmol/l to 6.38 mmol/l at the end of the reperfusion
phase. Respectively, lactate levels raised from 1.4 mmol/l
to 4.3 mmol/l and pH decreased from 7.42 to 7.35.

Discussion & Conclusions: Prolonged pelvic bleeding
control with infra-renal REBOA is safe and effective. The
method can be applied in the pre-hospital setting with
prolonged evacuation time.

Matan Golan
[email protected]
Adir Sommer, Rafi Gerasi, Noy Mark, Anat Leubin, Eran Shasha, Arik Eisenkraft, Dean Nahman
Introduction: Tension pneumothorax and hemothorax are
leading causes of preventable battlefield deaths. Current
methods present difficulties in diagnosis, and are not
applicable under warfare conditions, i.e. under fire, in
darkness, surrounded by intense noise.

Objective: A feasibility study to develop a medical device
able to collect, analyze, and classify the unique acoustic
signature for pneumo/hemothorax.

Methods: Using a pig animal model, we utilized a device
consisting of two sensitive modified microphones to
sample 10-15 seconds recordings over the pig’s thorax.
The thoracic cavity was injected with increasing volumes
of 200, 400, 600, 800, and 1000 ml of air/saline to simulate
pneumothorax/hemothorax, respectively. The data was
analyzed using a dedicated algorithm that collected the
acoustic signals unique to each pathology, filtered the
background noises, and clustered the signals according to
their distinctive characteristics.

Results: A unique signal could be detected after 10-15
seconds. The algorithm was able to significantly identify
and classify (p<0.01) the difference between normal lung
tissue and the presence of pneumo/hemothorax, starting
from 200 ml and regardless of the presence of background
noise. Additional statistical processing is currently being
completed and will be presented at the conference itself.

Discussion & Conclusions: The study deals with the
development of a medical device, independent of external
factors that can delay the diagnosis and treatment and
enables objective rapid diagnosis. The feasibility of
distinguishing pneumothorax, hemothorax and normal
lung tissue has been achieved through the use of a
dedicated algorithm. Additional studies are required to
increase sample size, to upgrade the algorithm’s realtime
detection ability against a predetermined dataset,
and to assemble the device in an operational manner.

Adir Sommer
[email protected]
Uri Levor, Itay ketko, Chen Fleischmann, Ran Yanovich
Over the past decade, significant transformations have
occurred in the field of nutrition in the IDF. Food product
lists that allocated to units were adapted to the needs of
combat units, a variety of food product were added to suit
special populations, professional directives were written,
food transportation was improved and a new professional
array cadre of 30 military nutritionists was enlisted.
Despite the short time devoted to the professional
management of the field of nutrition in the IDF, the
scientific knowledge accumulated in this field over the
years, both military and civilian, is extensive.
From the start, we have strived to adapt and assimilate
the relevant existing knowledge in the world of nutrition
to the combatant’s most urgent and significant health
and physiological needs. This effort is conducted while
constantly viewing the balance between performance
enhancement and maintenance of health and well-being.
In this lecture, the main transformations in the field of
IDF nutrition will be discussed, based on the knowledge
and deep understanding of the combatants’ unique needs.
Original scientific studies conducted by the military
physiology unit, which led to knowledge applied in IDF
units today will be presented, emphasizing 3 topics:
 Evaluating energetic needs of combat units.
 The lightweight feeding concept for infantry soldiers.
 The nutrition-junction model: an advanced model for
nutrition management in combat units

Uri Levor
[email protected]
Charles Milgrom, Elhanan Zloczower, Chen Fleischmann, Regev Landau, Tarif Bader, Aharon S. Finestone
Introduction: Since 1983 the Israel Defense Forces (IDF)
has diagnosed and treated stress fractures (SF) according
to a protocol based on clinical presentation, X-rays and
bone scan diagnosis and staging. Self-reported levels of
recruit bone pain during their activities is not part of the
SF diagnosis protocol.

Objective: To test if levels of self-reported tibia pain during
activities can be a predictor of tibia SF.

Methods: In a prospective cohort study, 429 elite infantry
soldiers were reviewed prospectively for signs and
symptoms of tibia SF every 2-3 weeks during 14 weeks
of basic training. Soldiers were sent for a bone scan if
they had a suspected femoral SF or long standing pain in
the tibia according to the IDF protocol for diagnosis and
treatment of SF. Recruits with suspected tibia SF were
asked to grade their tibia bone pain on a scale of 0-10
during rest, walking, during exertion and post exertion.
A correlation between the recruit tibia pain level at first
complaint for tibiae with and without SF was performed.
2-sided Wilcoxon scores were used for comparisons.

Results: 28 recruits with findings compatible with tibia
SF in 46 tibiae were sent for bone scans. Overall, 29
symptomatic tibia SF were diagnosed by bone scan. A
further SF was seen on an X-ray. Recruit’s tibia pain
scores were slightly higher where no SF was present, but
this was not statistically significant.

Conclusions: Self-reported tibia pain levels has no
predictive clinical value in diagnosing tibia SF and should
not be added to the IDF stress fracture diagnosis and
treatment protocol.

Regev Landau
[email protected]
Lilach Gavish, Elad Spizer, Ilan Friedman, Joseph Lowe, Nathalie Folk, Noa Mahervax, Yonatan Zarbiv, Yevgeni Gelman, Lev Vishnevski, Yevgeni Fatale, Michael Herman, Gofshtein Roni, Arnon Gam, Arik Aisenkraft, Yair Barzilay
Introduction: Knee pain as part of over-use/load pathology
is one of the most common complaints of combat
soldiers. Photobiomodulation therapy (PBMT) is clinically
used for wound-healing acceleration and pain reduction.
Specifically, PBMT was shown to reduce osteoarthritis
knee pain.

Objective: Evaluation of the efficacy of PBMT over

Methods: Prospective, double blind, sham-controlled,
randomized, clinical trial. Combat soldiers/policemen
diagnosed with anterior knee pain on the background of
over-use/load received a series of 4 weekly physiotherapy
sessions and in addition were randomly assigned to
receive active or sham PBMT twice a week (Phys+PBMT
vs. Phys+Sham). Evaluations were collected before/after
end of treatment series and 3 months later (FU-3M) and
included subjective pain (0="no pain" to 100="intolerable
pain"), satisfaction, and Kujala activity score. Participants
and evaluators were blinded to group allocation.

Results: 26 soldiers/policemen (Male:Female 15:11;
Age=22.6±8.5 years-old, BMI=24.2±3.9) completed the
study protocol (13 per group, total 46 knees). At the end
of the treatment, pain level was significantly reduced only
in the Phys+PBMT group (p=0.031 by repeated-measures
mix-design ANOVA adjusted to baseline pain). At FU-3M,
the improvement was still apparent but not significant
(p=0.077). At the end of the treatment 81% of participants
were satisfied but at FU-3M, satisfaction levels were 75%
in Phys-PBMT but dropped to 33% in Phys-Sham (0.056
by chi-square). Likewise, Kujala score at FU-3M was
significantly improved over baseline in Phys+PBMT, but
the improvement achieved at the end of treatment in the
Phys+sham disappeared (p=0.027 adjusted to baseline

Discussion: PBMT in addition to physiotherapy was found
to significantly reduce knee pain and improve activity over
physiotherapy alone. The benefits of the treatment were
partially maintained at FU-3M. Finding a drug free, simple
treatment, that can reduce knee pain and lead to earlier
return to duty, is important both for the individual and the

Lilach Gavish
[email protected]
Idan Tsadok, Sagi Shpitzer, Itay Ketko, Mickey Scheinowitz, Yoram Epstein, Ran Yanovich
Introduction: Combat soldiers perform intense physical
activities under extreme environmental conditions. This
might aggravate physiological stress by increasing core
body temperature (Tc), leading to heat exhaustion and
heatstroke. Thus, monitoring changes in Tc is of utmost
importance. Nowadays, reliable and accurate monitoring
is acquired invasively, and there are no products to
measure Tc noninvasively in field.

Objective: To evaluate the possibility of monitoring Tc noninvasively
by the T-core sensor (Drager, Germany).

Methods: 14 healthy young males participated in the
study, which consisted of 3 days of 60 minutes of sitting
in comfortable environmental conditions followed by 90
minutes of moderate exercise, under different hot climatic
conditions. Temperatures from T-core sensors, which
were placed on the subject’s forehead and wrist were
recorded continuously in parallel to rectal temperature
(Tre) using a thermistor (YSI 401). Models have been built
to adjust T-core values to Tre. Using a MATLAB software
independent algorithm 70% of the measurements were
chosen randomly to build the models and the remaining
30% were used to test their reliability. Bland-Altman
analysis and Pearson’s correlation coefficients were used
to analyze the results.

Results: Measured Tre was between 36.5-38.9oC. A high
statistical correlation was found between Tre and T-core
values: (forehead) and (wrist). The mean forehead model
error was and for the wrist. The 75th percentile of the
forehead calculated temperature errors was, and for the

Discussion & Conclusions: The developed models enable
to use the T-core for monitoring Tc under exercise-heat
conditions with high accuracy. The sensor can be used on
other sites than the forehead (as the manufacturer offers),
which are more comfortable in field. Further studies,
should be conducted in order to verify that the T-core can
be used under field conditions.

Idan Tsadok
[email protected]
Sagi Shpitzer, Saar Ashri, Ofer Eitan, Amir Shufani, Ran Yanovich
Introduction: Exertional heat stroke (EHS) is a dangerous
and potentially fatal condition frequently encountered in
young active populations such as soldiers. In the Israel
Defense Force (IDF), a Heat Tolerance Test (HTT) involving
moderate exertion under hot conditions is part of the
return to duty protocol following EHS in order to identify
heat intolerant individuals. There are very little data
regarding the characteristics of a HTT in young females
and previous work suggested that different criteria should
be used for them.

Objective: To compare the HTT characteristics and results
of young females with those of men.

Methods: In this retrospective study we examined HTTs
performed in our institution during the years 2007-2019
and stratified the data according to sex. The compared
variables included patient level data acquired pre, during
and post HTT.

Results: The tests of 33 females and 453 males were
included in the study. The groups differed in baseline
characteristics by age, height, weight and body surface
area. Females had higher core temperatures than males at
baseline, 60 minutes and 120 minutes (by 0.22C°, 0.21C°,
0.19C° respectively, p<0.01), but the rise in temperature
during the test was found to be identical between the
groups (0.89C° vs. 0.91C°, p=NS). Similarly, the measured
heart rate (HR) in females was higher than in males at
baseline (85 BPM vs. 75 BPM respectively, p<0.01), but
the increase in HR during the test was similar between
the groups (54BPM vs. 49BPM, p=NS). Females were also
found to have a 10% lower sweat rate during the test (372
gr/hr/m2 vs.412 gr/hr/m2, p<0.01).

Conclusions: During HTT female soldiers had a higher
baseline core temperature and HR compared to males,
but showed similar dynamics and rise in these values
during the test. The use of diagnostic criteria for heat
tolerance which take into account the trend during the
whole test should be applied in this population rather than
rigid cutoff values.

Sagi Shpitzer
[email protected]
Leah Shelef, Ishai Nir, Lucian Tatsa-Laur, Niv Gold, Ariel Ben Yehuda
Introduction: A study from 2016 regarding the efficiency
of the Suicide Prevention Program in the IDF has found
that the OR of the program on time until death by suicide
has been 0.476 (CI=0.37-0.60, p<0.001 95%). That means
there was a 47% reduction of suicide cases in the army.
When other variables where taken into account, the most
pronounced results where for males, soldiers who were
born in Israel, soldiers from high socio-economic status,
soldiers with high intelligence score and fighters.

Objective: To examine the SPP’s efficiency over a greater
number of years and determine more accurately changes
in characteristics of soldiers who died by suicide.

Methods: A retrospective nested case control study
comprising of 1,462,882 soldiers who finished military
service and 491 who committed suicide during military
service between 5/1/1992 and 31/12/2016. Characteristics
that were examined included gender, IQ, military
profession, psychiatric diagnosis, ethnicity, religion and
socio-economic status.

Results: Analyzing variables before and after the SPP’s
implementation showed that before implementation the
suicide risk was greater for males, fighters, soldiers
of Ethiopian ethnicity and Druse. After the SPP’s
implementation there was a decline in male soldiers’
risk compared with females, in Druse soldiers’ risk and
in support role soldiers’ risk. The relative risk from being
of Ethiopian origin or from having a psychiatric condition
has risen.

Conclusions: The SPP succeeded in lowering overall
suicide rate in the IDF but affected several demographic
groups more than others.

Ishai Nir
[email protected]
Conference Posters Abstracts
Nirit Yavnai, Lihi Simchas, Michal Pantanowitz, Shelly Bar-Sela, Shany Funk, Gordon Waddington, Shani Svorai Band, Nili Steinberg
Introduction: Fitness is tested routinely with better fitness
associated with reduced risk of injury within a military
Objective: To assess baseline predictors of change of
fitness in soldiers undergoing the Infantry Commanders
Course (ICC).

Methods: Pre and post ICC course, 169 soldiers were tested
for combat physical fitness test, BMI measurement, Ankle
Proprioception, Postural Balance, and Ankle Instability.
Results: The running, the agility, ankle proprioception
and postural balance improved from start to finish of
the course (p<0.01 for each). Stepwise linear regression
showed that lower baseline BMI and faster 3,000m time
were associated with faster final 3,000m time (R2=0.28,
F=25.63, df=1:134, p<0.01). Individuals with lower BMI at
baseline, combined with slower 3,000m times, showed the
most capacity to improve their running relative to the rest
of the group (R2=0.62, F=110.25, df=1:134, p<0.01).
Faster baseline agility performance, more stable ankles
and faster 3,000m were associated with faster final agility
time (R2=0.16, F=8.26, df=1:133, p<0.01). Faster baseline
agility, greater ankle stability but slower 3,000m run was
associated with greater agility improvement than the rest
of the group (R2=0.29, F=18.13, df=1:133, p<0.01).

Conclusions: ICC improves fitness and lower limb
performance. Those who are fit at the start are still
the fittest in the cohort at the end, and those who start
with low agility have difficulty gaining agility. However,
those who start with low fitness aerobically gain the
most improvement. Ankle instability affects the ability to
gain agility. Running and agility tests examine different
aspects of fitness from the postural balance and the
proprioception tests. This indicates potential to gather
information about other aspects of fitness and potential
injury prevention that is not captured within the 3,000m
run and the agility tests.

Lihi Simchas
[email protected]
Simson Yedidia, Nahum Meitav, Rama Zilber
Introduction: Published research indicates there is a
negative correlation between sleeping quality and sport’s
achievements. Most of the research deals with professional
athletes with little discussion on other populations.

Objective: Examine the relationship between Sleep Quality
and sport’s achievements in the physical’s exam among
combat’s Israeli soldiers, all assessed by a questionnaire.

Methods: We created a three parts questionnaire: (1)
Socio-demographical; (2); Results of the IDF Physical
Achievements audit; (3) Assessment of sleeping quality.
The Alpha Cronbach score for the physical ability
questionnaire and for the sleeping quality questionnaire
was 0.6. We conducted a convenience sampling.
Results: The study group included a total of 50 soldiers,
all male in different phases of their compulsory military
service. The average age of the sample’s participants was
21 years old. We found a positive -significant correlation
between reported sleep quality and reported 3,000m
running test (p<0.05), however we did not find a significant
correlation between sleeping quality and other nonaerobic
physical ability tests. Additional variables tested
indicated a negative and significant correlation between
the number of soldiers sleeping in the same space and
their results in the 3,000m running test of: The more
soldiers sharing the same sleeping space the poorer
results achieved.

Discussion & Conclusions: a signification positive correlation
was found between sleeping qualities and aerobically and
sportive achievements among soldiers serving in a fields
units. The total number of soldiers sharing a sleeping
space is also a valuable and yet not examined variable,
which also seems to be related to sleeping quality.

Yedida Samson [email protected]
Nahum Meytav [email protected]
Diana Kontorovich-Chen, Pavel Gorenbein, Arina Gurevich
Introduction: Diazepam (Valium) is a derivative of the
benzodiazepine family. In the IDF it is mostly used as a
sedative / anticonvulsant including after exposure to
organophosphates, which makes the medicine essential
in emergency kits. The IDF emergency kits are refreshed
every 18 months. Therefore, any preparation in these kits
must have a remaining shelf life of 18 months from the
time it reaches the IDF’s inventory. The Medical Research
and Development Laboratory of the Medical Corps is
responsible for ensuring that any preparations in these
kits meets the required quality throughout the kit life.

Objective: To investigate all Diazepam preparations,
including all dosage forms, to ensure they comply with all
the parameters defined by the manufacturer throughout
its life, assuming that the storage conditions of these
preparations do not comply with the storage guidelines of
the manufacturer (25°C).

Methods: The main method for examining diazepam (as
in most pharmaceutical preparations) uses HPLC (High
Performance Liquid Chromatography). Using this method,
it is possible to and quantify the active ingredients and
possible impurities in the preparation. The knowledge and
experience of the laboratory staff, the quality and sensitivity
of HPLC testing methods are constantly improving.

Results: In 2016, a new decomposition material was
discovered in the Diazepam ampules ("Teva", Hungary)
at higher levels than the specification requirements.
At the end of the shelf life of the product (3 years), the
impurity concentration was 5 times higher than the
concentration approved by the Ministry of Health. The
same impurity levels were discovered simultaneously by
the manufacturer. This discovery resulted in shortened
shelf life of the preparation to only 18 months. The
possibility of including the Diazepam into emergency kits
was temporarily restricted.

Discussion & Conclusions: The R&D Department is
responsible for ensuring the quality and safety of all
emergency medical products in the IDF. Constant
investment in the development and improvement of the
analytical testing methods, like in this case, made it
possible to identify and quantify the degradation product
which may impair the safety of the preparation. In the next
stage, the department performed acute toxicity tests in
laboratory animals and found that there was no evidence of
the toxicity of the substance at the relevant concentrations.
Eventually, we located another manufacturer of Diazepam
ampules (Hameln) which shows very good stability, with
very slow rate of degradation. Hameln ampules are
stable for at least 3 years and therefore are suitable to be
integrated into the IDF emergency kits.

Presenter: Diana Kontorovich-Chen
[email protected]
Arina Gurevich, Pavel Gorenbein, Meital Zur
Introduction: Adrenaline is a lifesaving medicine used in
treatment of critical conditions such as cardiac arrest and
anaphylactic shock. Adrenaline is procured in significant
quantities by the IDF and stored in medical supply kits,
clinics and storage units. The IDF stockpiles its medical
equipment in field units, hence the storage conditions
do not meet the manufacturer’s requirements. R&D
Department of the Medical Corps performs extensive
testing of drugs and disposable medical equipment stored
in IDF. The critical items are tested when received from
the manufacturer, during their shelf life, at the end of the
emergency kit 18-months cycle, at the end of the shelf
life, and even beyond it, to provide sufficient data about the
quality of the item.
Adrenaline is a chiral molecule, with only one isomer
having pharmacological activity.

Objective: Providing the IDF with an effective and safe
preparation of Adrenaline, that withstands the IDF field
conditions, storage conditions and transportation.

Methods: Development of a validated method based on
the chemical structure of Adrenaline, considering the fact
that the existing method does not distinguish between the
different enantiomers and therefore does not determine
the efficiency of the preparation. Development of the above
mentioned method is important, taking into account the
fact that existing internationally accepted testing methods
do not discriminate between active and inactive form of
Adrenaline, which might enable manufacturing inefficient
Adrenaline ampoules.

Results: An analytical method was developed and
validated, based on the data collected for more than 20
years. It was found to reliably quantify both enantiomers
(L and D), providing an accurate picture of the efficiency
of the preparation. Recently, in light of a change of the
manufacturer of Adrenaline ampoules, a new European
made product was introduced for use in the IDF and civilian
health system. In analysis performed using our method,
it has been found that the preparation did not meet the
IDF and the international standards for Adrenaline
quality. Extremely low concentrations of active substance
(L-isomer) were found in multiple batches.

Conclusions: The utilization of chiral method developed in
the Pharmacy department of the Medical Corps enabled
the identification of a life-saving preparation that has
serious quality issues. This is despite the fact that it
is manufactured in a western world country (Europe,
USA, etc.), and although it is tested by the manufacturer
according to the latest international standards. Decrease
in efficiency of Adrenaline injections may lead to an
inadequate response to life saving procedure during
performing CPR, therefore this information is of critical
importance for the medical community. In accordance
with the obtained data, immediate instructions were
given to the medical personal to use an additional dose
in the event of inadequate response. Furthermore, this
information was reported to the Ministry of Health, and the
manufacturer was contacted to improve the production
process. Meanwhile, an extensive procurement activity
was carried out to locate an alternative distributor.

Presenter: Arina Gurevich
[email protected]
Limor Zitronblat, Rachel Dekel
Introduction: Families of combat commanders cope with
stressors including absences from home, emergency
situations, and existential dangers. Spouses must cope
with uncertainty and worry about their partners’ security,
and with most of the tasks involved in home and child-care
(Padden & Posey, 2013). The adjustment of the combat
commanders and their wives to these living conditions
are key factors in their functioning, their physical and
mental health, and their marital satisfaction (Belland &
Gkousgkounis, 2014).

Objectives: To examine – a) the association between the
two spouse’s adjustment and b) the contribution of dyadic
coping (positive or negative) to marital satisfaction.
Methods: Self report questionnaires were being collected
from a systematic sample of 400 combat commanders
and their spouses. Data was analyzed by rank.

Results: Preliminary results, based on 137 couples,
support positive associations between partner’s mental
health and functioning. There was a significant positive
correlation between the couple’s positive dyadic coping
and the couple’s marital satisfaction. There was a
significant negative correlation was found the negative
dyadic coping of the combat commander and his marital
satisfaction compared with his wife. Moreover, the wife’s
negative dyadic coping makes a significant contribution to
the marital satisfaction of the combat commander.

Conclusions: The families of IDF combat commanders
comprise a unique population that copes with a
demanding and challenging lifestyle. Although they spend
a very limited amount of time together, this study found
their dyadic coping is similar to that reported in other
similar studies around the world. The differences between
the spouses indicate a new perspective among combat
commanders regarding their traditional gender roles.

Presenter: Limor Zitronblat
[email protected]
Noy Mark, Ehud Tal, Dan Adam, Tzvi Friedman, Refael Gerasi
Introduction: Ultrasound (US) imaging is a very useful
method for medical diagnosis and for the early identification
of life threatening situations without any negative effects
on the patient. The field of view (FOV) of an ultrasonic
image is constrained by the width of the ultrasonic probe
and its maximum steering angle. Ultrasonic probes are
usually designed with a narrow aperture to avoid clatter
in the desired image. The narrower aperture allows
transmitting between bony processes, thus avoiding
the high clatter signals returning from such incidental
structures. Analysis of an investigated tissue-structure
may prove to be extremely difficult when the entirety of
the structure is only visible through means of multiple
frames in addition to the presence of noise (speckles) in
each image. To capture a larger FOV which contains the
entire structure of interest while enhance the quality of the
resulting panoramic image, the post-processing approach
of image-stitching may be applied.

Objective: Creation of enhanced panoramic image with
high resolution in order to demonstrate the intrinsic
structure of the tissue while producing accurate wideframe
visualization of underlying tissue. We tackle the
challenging conditions caused by non-rigid deformations
of the imaged structures, caused both by user-operation
and by the inherent internal dynamics of tissues.

Methods: We present a method for transforming an
ultrasonic clip into a single wide-frame image by means
of rigid image-registration augmented by information
provided by the Optical-Flow method (computer vision)
to account for non-rigid inter-frame movement. The nonrigid
augmentation aims to rectify the errors produced
under the assumption of strictly non-rigid transformations
between the overlapping frames. In addition, novel
method based on Diffusion Nets have been developed for
enhanced US image quality and resolution.

Results: The wide-frame images that were produced
by our algorithm from real data and from artificial data
are presented. We have shown that using a rigid affine
transformation as an initial estimation and augmenting it
by locally deforming the images using optical-flow-based
estimations of displacement-fields, is a reasonable and
practical alternative both for strictly rigid registration and
both for complex, purely non-rigid registration methods.
In addition, the Diffusion Net algorithm has shown
significant improvement in the resulting image compared
to the original recorded images.

Conclusions: A robust framework for the transformation
of an ultrasonic clip into a wide-frame image is developed
for better investigation of tissue structure. The method
and its implementation may serve as an important first
step in the design of such a framework. This technology
can be used for the creation of clear an understandable
panoramic image which can be used without training in
the field.

Presenter: Noy Mark
[email protected]
Saar Ashri, Ofer Eitan, Sagi Shpitzer, Ran Yanovich
Introduction: Heat intolerance is a physiological
characteristic which may lead to heat related injuries,
potentially fatal. In the Israel Defense Forces, all soldiers
who suffer from an exertional heat stroke are subjected
to a heat tolerance test (HTT) aimed at assessing their
tolerance to heat. Changes in heart rate variability (HRV), a
marker for sympatho-vagal modulation, have been shown
in previous studies to be associated with heat exposure
but have yet to be assessed in relation to heat tolerance.

Objective: To find differences in HRV indices between
individuals who were diagnosed as heat tolerant or heat
intolerant, and to compare HRV parameters with known
markers of heat intolerance.

Methods: We retrospectively analyzed HRV data acquired
from 313 HTTs performed in our institution during 2007-
2019. We divided the HTTs into two groups according to the
individual’s diagnosis of heat intolerance. We performed
the HRV analysis using the RHRV software.

Results: We computed ten time-domain indices from the
HRV data. Eight of those differed significantly between the
heat tolerant and heat intolerant groups (SDNN, SDANN,
Core body temperature at the beginning of the test was
found to be significantly correlated (p<0.05) with nine
indices, and the rise in body temperature during the last
hour correlated with seven indices. Only interquartile
range of RR (IRRR) correlated with weight and body mass
index (p<0.05).

Conclusions: Multiple HRV time-domain indices are
associated with heat intolerance. This novel association
should be further studied as an additional decision making
tool for the diagnosis of heat intolerance.

Presenter: Saar Ashri
[email protected]
Daniel S. Moran, Sagi Shpitzer, Reut Fried, Yoram Epstein, Ran Yanovich
Introduction: The current analysis of a Heat Tolerance Test
(HTT), which allows to evaluate the body’s response to an
exercise-heat stress is based on the dynamics of rectal
temperature and heart rate. Sweat rate, which reflects
the potential ability of the body to dissipate heat and,
thus, may serve as an adjuvant parameter to determine
tolerance to heat has never been analyzed.

Objective: To investigate whether heat intolerant
individuals differ in their sweating rate from heat tolerant
individuals, which might partially explain their sensitivity
to the exercise-heat challenge.

Methods: We used the database consisted of the results
of 328 HTTs from the IDF’s Institute of Military Physiology.
The HTT is based on a standardized exposure to an
exercise-heat stress of male soldiers (18-21 years old).

Results: Out of the present cohort that consisted of 328
HTTs, 270 tests were considered as negative, reflecting
a state of tolerance to heat (HT) and 58 tests were found
to be positive, reflecting a state of heat intolerance (HI).
The average sweat rate of the 328 HTTs was 778±248 g/h,
range: 200-1900 g/h. When sub-divided into the HT and
the HI groups, the average sweat rate in the HT group
and the HI group was similar (785±233 g/h, and 746±304
g/h, respectively) (p=0.27) and even when normalized for
body surface area (416±112 g/h/m2, and 391±149 g/h/m2,
respectively) (p=0.14).

Conclusions: The present study shows no difference in
sweating rate (total or adjusted to body surface area)
between HT and HI individuals. Therefore, the hypothesis
that HI individuals, as a group, suffer from low sweating
rate is not substantiated.

Presenter: Reut Fried
[email protected]
Dror Ofir, Inbar Kirshenboim, Ofek Luz
Introduction: Protective respirators are distributed to
soldiers and civilians without taking into account gender
and age differences. It is not known whether the resistance
of the respirator filter (1–1.5 cm H2O) will affect ventilation
(accumulation of CO2) or breathing sensation differently in
men and women of varying ages.

Objective: To examine age and gender effects of increased
breathing resistance on accumulation of CO2 and
breathing sensation.

Methods: Thirty-nine healthy men and women participated
in the study, divided into four groups: older women/men
(55-70 years of age), and younger women/men (18–25
years of age). Participants underwent examination by a
physician after taking their medical history and measuring
spirometry, blood pressure, O2 saturation, and resting
heart rate. Subjects breathed via a mask respirator for
45 min, during which we interchanged three different
filters imposing varying levels of resistance. We measured
inspiratory CO2 and O2, O2 saturation, transcutaneous PCO2
(PaCO2), heart rate, tidal volume, breathing frequency, and
breathing sensation.

Results: Female subjects were 10 cm smaller than the
males, and some of their pulmonary function indices
(FVC, FEV1, PEF) were significantly lower. Female subjects
reported a higher sensation of breathing; however, this
only reached statistical significance in the older group.
PaCO2 tended to be higher (by 5 mm Hg) in the older female
group, compared with the age-matched male group.

Discussion and Conclusions: The statistically significant
difference in breathing sensation observed in the present
study was seen to be correlated with an increase in
muscular effort. This was confirmed by the finding of
weakened respiratory muscles in the older female group,
and may be related to the accumulation of CO2 in the
blood. The present study was performed under resting
conditions. However, young female soldiers will be
required to use respirator systems during activities having
both low and high metabolic demand. The insignificant
difference found in this group (0.4 units) may thus reach
significant levels, inducing constraints that may limit their
physical and cognitive performance. Further research is
required to confirm this supposition.

* This research was supported by a grant from the Ministry of Defense.

Presenter: Dror Ofir
[email protected]
Roy Nadler1, Avishai M. Tsur, Avi Benov, Elon Glassberg, Jacob Chen
Introduction: Remote damage control resuscitation
(RDCR) paradigms in the Israel Defense Forces Medical
Corps (IDF-MC) have waxed and waned in recent years.
From overzealous crystalloid transfusion, which was
the mainstay of volume resuscitation in the early 2000s,
to Clinical Practice Guidelines (CPGs) that discourage
transfusion of crystalloids following the introduction of
freeze-dried plasma as the resuscitation fluid of choice
in 2014.

Objective: To investigate the trends in crystalloids use and
their congruency with changing CPGs.

Methods: All patients treated by the IDF-MC personnel
are recorded in the IDF prehospital trauma registry (ITR).
Records between January 2000 and October 2018 were
included. Crystalloid administration occurrence was
calculated monthly as the ratio between the number of
patients receiving crystalloids and the total number of
patients recorded in the ITR.

Results: During the study period, data for 17,453 patients
were recorded in the ITR. Between January 2000 and
December 2004, there were no statistically significant
changes in crystalloids administration occurrence
(Spearman’s rho=-0.08, p=0.52). Following the publication
of the 2004 CPGs, there was a significant decline in
crystalloid use (Spearman’s rho=-0.66, p<0.01). In 2010,
new CPGs were published, followed by a rise in crystalloid
use (Spearman’s rho=0.59, p<0.01). In 2014, the updated
CPGs were followed by a milder decline in crystalloid use
(Spearman’s rho=0.29, p=0.03). During 2018, four years
following the latest CPGs update, over 8% of casualties
were still treated with crystalloids.

Conclusions: The current study demonstrates considerable
changes in crystalloid administration following periodic
updates in RDCR-related CPGs. The study demonstrated
a significant drop in use of crystalloids following CPGs
indicating restrictive crystalloids use and a significant
rise following CPGs allowing permissive transfusion of

Presenter: Roy Nadler
[email protected]
Nirit Yavnai, Michal Pantanowitz, Shelly Bar-Sela, Shany Funk, Gordon Waddington, Lihi Simchas, Shani Svorai Band, Nili Steinberg
Introduction: Musculoskeletal injuries to the lower
extremities are major factors contributing to drop out
from military training.

Objective: To determine the prevalence of musculoskeletal
injuries and the parameters that differentiate between the
soldiers who incurred these injuries and those who did not
along 14 weeks of an infantry commanders’ course.

Methods: One-hundred and sixty-eight IDF soldiers were
recruited from an infantry commanders’ course. The
soldiers were tested on three occasions: before (pre), in
the middle (middle), and at the end (last) of the course
for anthropometric measurements, proprioceptive ability,
and dynamic postural balance (DPB), and they filled out
an ankle stability questionnaire (CAIT). A physiotherapist
(specializing in musculoskeletal injuries and in military
medicine) followed and recorded all musculoskeletal
injuries incurred by the soldiers during the entire course

Results: Fifty-eight soldiers out of the 168 (34.5%) reported
some pain/injury; 55.2% were injured in the first half of the
course and 44.8% in the second half. Time effects were
found for BMI, DPB asymmetry (P-M direction); DPB for
the dominant and non-dominant leg (P-M direction); and,
proprioception ability. Injury effects were found for DPB
asymmetry (P-M direction); DPB for dominant leg (P-M
direction); CAIT in the dominant and non-dominant leg;
and proprioception ability. An interaction (time * injury)
was found for proprioception ability. The variables that
entered the Cox regression were the pre-testing results of
the proprioception ability, DPB asymmetry (P-M direction),
and CAIT in the non-dominant leg.

Conclusions: As more than one out of three soldiers were
incurred musculoskeletal injuries, and since deficits
in proprioception ability, DPB and ankle stability in pretesting
were major factors contributing to injuries, specific
exercises for improving proprioception, DPB and ankle
stability should be generalized into the practical daily
preparation and training routines of the soldiers.

Presenter: Michal Pantanowitz
[email protected]
shrit Hoffer, Lilach Gavish, Zehava Ovadia-Blechman1, Gal Weizman, Eyal Katz, Yair Barzilay, Elad Spizer, Ilan Friedman, Noa Mahervax, Arnon Gam, Neta Rabin
Introduction: Knee pain are a common phenomenon
and are particularly prevalent among combat soldiers.
Diagnoses is determined by an orthopaedic surgeon
typically using imaging results (i.e. X-Ray/CT/MRI).
However, the time between initial report and diagnosis
may be lengthy in view of the low availability of military
orthopaedic surgeons.
As part of an interventional clinical study for the treatment
of knee pain in combat soldiers, conducted by the Institute
of Research in Military Medicine, infrared thermal images
(ITI) of knees and relevant clinical data were collected.
Coded data was shared with Afeka College researchers.

Objective: To develop an algorithm for automatic diagnoses
of knee pathologies based on ITI.

Methods: The data set included 82 ITI images of knees
before and after controlled physical effort (step-down
test) and individual anatomical maps marked with pain
level (0=no pain, 10=intolerable pain) according to the
orthopaedic surgeon. The image was segmented to 7
areas (center [around the patella] and 6 surrounding). A
temperature histogram was calculated for each area. The
pain status (0=no pain and 1=pain [pain≥4]) together with
histogram measures were used as the algorithm input.
Two machine learning methods were tested: (1) Logistic
regression; (2) Support vector machine (SVM) and were
evaluated for prediction of painful location before/after
physical effort. In each evaluation, 80% of the data was
used for the training set and 20% as the test set.

Results: Automatic diagnosis of painful areas resulted in
correct classification rate before and after physical effort
of 70.2% and 76.8% respectively using logistic regression
model and 72.7% and 78.8% respectively, using SVM.

Conclusions: The results demonstrate the feasibility of
ITI and machine learning for detection of knee pain.
The importance of this study is in future application of a
portable system for initial automatic identification of knee
injuries, enabling early diagnosis and treatment.

Presenter: Oshrit Hoffer
[email protected]
Avishai M. Tsur, Roy Nadler, Maya Siman-Tov, Irina Radomislensky, Kobi Peleg, Avi Benov, Elon Glassberg, Jacob Chen
Introduction: The IDF Medical Corps program "My Brother’s
Keeper" introduced advanced arterial tourniquets,
distributed tourniquets to every combat soldier, and
encouraged the liberal use of tourniquets for limb injuries.

Objective: To assess the effect of a military-wide
implementation of advanced tourniquets on the rates of
tourniquet applications, complications, and outcomes.

Methods: Two databases were merged: The Military
Trauma Registry, which includes all injured treated by
military teams, and The Israeli National Trauma Registry,
which includes data on hospitalized casualties. The
population were extremity casualties treated by military
teams and hospitalized in one of the 20 hospitals in
the trauma registry. Two periods were defined: 2006-
2013 "pre-intervention period" and 2014-2015 "postintervention

Results: A total of 1,578 extremity injuries were extracted
between 2006 and 2015. Of them, 320 (20.3%) from 2014–
2015. Tourniquet application rates were higher in the
post-intervention period (22.8% vs. 5.5%, p-value<0.001).
Rates of complications in tourniquet use and outcomes
were similar between the two periods: in-hospital
wound treatment (26.9% vs. 22.9%, p=0.155), in-hospital
amputation (1.6% vs. 1.6%, p=1.000), outcome of death or
rehabilitation facility (18.4% vs. 16.4%, p=0.425). Length of
stay was shorter in the post-intervention period (3 vs. 4,

Conclusions: "My Brother’s Keeper" program successfully
increased tourniquet application rates while not
aggravating complications and outcomes. The study’s data
suggest a shorter length of stay correlated with increased
prehospital tourniquet use.

Presenter: Avishai M. Tsur
[email protected]
Reoot Cohen-Koren, Dror Garbi, Shirley Gordon, Nirit Yavnai, Yifat Erlich Shoham, Leah Shelef
Introduction: During rescue missions combat flight
engineers are exposed to distressing sights, sounds
and smells of casualties. Such exposure increases the
vulnerability to emotional distress.

Objective: To predict which combat flight engineers are at
risk of developing emotional distress.

Methods: The Independent variables of this cross sectional
design study included demographics, exposure to
distressing sights and exposure to fatalities. Dependent
variables were: PTSD, somatization, depression, anxiety,
burnout, psychological distress, coping strategies, social
support and self-efficacy.

Results: Ages 31-40, exposure to 1-5 rescue events with
distressing sights and 1-3 events with fatalities were found
to be related to the highest levels of emotional distress,
specifically anxiety and mild depression.

Conclusions: Contrary to the authors’ expectations, the
age-group found to be most at risk for emotional distress
was the 31-40 years old and lower levels of exposure were
related to higher levels of emotional distress.

Presenter: Reoot Cohen-Koren
[email protected]
The 19th SHORESH Meeting, Israel 2019 | Working Groups Abstracts
Lt. Col. Ran Yanovich
The Israel Defense Forces’ Medical Corps Institute of
Military Physiology and the Unites States of America’s
Army Institute of Environmental Medicine (USARIEM)
have been collaborating on scientific projects for over
fifty years. The physiological stress working group’s
(PSWG) sessions in the SHORESH meeting is part of
this scientific collaboration, bringing together the best
exercise and military expert physiologists from both Israel
and the United States of America. In the 2019 SHORESH
meeting, the PSWG included eight sessions. The main
focus of the sessions was to share with the participants
the latest matters and novelties in the field of exercise and
military physiology and warfighters’ medicine, as follows:
(1) Environmental physiology and the heat tolerance test;
(2) Cognitive function; (3) Physical function; (4) Overuse
injuries prevention; (5) Medical innovations in physiological
monitoring; (6) Operational and mission-based nutrition;
(7) Female combatants; (8) Physical performance. In
addition, the PSWG participants visited the Home Front
Command’s (HFC) training base. During this visit, the
vision of the HFC was presented and discussed, focusing
on the physical and mental challenges that the HFC’s
male and female combatants encounter daily throughout
their unique operational activities. Those topics and other
concerns are detailed in the manuscript.
Maj. Roy Nadler, Capt. Avishai M. Tsur, Maj. Tomer Erlich, Maj. Diana Levi, Lt. Col. Jacob Chen
The Trauma and Combat Medicine session of the SHORESH
conference has dealt with three major challenges in combat
casualty care: data collection, performance evaluation,
and knowledge implementation. In data collection, The
Israel Defense Forces maintains the largest military
prehospital trauma registry in the world with over 18
thousand casualties. The documentation is continuously
improving in quantity and quality and has allowed making
policy based on relevant data, thus saving lives. The next
step is the ongoing development of the IDF’s BladeShield
101, a digital real-time documentation system that
allows continuous monitoring and simple transfer of data
between casualty teams. Using these tools, field clinical
studies and online pre/post interventions questionnaires,
provider’s performance is regularly evaluated. The IDF
examined the adherence to clinical practice guidelines,
the success rate in the performance of life-saving
procedures, and trends in medical care. Lessons learned
from data collection and performance evaluation studies
are immediately translated into clinical pearls and new
guidelines for medical educators. The IDF made all
clinical practice guidelines available to all providers via
a dedicated smartphone app called "TilBook", formed
professional WhatsApp groups for horizontal learning and
direct communication between trainers and providers,
and founded a "Dvar Torah". The latter consist of a weekly
message of about 300 words focused on a specific lesson,
an appropriate academic article, and a podcast recording
that providers could listen to on-the-go. The IDF are also
leading in the use of freeze-dried plasma and wholeblood
as resuscitation fluids. Remaining challenges
include improving provider’s skill acquisition, responding
to non-compressible hemorrhage, and developing lighter
protective gear.
Maj. Yuval Cohen, Lt. Shelly Atanelov, Maj. Libby Weiss, Lt. Itai Henn, Michael Zagatsky, Capt. Eli Kabakov, Lt. Col. Ido D. Dechtman
The SHORESH meet-up began in the 1980’s as a session
of Israeli and American working groups in the CBRN
field (chemical, biological, radiation, nuclear), in light of
the steadily developing unconventional weapons threat.
This year, for the first time, the meeting was divided into
3 separate sessions - chemistry, biology and radiation. In
this article we bring highlights of research work that was
Chemistry: Research from the US army showed reactive
skin decontamination lotion (RSDL) in deep wounds
contaminated by deadly doses of VX to be safe and
effective. Another study showed that expired RSDL is still
effective for use.
A study from the Israeli Institute of Biological Research(IIBR) examined new antidotal mixtures for nerve agent
poisoning. They were compared to the TAB (TMB4,
atropin, benactyzine) currently dispensed in the IDF.
A superior formulation, found to be the most efficient
by all parameters examined was marked as a potential
replacement for the TAB auto-injector. Another study from
the IIBR compared the efficacy and safety of different
concentrations of atropine in the treatment of ocular
insult secondary to organophosphates. A 0.1% atropine
solution (as compared to the 1% solution currently used)
had the same therapeutic results with fewer side effects.

Biology: The biology session discussed capabilities to
detect and monitor biological pathogens. The challenge
is quick, real-time detection in the field. Currently there
are two main methods of detection - biosensors and
micro-fluid chips that are effectively a "lab on a chip"
(PCR based). An Israeli study regarding detection by a
photometric based chip was presented.
Radiation: Different treatment doctrines were discussed
with training plans of the two armies. The Israeli’s
stressed their forecast of a problem with the "worriedwell"
population in a radiological incident and the plan
to set up dedicated centers for radiological checkup and
decontamination of low-risk populations. This might
include ARS diagnosis by biological dosimetry. In light of
uncertainty regarding the effect of a radiating fragment
in the body of an injured individual, it was decided to
co-plan research in this field of mutual interest. The
Israeli’s presented a development for the treatment
of acute radiation syndrome (ARS): an intra-muscular
injection of mesenchymal cells, which improves blood
count, inflammation indices and the intestinal function.
A possible treatment for radiological burn victims made
from pineapple enzymes was also presented.
Or Danoch, Inbal Galor, Eva Avramovich,
On April 2019, the SHORESH Conference was held in
Israel. This year, the infectious diseases group was held
under the concept of "One Health". Public health branch
of the IDF Medical Corps fulfill this approach in practice
for many years. In this article we present the "One Health"
approach, using as an example the recent outbreak of
Leptospirosis that occurred in Israel in the summer of
The "One Health" approach is based on the notion that
humans and animals share many environmental and
biological risks, such as infectious pathogens, toxins
and climate changes. In order to detect, treat or prevent
emerging and re-emerging pandemics in human or
animal populations, it is crucial to address the interactions
between all creatures on earth. This approach calls for an
international cooperation between different disciplines in
health care and public health in order to create common
knowledge for designing new and improved guidelines for
a wide range of public health issues.
Leptospirosis is a zoonosis, which is associated with
human exposure to pathogenic Leptospira. In the recent
leptospirosis outbreak in Israel in August 2018, exposure
was linked to contaminated recreational water bodies
in northern Israel. Contamination rose from infected
cattle that purchased the infection from wild boar. The
awareness of the multidisciplinary team that dealt
with the first cases enabled early detection, diagnosis
and control measures to be implemented. Involvement
of epidemiologists, infectious disease specialists,
veterinarians, microbiologists, and the Israel Nature and
Parks Authority helped to rapidly contain the outbreak
Lt. Col. Barak Gordon, Lt. Col. Yael Frenkel Nir, Maj. Idan Nakdimon, Capt. Anna Levkovsky
The aerospace medicine workgroup at the 2019 SHORESH
meeting discussed topics central to aviation medicine:
epidemiology of medical conditions in aircrew, visual
function, spatial orientation in flight, stressors in
medical evacuation, cognitive performance in flight and
mental health in remotely piloted aircraft operators. Two
conditions are elaborated here:
Neck problems in air crew: Neck problems are prevalent
in air crew in both rotary and fixed-wing platforms. One
study found a prevalence rate of 36%-47% in helicopter
pilots, and 47% in fighter-jet pilots. Another study showed
up to a third of the fight-jet pilots that reported neck pain
were grounded for 3 days or more due to pain. Studies
of various treatment modalities were presented: virtual
reality aided treatment was ineffective, partly due to poor
adherence. Treatment in a Multi-Cervical Rehabilitation
Unit was found to increase neck muscle strength and
range of motion. Several research projects comparing
treatment modalities were also presented ("Iron Neck",
"Neck X" and research into the effect of helmet mass and
center of gravity on various neck parameters).
Fatigue and sleep deprivation in aircrew: The "Dead Tired"
workshop of the Israeli Air Force was presented as well
as various studies into sensing fatigue based cognitive
batteries, electroencephalogram signal analysis, prepulse
inhibition and galvanic skin response. Other
studies presented included using the oddball test for
differentiation of sleep deprivation sensitive and resilient
populations, and the quality and length of military aircrew
in active duty.
Maj. Yinon Matsliah, Ben Aviner, Yehuda Arieli
Decompression sickness (DCS) is caused by formation
of inert gas bubbles in tissues or in the blood. Most
patients experience mild sequelae, but some suffer from
severe neurological injury. Discussions of advancements
in decompression disease research in the SHORESH
convention were focused on:
1. Personal risk assessment algorithms for clinical
decompression which will allow for quantifying
individual risk. This can be used for triage and for
choosing priorities for recompression treatments in a
disabled submarine (DISSUB) event.
2. Technical divers use gas mixtures of trimix (Nitrogen,
Helium and Oxygen) or Heliox (Helium & Oxygen). The
Navy Experimental Diving Unit (NEDU) presented a trial
that compared safety in Heliox vs. Trimix dives.
3. New treatment options for DCS, including animal
experiments of Perfluorocarbons (PFC), or nitrate
treatments for reducing venous gas emboli rate.
4. A new theory on the pathophysiology of DCS presented,
offered the formation of nanobubbles on endovascular
"active hydrophobic spots" (AHS) created by circulating
lung surfactant.
5. Morphological changes in Electron Microscopy of spinal
cord decompression injuries offered a bubble formation
inside myelin fibers as a possible injury mechanism.
6. Flying limitations after diving.
Oxygen Toxicity and Closed Circuit Diving: Combat divers
use closed circuit apparatus that allows oxygen breathing
for stealth and much smaller breathing gas tanks.
Increased oxygen exposure can lead to both pulmonary
and CNS oxygen toxicity.
1. In some cases, use of Nitrox mixtures (Oxygen enriched
air) and pure oxygen is carried in different parts of
military dives. We discussed quantification of the risks
for oxygen toxicity in Oxygen/Nitrox dives.
2. The US navy is conducting research on early detection of
pulmonary oxygen toxicity using nitrous oxide derivatives
as a biological marker and impulse oscillometry (IOS).
Since oxygen diving protocols differ between the Israel
navy and the US navy, NSMRL (Naval Submarine
Medical Research Laboratory) representatives offered
to conduct measurements using the same methods
used in Israeli combat divers.
3. The Israel Naval Medical Institute presented a study of
Day - Night Schedule shifts as a risk factor for CNS
oxygen toxicity and suggested ways to reduce the risk
during training periods.
4. The Israel Naval Medical Institute showed dose
dependent breaching of blood brain barrier during
hyperbaric oxygen exposures in animal models
(including subtoxic levels), and discussed clinical
implications of those findings for possible screening
for long term effects of CNS oxygen toxicity, and
also for cross-BBB drug administration using
hyperbaric oxygen.
DISSUB: Lessons learned from the search and rescue
operation that was carried in 2017 in an attempt to locate
the missing Argentinian submarine the "San Juan" were
presented. Several consideration of Escape vs. Rescue
operations were discussed, as well as new concepts in
DISSUB casualty triage and treatment.
Lt. Col. (res.) David Gertz, Lt. Col. (res.) Chen Kugel, Col. Louis N. Finelli, Lt. Col. Alice J. Briones
The Victim Identification/Forensic Pathology session was
populated with 25 senior participants from both countries.
There were 27 presentations, 10 in-depth discussions, two
site visits (Operations Base of the IDF Chief Chaplaincy
Corps and The Israel National Institute for Forensic
Medicine), and two joint sessions.
After opening comments and introductions by both POC’s,
COL Finelli reviewed the impact of the new Defense
Health Agency (DHA) on the administrative structure of
military medicine in the US including the Armed Forces
Medical Examiner System (AFMES) and reviewed its
mission, structure and new facilities. The focus was then
broadened to include current technological advances in
AFMES DNA operations. This was followed by updates and
insights from recent missions of the POW/MIA Accounting
Agency at Hickam AFB in Honolulu, Hawaii.
Advances in the use of Mitochondrial DNA for Victim
Identification were presented and discussed as were novel
emerging molecular technologies in victim identification
including the use of retrotransposons for vitality
determination and micro-RNAs for tissue typing.
Dilemmas and decisions in the interface between the IDF
Chaplaincy and the IDF Medical Corps were discussed
as was the operational importance of an event-specific
approach to the external forensic survey. The state-ofthe-
art for processing of contaminated human remains
for victim identification was presented with emphasis on
unmet needs and future directions.
The joint session on Aviation Pathology with Aerospace
Medicine dealt with lessons and injury patterns from
mishap investigations, identification of desiccated
remains, and the important insights gained from
collaboration between air investigators and flight
surgeons. The joint session on preventable deaths with
Combat Casualty Care (CCC) focused on forensic insights
from both countries. Particular focus was on armorrelated
issues and retrospective mortality reviews, as well
as a presentation of a new, structured CCC checklist for
the forensic pathologist.
The session ended with a presentation of advanced logistics
and novel technologies in military medicine including
the role of unmanned aerial vehicles (drones) for victim
identification and vitality determination in circumstances
of limited access and mass casualty events.
Eight action items for follow-up collaborative efforts were
presented at the executive outbrief session that ended this
year’s particularly productive conference.
Col. Ariel Ben-Yehuda, Maj. Ravit Rubinstein, Lt. Col. Lucian Tatsa-Laur, Mor Nahum, Maj. Noa Barazin-Cohen, Maj. Alex Davidov, Maj. Niv Gold
but it is a major risk factor for developing PTSD and a
serious operational challenge. Approaching the immediate
and acute phase of stress during combat activities, is a
major effort in the Mental Health Department in the IDF
and was the subject of recent collaboration with the US
army. Since 2013 the IDF embedded a new short protocol
(MAGEN) following Salmon’s PIE principles, in order for a
soldier buddy to give immediate psychological first aid for
a mentally distressed soldier during battle. The MAGEN
protocol was introduced and accepted as an action item
for future SHORESH meetings and research collaboration
between armies. In addition, in the years since "Protective
Edge Operation" (2014) we have refreshed and validated
our chain of mental care and evacuation in operational
The digital revolution gave birth to new opportunities.
The fact that almost everyone carries a smartphone, and
sometimes wear a smartwatch, brought to mind the idea
that we might use this digital footprints and constant
monitoring of physiological, cognitive and behavioral data
for mental health purposes, in times of routine training
and in operational situations. In the last SHORESH
meeting there was a session dedicated for wearables and
digital monitoring, in which several works were presented,
by both armies; this was also agreed as an action item for
future meetings and cooperation
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