Israel Medical Association Journal

The cause of death for Pharaoh Tutankhamun (ca. 1330–1324 BCE) is still unknown despite the advancement in modern paleopathology and the introduction of computed tomography mummy examination and modern molecular pathology, including PCR-based gene analysis. Many speculations regarding his unexpected death have been published, including crush injury, infectious diseases such as malaria, and hereditary disease. We discuss for the first time all these events that could have ultimately caused Tutankhamun's sudden death, particularly sickle cell disease, which can cause osteonecrosis and lead to walking disability, bone deformities, and fragility. Malaria-associated tropical splenomegaly, as an acquired infectious disease, and the crush injury, which represents an acute event, were verified by a left distal femur fracture that contributed to splenic rupture as a major fatal event. We highlight important issues that can provide clinicians and clinical care practitioners with a broad vision while analyzing such cases.

A dramatic portrait bust of the physician Gabriele da Fonseca (1586? to 1668) at prayer is considered by art historians to be one of the finest late works of Gian Lorenzo Bernini (1598–1680), the preeminent sculptor of 17th century Rome. This statue is of medical as well as artistic interest. First, Fonseca is shown wearing his physician’s robe, thus celebrating his successful career as a leading medical figure in Rome, holding both Papal and university appointments at the highest level. In addition, the positioning of the statue in a special chapel designed by Bernini highlights Fonseca’s role as an influential participant in the introduction of quinine into Europe as a cure for malaria. Last, an examination of the statue’s hands identifies a number of pathologies and anatomical anomalies that raise interesting questions, regrettably unanswerable given the information presently available, concerning Fonseca’s illnesses and cause of death.

In this study, we analyzed computed tomography (CT) radiological findings from trauma treated at a single hospital in the aftermath of the terror attack in Israel on 7 October 2023. The study includes images from 34 consecutive patients, consisting of 33 males and 1 female, ranging in age from 19 to 68 years. The majority of these patients underwent both chest-abdominal-pelvic (76%) and head and neck CT scans (64.7%). Key findings highlight a high incidence of head and neck injuries (55.9%), chest trauma (44.1%), and various injuries such as soft tissue lacerations (100%), fractures particularly skull fractures at 32.4%, and brain hemorrhages (23.5%). The limitations of this study include its single-center scope and the focus on stable patients, which may bias the representation of injury types. This case series provides critical insights into the radiological impacts of large-scale terror events, emphasizing the importance of comprehensive preparedness and research in the field of mass-casualty incident response.

On 7 October 2023, a large-scale invasion by armed Hamas terrorists occurred in southern Israel. Approximately 1500 militants breached the Gaza security barrier using tractors, RPGs, and explosives. Concurrently, the terrorists utilized various means including armed vehicles, motorized paragliders, sea incursions, and a massive rocket attack launched toward Israel. On entering Israeli territory, the militants dispersed and targeted several towns, kibbutzim (collective communities), and Israel Defense Forces (IDF) military bases near Gaza. This strategy resulted in a death toll exceeded 1300 civilians and soldiers. In addition, more than 240 individuals were abducted. This attack occurred in one day. In this article, we introduce the Israeli National Institute of Forensic Medicine, which specialized in forensic analysis during mass casualty incidents, and pivotal role it played on 7 October. We present a detailed discussion on methods, challenges, and adaptations the institute took in response to the event of 7 October.

The ancient, Biblical, holy Ten Commandments were presented to humanity to serve as guidelines for relationships between individuals and the deity they worship as well as a benchmark for living in civilized communities, irrespective of religious affiliation. The commandments are also embedded in medical education taught to medical students and other health professions throughout the world. Thus, the Ten Commandments are embedded in the medical communications curriculum at Adelson School of Medicine, Ariel University, Ariel, Israel. Unfortunately, most of these commandments were desecrated during the violent, hostile, merciless, and ruthless attack inflicted by the Hamas terror organization on villages, rural communities, and cities in southern Israel on 7 October 2023. We define the Ten Commandments in terms of medical education and describe their desecration by Hamas terrorists before and during the Iron Swords war.

Chronic obstructive pulmonary disease (COPD) is a common lung disease characterized by restricted airflow, changes of lung tissues, and breathing difficulties [1]. Most patients are treated at home to maintain a stable lifestyle and quality of life [2].

An important feature of COPD is exacerbation, which is an acute worsening of symptoms that can result in decreased pulmonary functions, increased risk of death, and poorer quality of life. The frequency and severity of each exacerbation results in further worsening of pulmonary function [3]. Depression in COPD patients may cause objective impairment in function and decreased adherence to therapeutic interventions [4].

Acute stress disorder is characterized by acute reaction in the first month following exposure to a traumatic event such as threatened death, serious injury, or sexual assault. Symptoms include intrusion, dissociation, negative mood avoidance, and arousal [5]. Stress on a more continuous basis can significantly debilitate a person's emotional and physical wellbeing, lead to depression and weakened immune system, and influence patients with already stressful and progressive conditions such as COPD.

We present a patient previously diagnosed with COPD who experienced an acute terror attack, which was a major and stressful event that caused severe exacerbation of the disease.

Background: Cases of second trimester pregnancy loss can be treated either pharmacologically or by surgical evacuation. Misoprostol, an E1-prostaglandin analog, is used to facilitate the evacuation of the uterus.

Objectives: To determine the risk factors associated with patients who were treated with five or more repeated doses of misoprostol.

Methods: We conducted a retrospective study of patients treated with vaginal misoprostol at our institution between December 2016 and October 2021 for second trimester pregnancy loss.

Results: In total, 114 patients were eligible for analysis; 83 were treated with < 5 doses and 31 with ≥ 5. We recorded each case in which repeated doses were administered, irrespective of predetermined conditions such as gravidity, parity, maternal age, or gestational age. Moreover, cases of five or more misoprostol dosing were not associated with an increased complications rate, except for the increased duration of hospitalization (3.1 vs. 2.2 days, P-value < 0.01).

Conclusions: Repeated dosing could not be predicted before treatment among those treated with vaginally administered misoprostol for second trimester pregnancy loss. However, low complication rates of repeated dosing may reassure both physicians and patients regarding safety, efficacy, and future fertility.

Background: Hip fractures are a public health problem that disproportionately affects the elderly. Displaced femoral neck fractures were treated historically with hemiarthroplasty, but the use of total hip arthroplasty (THA) is increasing showing superior long-term results.

Objectives: To assess whether THA has superior short-term results compared to bipolar hemiarthroplasty for displaced femoral neck fractures.

Methods: Two groups of active older patients underwent either cementless bipolar hemiarthroplasty or THA for displaced femoral neck fracture. All patients were operated on using the direct lateral approach to the hip joint. Patients were assessed using the Harris Hip Score at hospital discharge and at 6 weeks follow-up.

Results: We included 40 patients ages 65–85 years; 18 underwent bipolar hemiarthroplasty and 22 THA. The number of women in each group was similar, as was mean age: 73.1 ± 4.2 years in the hemiarthroplasty group and 71.0 ± 3.7 in THA. Harris Hip Score on hospital discharge was similar in both groups. Walking ability at discharge was better in the THA cohort and they were discharged sooner: 5.2 ± 1.3 vs. 6.4 ± 1.7 days following hemiarthroplasty (P = 0.021). At 6 weeks follow-up, the mean Harris Hip Score was higher in the THA group (78.6 ± 11 vs. 61.5 ± 17 for hemiarthroplasty, P < 0.001). Patients in the THA group walked longer distances, needed less support while walking, and reported less pain.

Conclusions: Better short-term results at hospital discharge and at 6 weeks follow-up after THA contributed to earlier patient independence and shorter hospital stays.

Background: With age, colorectal cancer (CRC) prevalence rises. The elderly (> 75 years), and the very elderly (> 85 years) are especially vulnerable. The advantages of screening must be assessed in the context of diminished life span and co-morbidities.

Objective: To compare CRC findings in colonoscopies that were performed following a positive fecal occult blood test/fecal immunochemical test (FOBT/FIT) in both elderly and very elderly age groups with those of younger patients.

Methods: We identified colonoscopies conducted between 1998 and 2019 following a positive stool test for occult blood in asymptomatic individuals. A finding of malignancy was compared between the two patient age groups. Furthermore, a sub-analysis was performed for positive malignancy findings in FOBT/FIT among patients > 85 years compared to younger than < 75 years.

Results: We compared the colonoscopy findings in 10,472 patients: 40–75 years old (n=10,146) vs. 76–110 years old (n=326). There was no significant difference in prevalence of CRC detection rate between the groups following positive FOBT/FIT (2.1% vs. 2.7%, P = 0.47). Similar results for non-significant differences were obtained in the sub-analysis compared to malignancy detection rates in the very elderly 0% (n=0) vs. 2.1% for < 75 years old (n=18), P = 0.59.

Conclusions: Although the prevalence of CRC increases with age, no significant increase in the detection rate of CRC by FOBT was found in either the elderly or very elderly age groups. Screening colonoscopies in elderly patients should be performed only after careful consideration of potential benefits, risks, and patient preferences.

Background: Ventricular assist devices (VADs) play a critical and increasing role in treating end-stage heart failure in pediatric patients. A growing number of patients are supported by VADs as a bridge to heart transplantation. Experience with VADs in the pediatric population is limited, and experience in Israel has not been published.

Objectives: To describe this life-saving technology and our experience with VAD implantation in children with heart failure, including characteristics and outcomes.

Methods: We conducted a retrospective chart review of all patients who underwent VAD implantation at Schneider Children's Medical Center from 2018 to 2023.

Results: We analyzed results of 15 children who underwent VAD implantation. The youngest was 2.5 years old and weighed 11 kg at implantation. In eight patients, HeartMate 3, a continuous-flow device, was implanted. Seven patients received Berlin Heart, a pulsatile-flow device. Three children required biventricular support; 11 underwent heart transplants after a median duration of 169 days. Two patients died due to complications while awaiting a transplant; two were still on VAD support at the time of submission of this article. Successful VAD support was achieved in 86.6% of patients. In the last 5 years,79%  of our heart transplant patients received VAD support prior to transplant.

Conclusions: Circulatory assist devices are an excellent bridge to transplantation for pediatric patients reaching end-stage heart failure. VADs should be carefully selected, and implantation techniques tailored to patient's weight and diagnosis at a centralized pediatric cardiac transplantation center. Israeli healthcare providers should be cognizant of this therapeutic alternative.

Higher potency bisphosphonates, typically intravenous formulations, are given at lower doses for postmenopausal women. The treatment has improved compliance compared to daily oral therapy. Since bisphosphonates are exclusively excreted via the kidneys, intravenous formulation has been associated with deterioration of renal function, specifically in the setting of preexisting renal disease or concomitant use of nephrotoxic agents [1].

Anti-tumor necrosis factor-alpha (anti-TNFα) medications are the most frequently used biologicals to treat inflammatory bowel disease (IBD). Little is known about the ocular side effects of this drug category. We present a case series of six young patients with Crohn disease (CD) and no previous ophthalmologic manifestations who developed blepharitis after commencing treatment with anti-TNFα therapy. Six otherwise healthy patients with CD, with no history of allergies or prior ocular complaints, developed blepharitis at a median of 7.5 months after the initiation of anti-TNFα therapy. All ophthalmic findings were treated topically. The ocular symptoms of two of the patients resolved shortly after discontinuation of the anti-TNFα treatment. The other four presented with relapsing-remitting symptoms. Blepharitis is a common ocular disease in the general population and an extra-intestinal manifestation in patients with IBD. It may be an adverse effect of anti-TNFα therapy in this patient population.

On Saturday, 7 October 2023, the Jewish holiday of Simchat Torah, our entire country woke to a reality of the worst terror attacks it has ever known, despite its long history of wars and terror. These horrific attacks included killing and burning babies, children, women, men, and the elderly; raping women; beheading babies; destroying settlements; and kidnapping more than 240 civilians and soldiers. The severe traumatic events created different circles of those exposed to trauma. In each group, the intensity of the trauma was different and had different characteristics.

Background: Low-risk venous thromboembolism (VTE) patients are advised to be discharged from the emergency department (ED) on direct oral anticoagulants (DOACs) treatment. There is no data on whether this recommendation is followed in Israel.

Objectives: To characterize newly diagnosed VTE patients who were discharged from the ED, their anticoagulation treatment at the ED, the recommended discharge protocol, and patient adherence.

Methods: We conducted a retrospective cohort study, which included all newly diagnosed VTE patients who were discharged from the ED. Collected data included demographic and clinical background; anticoagulation treatment at the ED, recommended discharge protocol and its subsequent adherence, patient subsequent, recommended hematological evaluation, and adverse events.

Results: The study group included 443 patients, 89% with deep vein thrombosis (DVT). Approximately three-quarters were treated with anticoagulants in the ED, 98% with enoxaparin. At discharge, anticoagulants were recommended for all; 49% continued enoxaparin, 47% DOACs, and 4% warfarin. After 4 weeks, 67% were treated with DOACs, 22% with enoxaparin, 5% with warfarin. Approximately 6% discontinued all treatment. After 12 weeks, 90% of the patients who were taking DOACs adhered to the protocol, whereas only 70% and 50% among the enoxaparin and warfarin users, respectively, did. Only 56% were referred for hematological evaluation. The 12-week rate of adverse reactions was approximately 2%. The use of DOACs and the recommendation for further hematological evaluation increased over time.

Conclusions: Clinician training regarding discharge of VTE patients from the ED should continue.

Background: In the past decade, numerous new imaging and laboratory tests have been implemented that significantly contribute to improved medical diagnostic capabilities. However, inappropriate utilization, which occurs on a large scale, has significant ramifications for both patient care and health systems.

Objectives: To assess the impact of a novel clinical decision support system (CDSS) applied to our electronic medical records on abdominal ultrasonography utilization pattern.

Methods: We conducted a retrospective cohort study comparing patterns of abdominal ultrasound utilization in cases of liver enzyme elevation, with and without CDSS, between February and May in 2017 (before CDSS implementation) and during the same months in 2018 (after CDSS implementation). The following parameters were collected: number of tests ordered according to the guidelines, tests with a diagnostic value, and order forms completed with any data or a diagnostic question. The comparison was conducted using chi-square test.

Results: Of 152 abdominal ultrasound tests, 72 were ordered in the pre-implementation period and 80 in the post-implementation period. The system failed to reach statistical significance regarding the rates of ordered tests according to the guidelines and/or tests with a diagnostic value. However, the use of the CDSS had a statistically significant impact regarding completing the order form with data, including a specific diagnostic question.

Conclusions: The effect of the system on the efficiency of test utilization was partial. However, our findings strongly suggested that CDSS has the potential to promote proper usage of complementary technologies.