Israel Medical Association Journal

Background: The massive terrorist attack on a mixed population of civilians, soldiers, and foreigners on October 7, 2023, resulted in 1200 casualties and led to many major personal identification issues. At the Israel National Center for Forensic Medicine (INCFM), addressing the mass casualty incidents required precision that included technical, ethical, and humanitarian dimensions. Many obstacles arose that were attributable to the vast number and diversity of victims and the heavy workload in the setting of a small forensic team.

Objectives: To define the various methods utilized for victim identification.

Methods: The different types of identification were visual, primary, and circumstantial. Primary methods compared unique and stable characters of the human body, including fingerprints, comparisons of dental data, X-rays, and medical databases. We implemented other methods (anthropology, genetics) and novel creative strategies (digital photography taken by random individuals using mobile phones) and computed tomography (CT) scan at another designated site other than at the INCFM.

Results: Often, visual recognition and extraction of DNA were impossible because of burnt human remains. Hence, a comparison method of antemortem and postmortem CT findings became imperative for many unidentified victims. The more complex cases included the finding of body parts of more than one individual in different body bags (comingled remains). In such situations, we matched the body parts by utilizing DNA methods. We present seven case challenges.

Conclusions: We utilized various known and novel methods for victim identification in the aftermath of the events of 7 October 2023 while addressing ethical issues in a case series.

Background: Military medicine has evolved significantly over the past 50 years, advancing from basic treatments and limited evacuations to sophisticated combat casualty care. Innovations such as hemorrhage control, early blood product administration, and telemedicine have greatly improved battlefield care. Rapid evacuation systems and skilled medical teams have reduced mortality and morbidity rates.

Objectives: To review the transformation of the Israel Defense Forces Medical Corps (IDF-MC) in combat casualty care over the past 50 years, focusing on recent applications during the Iron Swords war.

Methods: Data were collected from the personal experiences of IDF-MC doctors, IDF archives, and relevant military medical literature, with an emphasis on life-saving strategies, personnel, equipment, mental health support, and civil–military cooperation.

Results: Rapid evacuation and immediate care have improved survival rates, while increased front-line deployment of medical staff has enhanced response capabilities. Modern medical tools and techniques, such as tourniquets and blood products, have been widely adopted. Improved psychological support strategies ensure better mental health outcomes for soldiers. Enhanced coordination with civilian trauma systems optimizes care and resource allocation, leading to more efficient and effective casualty treatment.

Conclusions: The IDF-MC's advancements in rapid evacuation and front-line medical support have significantly improved combat casualty outcomes. Continued innovation and collaboration with civilian systems are essential for further progress in military medicine. Future technological advancements are anticipated to further enhance military medical care.

On 7 October 2023, the Hamas terror organization launched an unprecedented terror attack on Israel. Their forces infiltrated the country from the Gaza Strip invading nearby kibbutzim (collective farm settlements) and towns. During the attack an estimated 1200 Israelis were murdered and another 255 taken hostage, including children and older people, women and men.

Background: Allergic rhinitis (AR) is a common illness. Worldwide prevalence varies between 5% and 50% depending on self-reported surveys, test-based studies, geographic location, and age. Despite the clinical relevance of AR in the Israeli population, few studies have characterized the sensitization profiles and key pollen aeroallergen.

Objectives: To describe the most common aeroallergens eliciting a positive skin prick test (SPT) in AR patients across three different main climate zones in Israel.

Methods: We evaluated SPT of aeroallergen sensitization in 1308 AR patients from three topographically and climatically different areas of Israel, describing humidity levels, temperature, and urbanization.

Results: The overall prevalence of positive SPT among patients presenting with AR symptoms was 86%. Indoor aeroallergen sensitization was observed in 76% of patients. Monosensitization was noted in 20% of patients, and polysensitization was noted in 65%. Among the 1308 cases of AR, the top four aeroallergens were mites, olive tree pollen, grass pollen, and cat dander. The top aeroallergen in Israel's central district were mites (62%), olive tree pollen (36%), and grass pollen (30%). In the coastal plains, mites (92%), cat dander (36%), and olive tree pollen (33%) were most prevalent, and in the south mites (77%), olive tree pollen (30%), and grass pollens (26%) were most common.

Conclusions: The top four aeroallergens eliciting a positive SPT were mites, olive tree pollen, grass pollen, and cat dander. Identification of a major aeroallergen can tailor the allergist's SPT panels and specify which aeroallergen should be used for immunotherapy.

Background: Cardiac implantable electronic devices (CIEDs) with endocardial leads crossing the tricuspid valve can lead to or worsen tricuspid regurgitation (TR), causing substantial morbidity and mortality. Despite a recent randomized controlled study revealing a low short-term incidence of device-related TR (DRT) post-CIED implantation, uncertainties persist regarding the efficacy of intra-procedural 2-dimensional transthoracic echocardiography (2DTTE) in preventing long-term TR.

Objectives: To conduct a long-term follow-up study on patients with CIED implants based on a previous study conducted at our hospital.

Methods: In a retrospective study at Assuta Ashdod Medical Center (2018–2019), patients undergoing de-novo CIED implantation with (n=39, group 1) or without (n=51, group 2) intra-procedural 2DTTE were analyzed. Clinical, demographic, and long-term (> 1 year) echocardiographic data were collected and compared.

Results: The study included 90 patients (mean age 72.3 ± 11.0 years, 63% male, 23% ICD, 50% active leads, follow-up 32.8 ± 11 months). TR aggravation was found in 25% of patients (13 in group 1, 10 in group 2), with no statistical difference between groups. Multivariate analysis identified a history of atrial fibrillation (AF) as the sole significant factor in long-term TR deterioration (OR=3.44, 95%CI 1.13–10.43, P = 0.029). Other clinical, demographic, echocardiographic, and device-related factors did not significantly contribute to long-term DRT.

Conclusions: After one-year post-CIED implantation, the incidence of DRT significantly increases. Intra-procedural 2DTTE does not effectively reduce long-term DRT, suggesting that implantation-related mechanisms are less likely the primary cause. AF likely plays a major role in the pathogenesis of long-term TR in this subset post-CIED implantation.

Background: The Agatston coronary artery calcium (CAC) score is a decision-guiding aid for risk assessment and personalized management in the primary prevention of atherosclerotic cardiovascular disease.

Objectives: To explore the real-life clinical experience of CAC testing by characterizing its indications, significance of scores, and corresponding lipid-lowering treatments.

Methods: A retrospective descriptive study of patients treated at the lipids clinic at Rabin Medical Center (Beilinson Campus), who underwent CAC score evaluation between 2017 and 2022 was conducted. The data collected from electronic medical files included demographics, co-morbidities, indications for the test, CAC score levels, and the recommended therapeutic regimen.

Results: The study cohort included 88 patients. The main indication was assessment of the existence of atherosclerosis in cases where there was no clear indication for lipid lowering treatment (65, 74%). In most patients, there was no evidence of atherosclerosis (CAC = 0 AU, n=30) or only mild disease (CAC=1–99 AU, n=35). As the CAC score increased, more patients were prescribed lipid lowering treatments, from very few prescriptions in those with a CAC score of 0 AU and almost 100% among those with score of ≥ 400 AU. The factors that predicted CAC > 0 AU were male sex and older age.

Conclusions: CAC scores should be used more often to determine risk assessment. Further analysis of the implications of scores between 0–400 AU is needed.

Background: Cardiac implantable electronic devices (CIEDs) are associated with risks of device-related infections (DRI) impacting major adverse outcomes. Staphylococcus aureus (SA) is a leading cause of early pocket infection and bacteremia. While studies in other surgical contexts have suggested that nasal mupirocin treatment and chlorhexidine skin washing may reduce colonization and infection risk, limited data exist for CIED interventions.

Objectives: To assess the impact of SA decolonization on DRI rates.

Methods: We conducted a retrospective, single-center observational study on consecutive patients undergoing CIED interventions (March 2020–March 2022). All patients received pre-procedure antibiotics and chlorhexidine skin washing. Starting in March 2021, additional pre-treatment with mupirocin for SA decolonization was administered. DRI rates within 6 months post-implantation were compared between patients treated according to guidelines (Group 1) and those receiving mupirocin in addition to the recommended guidelines (Group 2).

Results: The study comprised 276 patients (age 77 ± 10 years; 60% male). DRI occurred in five patients (1.8%);80% underwent cardiac resynchronization therapy procedures. In Group 1 (n=177), four patients (2.2%) experienced DRI 11–48 days post-procedure; three with pocket infection (two with negative cultures and one with local Pseudomonas) and one with methicillin-sensitive SA endocarditis necessitating device extraction. In Group 2 (n=99), only one patient (1%) had DRI (Strep. dysgalactiae endocarditis) 135 days post-procedure (P = NS).

Conclusions: The routine decolonization of SA with mupirocin, in addition to guideline-directed protocols, did not significantly affect DRI rates. Larger prospective studies are needed to evaluate the preventive role of routine SA decolonization in CIED procedures.

Background: One-third of patients with acute decompensated heart failure (ADHF) develop worsening kidney function, known as type I cardiorenal syndrome (CRS). CRS is linked to higher mortality rates, prolonged hospital stays, and increased readmissions.

Objectives: To explore the impact of real-time monitoring of urinary output (UO) trends on personalized pharmacologic management, fluid balance, and clinical outcomes of patients with ADHF admitted to a cardiac intensive care unit.

Methods: Our study comprised 35 patients who were hospitalized with ADHF and continuously monitored for UO (UO_elec). Standard diuretic and fluid protocols were implemented after 2 hours of oliguria, and patient outcomes were compared to a historical matched control (HMC) group. Patients were assessed for daily and cumulative fluid balance (over 72 hours) as well as for the occurrence of acute kidney injury (AKI).

Results: Significantly more patients in the UO_elec group demonstrated negative fluid balance daily and cumulatively over time in the intensive care unit compared to the HMC group: 91% vs. 20%, respectively (P < 0.0001 for 72-hour cumulative fluid balance). The incidence of AKI was significantly lower in the UO_elec monitoring cohort compared to the HMC: 23% vs. 57%, respectively (P = 0.003). Moreover, higher AKI resolution, and lower peak serum creatinine levels were demonstrated in the UO_elec group vs. the HMC group.

Conclusions: Implementing real-time monitoring of UO in ADHF patients allowed for early response to oliguria and goal-directed adjustment to treatment. This finding ultimately led to reduced congestion and contributed to early resolution of AKI.

IgG4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition. Accumulated research and data since 2003 have increasingly affirmed its classification as a systemic disease. Although IgG4-RD generally presents with involvement of one or several organ systems, it can affect almost any organ. The disease manifests gradually with the development of tumor-like lesions.

Constitutional symptoms, such as systemic fever and elevated inflammatory markers, are generally absent in association with this pathological condition. However, it is common for patients to exhibit allergy characteristics in addition to a slight increase in peripheral blood eosinophilia. The clinical manifestations of the disease exhibit variability on the specific organ system affected. Specific involvement of organs can ultimately result in organ failure. For example, retroperitoneal fibrosis commonly leads to post-renal failure [1]. The 2020 Revised Comprehensive Diagnostic (RCD) criteria for IgG4-RD include three components for diagnosis: clinical and radiological components (1), serological diagnosis (2), and unique pathological diagnosis (3). When all three are present it is a definitive diagnosis. The presence of components 1 + 3 constitutes a probable diagnosis, while the presence of components 1 + 2 indicates possible diagnosis [2].

Testicular involvement of IgG4-RD has been described in a few case reports. However, the uniqueness of our case is the manifestation of a testicular mass as a different target organ of relapse in a patient in remission from retroperitoneal fibrosis.

Nasopharyngeal angiofibromas represent a rare occurrence. They are characterized by vascular fibrous proliferation within the nasopharynx. While histologically benign, they exhibit a local aggressiveness, predominantly afflicting adolescent males. Despite their typically nasopharyngeal location, the exact etiology remains elusive.

Microscopically, angiofibromas manifest as a combination of vascular elements, featuring slit-like capillaries or dilated branched vessels, in addition to a stromal component comprising collagenous matrix and fibroblasts.

To the best of our knowledege, we presented the first documented example of an extra-nasopharyngeal angiofibroma in an adult male, which presented with a distinctive histologic pattern of epithelioid fibrous papule. Clinical manifestations included left-side aural fullness and gradual hearing loss over the course of 5 years. Examination revealed a mass within the left external auditory canal tethered to the posterior wall by a stalk. The audiometric assessment revealed a moderate to severe conductive hearing impairment in the left ear. Surgical excision of the mass was performed, with subsequent histopathological and immunohistochemical analysis unveiling this unforeseen diagnosis.

In this case report, we underscored the potential for angiofibromas to occur in atypical anatomical sites and highlighted the importance of recognizing their benign nature to prevent misdiagnosis as malignant tumors.

Cardiac amyloidosis is a form of restrictive cardiomyopathy resulting from the accumulation of misfolded protein aggregates in the myocardial extracellular space. Cardiac amyloidosis stems primarily from the misfolding of monoclonal immunoglobulin light chains (AL) originating from abnormal clonal plasma cell proliferation or transthyretin amyloidosis (ATTR).

Diagnosis of amyloidosis demands a high index of suspicion and requires histological confirmation of pathognomonic green birefringence under polarized light when an infiltrated tissue specimen is stained with Congo-red staining [1,2].

Pleural involvement of systemic amyloidosis has rarely been reported and is considered a serious complication [3]. Pleural amyloidosis is diagnosed with the identification of amyloid deposits in pleural biopsy specimens. However, pleural biopsies are rarely performed for this indication.

We describe the case of a patient with AL cardiac amyloidosis presenting as intractable pleural effusion and diagnosed via pleural biopsy.

Medical educators often find teaching useful findings on physical examination challenging. Important findings must be easy to remember and applied or they will soon be forgotten by students. The use of elegant, thought-provoking art for teaching examination skills makes learning enjoyable and memorable. Physicians need the ability to quickly perform and incorporate a limited useful physical examination into patient encounters to be good diagnosticians.

In the last hundred years, the science of fracture repair has significantly changed. Management has moved from a simple metabolic and hormonal concept of bone regeneration to an inflammatory concept and now to a more complicated immunological description. Fracture repair has been considered age-dependent and related to diabetes, nutrition, hormone connection, autoimmune diseases, rheumatic arthritis, and nicotine. Recently a new branch of medicine, osteoimmunology, which deals with the mechanism of fracture repair, has been introduced.

Background: Patients with mechanical prosthetic heart valves must be treated with vitamin K antagonists (VKA) due to an increased risk of valve thrombosis and systemic embolism.

Objectives: To assess the effects of the COVID-19 pandemic on VKA treatment control in patients with mechanical prosthetic heart valves.

Methods: We conducted a retrospective nationwide cohort study using the Clalit Health Services database. The cohort included patients who underwent either aortic or mitral valve replacement using a prosthetic mechanical valve. The primary outcomes included the overall time in therapeutic range (TTR) and the percent of patients with a TTR < 50% during the first year of the COVID-19 pandemic compared to preceding year.

Results: The cohort included 2381 patients. The percentage of patients who had at least two international normalized ratio (INR) tests during the first year of the COVID-19 pandemic was significantly lower compared to the year preceding the pandemic (81% and 87%, respectively, P < 0.001). In both years, the percentage of patients without any documented INR test was high (31.5% in the first COVID-19 pandemic year and 28.9% in the preceding year, P < 0.001). TTR was significantly lower during the 1st year of the COVID-19 pandemic compared to the preceding year (68.1% ± 26 and 69.4% ± 24, P = 0.03). A TTR > 50% was demonstrated in 78% and 81% during the pandemic and the preceding year, P = 0.009.

Conclusions: We noted overall poor VKA control in patients with mechanical heart valves. During the COVID-19 pandemic, VKA control became even worse as reflected by significantly lower TTR and INR tests rates.

Background: Cloacal malformation represents the rarest and most complex congenital anorectal malformation in females and is characterized by the convergence of urinary, gynecological, and intestinal systems within a single common channel. Three-dimensional computed tomography reconstruction (3D CT cloacagram) has emerged as a valuable method for anatomical assessment and preoperative planning.

Objectives: To evaluate our experience with 3D CT cloacagram and assess its results.

Methods: This retrospective case series included all patients with cloacal malformation who underwent preoperative 3D CT cloacagram at a single institution during 2019–2023. Collected data included patient characteristics, timing of the 3D CT cloacagram, results of the 3D CT cloacagram, comparison with endoscopic results, surgical procedures, and postoperative outcome.

Results: Six patients with cloacal malformation were included in this study, including two with posterior cloaca. The median common channel length on 3D CT cloacagram was 24.5 mm (range 9–48 mm) and the median urethral length was 15.5 mm (range 13-24 mm). The surgical approach involved a combined abdominoperineal approach in three patients and posterior sagittal anorectal vaginal urethral plasty in one patient. Two patients were awaiting surgical reconstruction at the time of publication.

Conclusions: Our implementation of 3D cloacagram has facilitated precise measurements of both the urethra and common channel lengths, two key factors in formulating surgical strategies for cloacal reconstruction. Moreover, this technique has markedly improved our capacity for surgical planning contributing to colorectal, gynecological, and urological perspectives.