Acute response to the October 7th hostage release: rapid development and evaluation of the novel ReSPOND protocol implementation within a children's hospital.

BACKGROUND: The decision to allocate hospitals for the initial reception of hostages abducted on the October 7th Hamas attack introduced an array of unprecedented challenges. These challenges stemmed from a paucity of existing literature and protocols, lack of information regarding captivity conditions, and variability in hostage characteristics and circumstances. OBJECTIVE: To describe the rapid development, implementation and evaluation of the Hostage-ReSPOND protocol, a comprehensive trauma-informed procedure for the care of hostages, including young children, their caregivers and families, immediately following their release from prolonged captivity. METHODS: A multidisciplinary expert focus group conducted a comprehensive literature review to develop the ReSPOND protocol, consisting of: Readiness of teams via multifaceted trainings, utilizing live simulations and video debriefings; Specialized professional teams experienced in providing holistic trauma-informed care; Personalized care tailored to individualized and developmentally-informed needs; Optimal safety rooted in creating a secure environment and trauma-informed response to young children, adolescents, caregivers and families; and Navigating Discharge, through coordination with community-based care systems. RESULTS: A designated facility at the Children's hospital was carefully prepared for receiving 29 hostages, aged 3.9-80 years, 28% under the age of 18. Implementation of the ReSPOND protocol, which prioritized holistic psychosocial interventions above urgent medical care, proved feasible and effective in managing the diverse and complex needs of returnees as per provider report. Finally, systemic assessment of returnee's immediate and long-term mental health needs proved highly challenging. CONCLUSIONS: There is currently no literature addressing the response to released hostages, especially those involving infants, young children and families within a children's hospital facility. This study has the potential to fill a crucial gap in knowledge by introducing a novel protocol which could offer valuable insights for public health organizations tasked with providing acute care to diverse individuals and families experiencing extreme, multi-layered mass traumatization.

Obesity Is Associated with Fatty Liver and Fat Changes in the Kidneys in Humans as Assessed by MRI.

BACKGROUND: Obesity is associated with metabolic syndrome and fat accumulation in various organs such as the liver and the kidneys. Our goal was to assess, using magnetic resonance imaging (MRI) Dual-Echo phase sequencing, the association between liver and kidney fat deposition and their relation to obesity. METHODS: We analyzed MRI scans of individuals who were referred to the Chaim Sheba Medical Center between December 2017 and May 2020 to perform a study for any indication. For each individual, we retrieved from the computerized charts data on sex, and age, weight, height, body mass index (BMI), systolic and diastolic blood pressure (BP), and comorbidities (diabetes mellitus, hypertension, dyslipidemia). RESULTS: We screened MRI studies of 399 subjects with a median age of 51 years, 52.4% of whom were women, and a median BMI 24.6 kg/m2. We diagnosed 18% of the participants with fatty liver and 18.6% with fat accumulation in the kidneys (fatty kidneys). Out of the 67 patients with fatty livers, 23 (34.3%) also had fatty kidneys, whereas among the 315 patients without fatty livers, only 48 patients (15.2%) had fatty kidneys (p < 0.01). In comparison to the patients who did not have a fatty liver or fatty kidneys (n = 267), those who had both (n = 23) were more obese, had higher systolic BP, and were more likely to have diabetes mellitus. In comparison to the patients without a fatty liver, those with fatty livers had an adjusted odds ratio of 2.91 (97.5% CI; 1.61-5.25) to have fatty kidneys. In total, 19.6% of the individuals were obese (BMI ≥ 30), and 26.1% had overweight (25 < BMI < 30). The obese and overweight individuals were older and more likely to have diabetes mellitus and hypertension and had higher rates of fatty livers and fatty kidneys. Fat deposition in both the liver and the kidneys was observed in 15.9% of the obese patients, in 8.3% of the overweight patients, and in none of those with normal weight. Obesity was the only risk factor for fatty kidneys and fatty livers, with an adjusted OR of 6.3 (97.5% CI 2.1-18.6). CONCLUSIONS: Obesity is a major risk factor for developing a fatty liver and fatty kidneys. Individuals with a fatty liver are more likely to have fatty kidneys. MRI is an accurate modality for diagnosing fatty kidneys. Reviewing MRI scans of any indication should include assessment of fat fractions in the kidneys in addition to that of the liver.

Fluctuations in Serum Creatinine Levels During Hospitalization and Long-Term End-Stage Kidney Disease and Mortality.

Importance: Acute kidney injury is associated with poor outcomes, but the clinical implication of reversible serum creatinine level fluctuations during hospitalization not necessarily defined as acute kidney injury is poorly understood. Objective: To investigate the long-term outcomes of patients without previously diagnosed kidney disease who present with decreased kidney function and are subsequently discharged with apparently normal kidney function. Design, Setting, and Participants: A retrospective cohort study was conducted of patients hospitalized in a large tertiary hospital in Israel between September 1, 2007, and July 31, 2022. The study included patients admitted to an internal medicine ward. Patients had not undergone dialysis during the index hospitalization, had at least 3 creatinine tests performed during hospitalization, and had a discharge estimated glomerular filtration rate (eGFR) exceeding 60 mL/min/1.73 m2. Patients with preexisting chronic kidney disease were excluded. Exposure: Glomerular filtration rate was estimated from serum creatinine values using the updated 2022 Chronic Kidney Disease Epidemiology Collaboration formula, and eGFR greater than 60 mL/min/1.73 m2 was regarded as normal. Exposure was defined based on the association between the first and last values determined during hospitalization. Main Outcomes and Measures: All-cause mortality in the year following the index hospitalization and end-stage kidney disease (ESKD) in the 10 years following the index hospitalization. Results: A total of 40 558 patients were included. Median age was 69 (IQR, 56-80) years, with 18 004 women (44%) and 22 554 men (56%). A total of 34 332 patients (85%) were admitted with a normal eGFR and 6226 (15%) with decreased eGFR. Patients with decreased eGFR on presentation had an 18% increased mortality in the year following hospitalization (adjusted hazard ratio [AHR], 1.18; 95% CI, 1.11-1.24) and a 267% increased risk of ESKD in the 10 years following hospitalization (AHR, 3.67; 95% CI, 2.43-5.54), despite having been discharged with apparently normal kidney function. The highest risk was noted in patients who presented to the hospital with an eGFR of 0 to 45 mL/min/1.73 m2. Conclusions and Relevance: The findings of this cohort study suggest that patients who present with decreased kidney function and are discharged without clinically evident residual kidney disease may be at increased long-term risk for ESKD and mortality.

The Use of Rapid COVID-19 Antigen Test in the Emergency Department as a Decision-Support Tool.

The emergency department (ED) is the initial point of contact between hospital staff and patients potentially infected with SARS-CoV-2, thus, prevention of inadvertent exposure to other patients is a top priority. We aimed to assess whether the introduction of antigen-detecting rapid diagnostic tests (Ag-RDTs) to the ED affected the likelihood of unwanted SARS-CoV-2 exposures. In this retrospective single-center study, we compared the rate of unwarranted exposure of uninfected adult ED patients to SARS-CoV-2 during two separate research periods; one before Ag-RDTs were introduced, and one with Ag-RDT used as a decision-support tool. The introduction of Ag-RDTs to the ED significantly decreased the relative risk of SARS-CoV-2-negative patients being incorrectly assigned to the COVID-19 designated site ("red ED"), by 97%. There was no increase in the risk of SARS-CoV-2-positive patients incorrectly assigned to the COVID-19-free site ("green ED"). In addition, duration of ED admission was reduced in both the red and the green ED. Therefore, implementing the Ag-RDT-based triage protocol proved beneficial in preventing potential COVID-19 nosocomial transmission.

Medically Disqualifying Conditions Among Aircrew Candidates.

BACKGROUND: Medical selection criteria for Israeli Air Force (IAF) Flight Academy candidates are strict due to the extreme physiological stressors during military flight. In various air forces the causes for medical disqualification of Flight Academy candidates are different, mainly due to differences in the selection process and criteria. In the present study, we examined the medical conditions leading to disqualification of candidates for the IAF Flight Academy.METHODS: We reviewed the medical records of 3281 military Flight Academy candidates who underwent medical evaluation in the IAF Aeromedical Center between June 2016 and March 2018. For each disqualified candidate, we examined the cause or causes for disqualification divided into categories.RESULTS: Out of 3281 Flight Academy candidates, 519 candidates (15.8%) were disqualified. The most prevalent cause for disqualification were ophthalmological conditions, which constituted more than half of the disqualifications (55.0%). Among the ophthalmological conditions, nonsatisfactory visual acuity constituted more than half (57.4%). The following most prevalent causes were asthma (7.9%), allergic rhinitis (7.3%), renal and urinary conditions, and otolaryngologic conditions (5.2% each).DISCUSSION: The leading cause for disqualification of Flight Academy candidates was ophthalmological conditions, similar to other air forces. Our findings warrant an ongoing review of criteria for disqualification.Groner O, Frenkel-Nir Y, Erlich-Shoham Y, Shoval G, Gordon B. Medically disqualifying conditions among aircrew candidates. Aerosp Med Hum Perform. 2022; 93(4):384-389.

The effect of the Covid-19 pandemic on patient visits to the emergency department and hospitalizations in medical wards in an Israeli medical center.

BACKGROUND: The Covid-19 pandemic began in Israel on February 2020. Between February and October 2020, 2 periods of lockdown were imposed on Israeli population. OBJECTIVE: To assess the effect of the Covid-19 pandemic on visits to the emergency department (ED) and on hospitalizations in medical wards in Israel's Chaim Sheba Medical Center, and to compare the effect during the first and second lockdowns. METHODS: Data regarding the number of visits of non-Covid-19 patients to the ED and the number of admissions to the medical wards, were extracted from the computerized system of the hospital. Data were analyzed for patients' characteristics, length of stay in the medical wards, in hospital mortality and the rate of 7 and 30 days re-hospitalization, and compared to the same period during 2019. RESULTS: Total visits to the Sheba ED during March-October decreased by 18.5%. The most dramatic decrease occurred during the first lockdown. The number of patients admitted to the Sheba medical wards decreased by 28% (P < 0.05). The length of stay decreased from 3.69 days during 2019 to 3.42 days during 2020 (P < 0.01). The most pronounced decrease in the length of stay was observed during the second month of the first lockdown. During the pandemic, hospitalized patients at Sheba were older and were less likely to be males. The in-hospital absolute non-COVID mortality decreased from 913 to 858 respectively. CONCLUSIONS: The Covid-19 crisis emphasizes the role of medical wards in the care of complex patients. Medical wards in Israel were at the frontline of Israel's battle against this pandemic, while continuing to treat very complex non-Covid patients. To avoid burnout of the medical staff who treat very intensively complex patients, we believe these wards should be strengthen with specialists having expertise in treating these patients. Due to our insights, the Sheba medical Center is now redesigning the concept of how intensive care beds should be managed in a big tertiary center.

Emergency Department Triage in the Era of COVID-19: The Sheba Medical Center Experience.

BACKGROUND: Sheba Medical Center, Tel Hashomer, is a tertiary hospital located in the center of Israel. It is the largest hospital in Israel and was the first to face coronavirus disease-2019 (COVID-19) patients in the country at the beginning of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic. OBJECTIVES: To describe our experience with the COVID-19 pandemic, focusing on our triage method in the emergency department (ED). Our goal was to keep the main hospitalization buildings clean of infection by separating COVID-19 positive patients from COVID-19 negative patients. METHODS: We divided our ED into two separate sections: a regular non-COVID-19 ED and an advanced biological ED. We created clear protocols of triage for suspected and confirmed COVID-19 patients. We reviewed the data of patients admitted to our ED during the month of March and analyzed the results of our triage method in separating COVID-19 positive from negative patients. RESULTS: During the month of March 2020, 7957 patients were referred to our ED. Among them 2004 were referred to the biological ED and 5953 were referred to the regular ED. Of the 2004 patients referred to the biological ED, 1641 (81.8%) were sampled for SARS-CoV-2 polymerase chain reaction of whom 143 (8.7%) were positive. Only two COVID-19 positive patients unintentionally entered the main clean hospital, making our triage almost full proof. CONCLUSIONS: Our triage method was successful in separating COVID-19 positive from negative patients and maintained the regular hospital clean of COVID-19 allowing treatment continuation of regular non-COVID-19 patients.

Vision improvement in pilots with presbyopia following perceptual learning.

Israeli Air Force (IAF) pilots continue flying combat missions after the symptoms of natural near-vision deterioration, termed presbyopia, begin to be noticeable. Because modern pilots rely on the displays of the aircraft control and performance instruments, near visual acuity (VA) is essential in the cockpit. We aimed to apply a method previously shown to improve visual performance of presbyopes, and test whether presbyopic IAF pilots can overcome the limitation imposed by presbyopia. Participants were selected by the IAF aeromedical unit as having at least initial presbyopia and trained using a structured personalized perceptual learning method (GlassesOff application), based on detecting briefly presented low-contrast Gabor stimuli, under the conditions of spatial and temporal constraints, from a distance of 40 cm. Our results show that despite their initial visual advantage over age-matched peers, training resulted in robust improvements in various basic visual functions, including static and temporal VA, stereoacuity, spatial crowding, contrast sensitivity and contrast discrimination. Moreover, improvements generalized to higher-level tasks, such as sentence reading and aerial photography interpretation (specifically designed to reflect IAF pilots' expertise in analyzing noisy low-contrast input). In concert with earlier suggestions, gains in visual processing speed are plausible to account, at least partially, for the observed training-induced improvements.

Large population study shows that adolescents with celiac disease have an increased risk of multiple autoimmune and nonautoimmune comorbidities.

AIM: Celiac disease (CD) is a systemic disorder that is associated with various autoimmune disorders and a higher prevalence of other diagnoses and complications. This large, cross-sectional, population-based study investigated the associations between CD and various medical conditions during late adolescence. METHODS: We included 2 001 353 Jewish Israeli adolescents who underwent a general health examination at a median age of 17.1 (16.9-17.4) years from 1988 to 2015. Comprehensive data regarding medical status were available for 1 588 041 (79%) subjects. A definite diagnosis of CD was based on accepted criteria. Covariate data included demographic measures and data on associated medical conditions. RESULTS: Overall, data on 7145 subjects with CD and 1 580 896 controls were analysed. Multivariate analyses showed that autoimmune diseases were significantly more common in subjects with CD, including insulin dependent diabetes, with an odds ratio (OR) of 5.5, inflammatory bowel diseases (OR = 3.8), arthritis (OR = 2.4), thyroid diseases (OR = 1.8) and psoriatic skin disorders (OR = 1.6). Further associations included asthma (OR = 1.5), bile stones (OR = 3.6), migraine (OR = 2.3), anaemia (OR = 1.7) and menstrual abnormalities (OR = 1.5). Long bone fractures and axial fractures were no more common in adolescents with CD than controls. CONCLUSION: CD was already associated with multiple comorbidities by adolescence, and these were not limited to autoimmune disorders.

Cardiovascular Risk Factors in Adolescents With Celiac Disease: A Cross-sectional Population-Based Study.

BACKGROUND: Recent data have shown that adults with celiac disease (CD) may have a higher prevalence of risk factors for cardiovascular disease (CVD) compared with the general population. Thus, we aimed to investigate the association of CD with CVD risk factors at late adolescence in a cross-sectional population-based study. METHODS: A total of 2,001,353 Jewish Israeli adolescents who underwent a general health examination at median age of 17.1 years from 1988 to 2015 were included. Covariate data included demographic measures, blood pressure (BP), resting heart rate, and risk factors associated with CVD. RESULTS: Overall, 10,566 cases of CD were identified (0.53%). Multivariate analysis showed that mean diastolic BP was significantly lower in subjects with CD (men: 72.0±8.7 vs 70.4 ±â€Š8.5, P < 0.0001; women: 70.0 ±â€Š8.3 vs 69.0 ±â€Š8.2, P < 0.0001), whereas systolic BP did not differ between groups. Resting heart rate was higher in CD cases (an absolute difference of 0.4 beats per minute, P < 0.0001). The proportions of overweight and obese subjects were significantly lower in CD cases. Noninsulin-dependent diabetes mellitus (relative risk [RR], 4.1; 95% confidence interval [CI] 2.8-5.7), hypercoagulability (RR, 2.6; 95% CI 1.5-4.5), and hyperlipidemia (RR, 1.9; 95% CI 1.2-3) were significantly more common in subjects with CD. CONCLUSIONS: At the age of 17 years, the prevalence of risk factors for CVD is higher in subjects with CD compared with the general population. There is, however, neither increase in BP nor increase in overweight and obesity rates.

Anthropometric measures and prevalence trends in adolescents with coeliac disease: a population based study.

OBJECTIVES: To investigate the impact of coeliac disease (CD) diagnosis on anthropometric measures at late adolescence and to assess trends in the prevalence of diagnosed CD over time. DESIGN: A population based study. PATIENTS: Prior to enlistment, at the age of 17 years, most of the Israeli Jewish population undergoes a general health examination. Subjects' medical diagnoses are entered into a structured database. INTERVENTIONS: The enlistment database was thoroughly searched for CD cases between the years 1988 and 2015. Medical records of 2 001 353 subjects were reviewed. MAIN OUTCOME MEASURES: Anthropometric measures at the age of 17 years. RESULTS: Overall, 10 566 CD cases (0.53%) were identified and analysed. Median age at data ascertainment was 17.1 years (IQR, 16.9-17.4). Multivariable analysis demonstrated that boys with CD were leaner (Body Mass Index 21.2±3.7 vs 21.7±3.8, p=0.02) while girls with CD were shorter (161.5±6 cm vs 162.1±6 cm, p=0.017) than the general population. The prevalence of diagnosed CD increased from 0.5% to 1.1% in the last 20 years with a female predominance (0.64% vs 0.46%). CD prevalence was significantly lower in subjects of lower socioeconomic status and those of African, Asian and former Soviet Union origin. CONCLUSIONS: Adolescent boys with CD were leaner and girls with CD were shorter compared with the general population. However, the clinical relevance of the small differences suggests that when CD is diagnosed during childhood, final weight and height are not severely impaired. Our cohort reinforces the observed increase in diagnosed CD.

Scrotal Hematoma Precipitated by Centrifuge Training in a Fighter Pilot with an Asymptomatic Varicocele.

BACKGROUND: Varicocele is quite common in the general population, affecting up to 15% of men. It is not considered disqualifying for the pilot's training program of the Israeli Air Force as long as there are no related symptoms or associated pathologies. During combat flight, increased venous pressure due to acceleration forces and anti-G straining maneuvers, used to counteract high gravitational G forces, can theoretically aggravate the venous blood pooling in varicocele, leading to rupture. CASE REPORT: We describe a case of a young fighter-jet pilot presenting with a painful inguinal hematoma extending to the scrotum a day after participating in centrifuge training. Sonographic examination demonstrated dilated spermatic veins and intratesticular varicocele along with subcutaneous thickening of the scrotal wall consistent with hematoma. DISCUSSION: The effects of high G loads on blood flow in spermatic veins, and especially in varicocele, still need to be determined. Varicocele rupture has been described in relation to increased intra-abdominal pressure and could theoretically occur during anti-G straining maneuvers. Such an acute adverse event during combat flight can be detrimental to flight safety and the pilot's well-being.

Persistent asymptomatic isolated microscopic hematuria in Israeli adolescents and young adults and risk for end-stage renal disease.

CONTEXT: Few data are available on long-term outcomes among adolescents and young adults with persistent asymptomatic isolated microscopic hematuria. OBJECTIVE: To evaluate the risk of end-stage renal disease (ESRD) in adolescents and young adults with persistent asymptomatic isolated microscopic hematuria. DESIGN, SETTING, AND PARTICIPANTS: Nationwide, population-based, retrospective cohort study using medical data from 1,203,626 persons aged 16 through 25 years (60% male) examined for fitness for military service between 1975 and 1997 were linked to the Israeli treated ESRD registry. Incident cases of treated ESRD from January 1, 1980, to May 31, 2010, were included. Cox proportional hazards models were used to estimate the hazard ratio (HR) of treated ESRD among those diagnosed as having persistent asymptomatic isolated microscopic hematuria. MAIN OUTCOME MEASURES: Treated ESRD onset, defined as the date of initiation of dialysis treatment or the date of renal transplantation, whichever came first. RESULTS: Persistent asymptomatic isolated microscopic hematuria was diagnosed in 3690 of 1,203,626 eligible individuals (0.3%). During 21.88 (SD, 6.74) years of follow-up, treated ESRD developed in 26 individuals (0.70%) with and 539 (0.045%) without persistent asymptomatic isolated microscopic hematuria, yielding incidence rates of 34.0 and 2.05 per 100,000 person-years, respectively, and a crude HR of 19.5 (95% confidence interval [CI], 13.1-28.9). A multivariate model adjusted for age, sex, paternal country of origin, year of enrollment, body mass index, and blood pressure at baseline did not substantially alter the risk associated with persistent asymptomatic isolated microscopic hematuria (HR, 18.5 [95% CI, 12.4-27.6]). A substantially increased risk for treated ESRD attributed to primary glomerular disease was found for individuals with persistent asymptomatic isolated microscopic hematuria compared with those without the condition (incidence rates, 19.6 vs 0.55 per 100,000 person-years, respectively; HR, 32.4 [95% CI, 18.9-55.7]). The fraction of treated ESRD attributed to microscopic hematuria was 4.3% (95% CI, 2.9%-6.4%). CONCLUSION: Presence of persistent asymptomatic isolated microscopic hematuria in persons aged 16 through 25 years was associated with significantly increased risk of treated ESRD for a period of 22 years, although the incidence and absolute risk remain quite low.