Israel Medical Association Journal

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.

Background: Among the most frequent complications following transcatheter aortic valve replacement (TAVR) is hemostasis imbalance that presents either as thromboembolic or bleeding. Deviations in platelet count (PC) and mean platelet volume (MPV) are markers of hemostasis imbalance.

Objectives: To determine the predictive value of pre- and post-procedural PC and MPV fL 1-year all-cause mortality in patients who underwent TAVR.

Methods: In this population-based study, we included 236 TAVR patients treated at the Tzafon Medical Center between 1 June 2015 and 31 August 2018. Routine blood samples for serum PC levels and MPV fL were taken just before the TAVR and 24-hour post-TAVR. We used backward regression models to evaluate the predictive value of PC and MPV in all-cause mortality in TAVR patients.

Results: In this study cohort, MPV levels 24-hour post-TAVR that were greater than the cohort median of 9 fL (interquartile range 8.5–9.8) were the strongest predictor of 1-year mortality (hazard ratio 1.343, 95% confidence interval 1.059–1.703, P-value 0.015). A statistically significant relationship was seen in the unadjusted regression model as well as after the adjustment for clinical variables.

Conclusions: Serum MPV levels fL 24-hour post-procedure were found to be meaningful markers in predicting 1-year all-cause mortality in patients after TAVR.

Background: Postpericardiotomy syndrome (PPS) is characterized by pleuro-pericardial inflammation, which occurs in patients undergoing surgical procedures involving the pleura, pericardium, or both. The syndrome is considered to be immune mediated. However, its pathogenesis is not fully understood. It has previously been demonstrated that the Mediterranean Fever (MEFV) gene, which is associated with familial Mediterranean fever (FMF), has a role in the activation and expression of several inflammatory diseases.

Objectives: To investigate whether carriage of the MEFV mutation may precipitate PPS or affect its phenotype.

Methods: The study population included 45 patients who underwent cardiac surgery and developed PPS. The control group was comprised of 41 patients who did not develop PPS. Clinical and demographic data was collected. The severity of PPS was evaluated. Genetic analysis to determine the carriage of one the three most common MEFV gene mutations (M694V, V726A, E148Q) was performed. The carriage rate of MEFV mutations in patients with and without PPS was compared. Association between MEFV mutation carriage and severity of PPS was evaluated. 

Results: The rate of mutation carriage in the MEFV gene was similar in patients with and without PPS (15.6% in the study groups vs. 29.3% in the control group, P = 0.1937). The rate of mutation carriage in the MEFV gene was significantly lower among patients with severe PPS as compared to patients with mild-moderate PPS (4.8% vs. 25%, P < 0.05).

Conclusions: Carriage of mutations in the MEFV gene is not associated with development of PPS; however, it may affect PPS severity.

 

Background: Glioblastoma multiforme (GBM) is an ultimately fatal disease that affects patients of all ages. Elderly patients (65 years and older) constitute a special subgroup of patients characterized by a worse prognosis and frequent comorbidities.

Objectives: To assess the efficacy of different treatment modalities in terms of survival in elderly patients with GBM¹.

Methods: Using retrospective analysis, we extracted, anonymized and analyzed the files of 74 deceased patients (aged 65 or older) treated for GBM in a single institution.

Results: Mean survival time was 8.97 months and median survival time 7.68 months. Patients who underwent tumor resection had a mean survival of 11.83 months, as compared to patients who underwent no surgical intervention or only biopsy and had a mean survival of 5.22 months (P < 0.0001). Patients who underwent full radiation treatment had a mean survival of 11.31 months, compared to patients who received only partial radiotherapy or none at all and had a mean survival of 4.09 months (P < 0.0001). Patients who underwent chemotherapy had a mean survival 12.4 months, compared to patients who did not receive any chemotherapy and had a mean survival of 5.89 months (P < 0.001).

Conclusions: Age alone should not be a factor in the decision on which treatment should be given. Treatment should be individualized to match the patient’s overall condition and his or wishes, while taking into consideration the better overall prognosis expected with aggressive treatment.
 

Background: A survey conducted among Israel Defense Force primary care physicians in 2001 revealed that they consider patients' needs more than they do organizational needs and that the education PCPs[1] currently receive is inadequate. In 2003 the medical corps initiated a multi-format continuous medical education program aimed at improving skills in primary care medicine.

Objectives: To measure and analyze the effect of the tailored-made CME[2] program on PCPs’ self-perception 3 years after its implementation and correlate it to clinical performance.

Methods: In 2006 a questionnaire was delivered to a representative sample of PCPs in the IDF[3]. The questionnaire included items on demographic and professional background, statements on self-perception issues, and ranking of roles. We compared the follow-up survey (2006) to the results of the original study (2001) and correlated the survey results with clinical performance as measured through objective indicators.

Results: In the 2006 follow-up survey PCPs scored higher on questions dealing with their perception of themselves as case managers (3.8 compared to 4.0 on the 2001 survey on a 5 point scale, P = 0.046), perceived quality of care and education (3.5 vs. 3.8, P = 0.06), and on questions dealing with organizational commitment (3.5 vs. 3.8, P=0.01). PCPs received higher scores on clinical indicators in the later study (odds ratio 2.05, P < 0.001).

Conclusions: PCPs in the IDF perceive themselves more as case managers as compared to the 2001 survey. A tailor-made CME program may have contributed to the improvement in skills and quality of care.

Background: Bisphosphonates are effective in the prevention and treatment of osteoporosis, yet their use is suboptimal.

Objectives: To measure bisphosphonate compliance among first-time users and identify factors associated with compliance.

Methods: We conducted a prospective follow-up of all women aged 45+ in the second largest health management organization in Israel who were prescribed bisphosphonates for the first time. The 4448 women were classified by drug dosage. Persistence and adherence measures of compliance were calculated for each woman over a 1 year period.

Results: Mean bisphosphonate persistence over a year was 216 days, with a mean medication possession ratio of 66%. Women whose medication was changed, whether from weekly to daily or daily to weekly, always had better persistence rates than those who consistently took the original dose. Persistence rates were as follows: 264 days for women who switched back and forth between daily and weekly doses, 229 days for those who switched from daily to weekly, 222 days for those who took the dosage weekly only, 191 days for those who switched to daily dosage, and 167 days for those who took the dosage daily only (P < 0.001). Switchers were also more likely to have adequate adherence rates (MPR[1] ≥ 80%): 81.3%, 76.6%, 67.5%, 61.3% and 52.2% respectively (P < 0.001). More than 20% of women stopped taking their medication within the first month. Women with higher supplemental insurance (offering significant discounts for weekly dose medications) had better persistence rates: 221 vs. 208 days (P = 0.03). Younger women and women on national pension insurance had the lowest persistence rates: 204 and 209 days respectively.

Conclusions: While weekly bisphosphonate takers had better compliance rates, persistence and adherence rates were inadequate for all groups. Changing medication to meet the needs of the patient, discounting weekly medications, and providing follow-up within the first months of prescription may promote compliance. 

Background: Oral lichen planus is a cell-mediated immune condition of unknown etiology. A possible association of OLP[1] with hepatitis C virus infection has been documented in specific populations. However, no such possible association has been studied in Israel.

Objectives: To assess the prevalence of HCV[2] antibodies among patients with OLP in Israel.

Methods: The prevalence of HCV seropositivity was studied in OLP patients (n=62) and compared with that of a control group (n=65) and with the prevalence among healthy volunteer blood donors (n=225,452) as representatives of the general population.

Results: The prevalence of HCV, as detected by the presence of anti-HCV antibodies screened by enzyme-linked immunosorbent assay, and confirmed by recombinant immunoblot assay, was 4.8%, 1.5% and 0.1%, respectively. HCV seropositivity in the OLP patients was significantly higher than in the healthy blood donors (P < 0.001).

Conclusions: A possible association between OLP and HCV is suggested. Therefore, screening OLP patients for antibodies to HCV is recommended.

Background: Familial Mediterranean fever is an autosomal recessive disease characterized by recurrent attacks of fever and serositis. The disease is caused by mutations in the MEFV gene, presumed to act as a down-regulator of inflammation within the polymorphonuclear cells.

Objectives: To present the results of 412 FMF patients genotyped for three MEFV mutations, M694V, V726A and E148Q.

Results: The most frequent mutation, M694V, was detected in 47% of the carrier chromosomes. This mutation, especially common among North African Jewish FMF[1] patients, was not found in any of the Ashkenazi (East European origin) patients. Overall, one of the three mutations was detected in 70% of the carrier chromosomes. M694V/M694V was the most common genotype (27%), followed by M694V/V726A (16%). The full genotype could be assessed in 57% of the patients, and one disease-causing mutation in an additional 26%. Only one patient with the E148Q/E148Q genotype was detected despite a high carrier rate for this mutation in the Jewish population, a finding consistent with a low penetrance of this genotype. The M694V/M694V genotype was observed in 15 patients with amyloidosis compared to 4 amyloidosis patients with other genotypes (P < 0.0001).

Conclusions: Because of low penetrance and as yet other undetermined reasons, mutation analysis of the most common MEFV mutations supports a clinical diagnosis in only about 60% of patients with definite FMF.

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