Evaluating emergency response at a hospital near the Gaza border within 24 h of increased conflict.

BACKGROUND: Frontline hospitals near active hostilities face unique challenges in delivering emergency care amid threats to infrastructure and personnel safety. Existing literature focuses on individual aspects like mass casualty protocols or medical neutrality, with limited analysis of operating acute services directly under fire. OBJECTIVES: To describe the experience of a hospital situated meters from hostilities and analyze strategies implemented for triage, expanding surge capacity, and maintaining continuity of care during attacks with limited medical staff availability due to hazardous conditions. A focus will be placed on assessing how the hospital functioned and adapted care delivery models in the event of staffing limitations preventing all teams from arriving on site. METHODS: A retrospective case study was conducted of patient records from Barzilai University Medical Center at Ashkelon (BUMCA) Medical Center in Israel within the first 24 h after escalated conflict began on October 7, 2023. Data on 232 admissions were analyzed regarding demographics, treatment protocols, time to disposition, and mortality. Missile alert data correlated patient surges to attacks. Statistical and geospatial analyses were performed. RESULTS: Patients predominantly male soldiers exhibited blast/multisystem trauma. Patient surges at the hospital were found to be correlated with the detection of incoming missile attacks from Gaza within 60 min of launch. While 131 (56%) patients were discharged and 55 (24%) transferred within 24 h, probabilities of survival declined over time reflecting injury severity limitations. 31 deaths occurred from severe presentation. CONCLUSION: Insights gleaned provide a compelling case study on managing mass casualties at the true frontlines. By disseminating BUMCA's trauma response experience, strategies can strengthen frontline hospital protocols optimizing emergency care delivery during hazardous armed conflicts through dynamic surge capacity expansion, early intervention prioritization, and infrastructure/personnel protection measures informed by risks.

Stain-Free Sperm Analysis and Selection for Intracytoplasmic Sperm Injection Complying with WHO Strict Normal Criteria.

This multi-center study evaluated a novel microscope system capable of quantitative phase microscopy (QPM) for label-free sperm-cell selection for intracytoplasmic sperm injection (ICSI). Seventy-three patients were enrolled in four in vitro fertilization (IVF) units, where senior embryologists were asked to select 11 apparently normal and 11 overtly abnormal sperm cells, in accordance with current clinical practice, using a micromanipulator and 60× bright field microscopy. Following sperm selection and imaging via QPM, the individual sperm cell was chemically stained per World Health Organization (WHO) 2021 protocols and imaged via bright field microscopy for subsequent manual measurements by embryologists who were blinded to the QPM measurements. A comparison of the two modalities resulted in mean differences of 0.18 µm (CI -0.442-0.808 µm, 95%, STD-0.32 µm) for head length, -0.26 µm (CI -0.86-0.33 µm, 95%, STD-0.29 µm) for head width, 0.17 (CI -0.12-0.478, 95%, STD-0.15) for length-width ratio and 5.7 for acrosome-head area ratio (CI -12.81-24.33, 95%, STD-9.6). The repeatability of the measurements was significantly higher in the QPM modality. Surprisingly, only 19% of the subjectively pre-selected normal cells were found to be normal according to the WHO2021 criteria. The measurements of cells imaged stain-free through QPM were found to be in good agreement with the measurements performed on the reference method of stained cells imaged through bright field microscopy. QPM is non-toxic and non-invasive and can improve the clinical effectiveness of ICSI by choosing sperm cells that meet the strict criteria of the WHO2021.

Amniotic fluid rubidium concentration association with newborn birthweight: a maternal-neonatal pilot study.

BACKGROUND: Although most biological systems, including human tissues, contain rubidium, its biogeochemical functions and possible role in neonatal birthweight are largely unknown. An animal study indicated a correlation between rubidium deficiency in the maternal diet and lower newborn birthweight. OBJECTIVE: This pilot study measured rubidium concentrations in amniotic fluid during the second trimester of (low-risk) pregnancy and investigated potential correlations between rubidium levels and third-trimester newborn birthweight-small for gestational age, appropriate for gestational age, and large for gestational age-and between preterm birth and term birth in uncomplicated pregnancies. STUDY DESIGN: This prospective, single-center study investigated a possible relationship between rubidium concentration in second-trimester amniotic fluid and third-trimester birthweight percentile. Amniotic fluid (at a median gestational age of 19 weeks) was sampled to determine rubidium concentration. Maternal and newborn characteristics were obtained from participant and delivery records. RESULTS: After screening 173 pregnant women, 99 amniotic fluid samples were evaluated. Midpregnancy median rubidium concentrations were significantly lower among newborns that were classified as small for gestational age than among newborns that were classified as appropriate for gestational age (106 vs 136 µg/L; P<.01). Based on a logistic regression random forest model, amniotic fluid rubidium was identified as a significant contributing factor to appropriate-for-gestational-age birthweight with 54% of the total contribution. CONCLUSION: Amniotic fluid rubidium concentration seems to be a strong predictor of appropriate-for-gestational-age birthweight and a potential marker for newborn birthweight classifications. In particular, low rubidium concentrations in amniotic fluid during midpregnancy are linked to third-trimester lower birthweight percentile. These findings could potentially serve as a valuable tool for early identification of pregnancy outcomes. Further investigation is necessary to fully explore the effect of rubidium on fetal development.

Does Iodine Intake Modify the Effect of Maternal Dysglycemia on Birth Weight in Mild-to-Moderate Iodine-Deficient Populations? A Mother-Newborn Prospective Cohort Study.

It is unclear how maternal glycemic status and maternal iodine status influence birth weight among individuals with mild-to-moderate iodine deficiency (ID). We studied the association between birth weight and both maternal glucose levels and iodine intake among pregnant women with mild-to-moderate ID. Glucose values were assessed using a glucose challenge test (GCT) and non-fasting glucose levels that were determined before delivery; individuals' iodine statuses were assessed using an iodine food frequency questionnaire; and serum thyroglobulin (Tg) and urinary iodine concentrations (UIC) were used to assess each group's iodine status. Thyroid antibodies and free thyroxine (FT4) levels were measured. Obstetric and anthropometric data were also collected. Large-for-gestational age (LGA) status was predicted using a Cox proportional hazards model with multiple confounders. Tg > 13 g/L was independently associated with LGA (adjusted hazard ratio = 3.4, 95% CI: 1.4-10.2, p = 0.001). Estimated iodine intake correlated with FT4 among participants who reported consuming iodine-containing supplements (ICS) after adjusting for confounders (ß = 0.4, 95% CI: 0.0002-0.0008, p = 0.001). Newborn weight percentiles were inversely correlated with maternal FT4 values (ß = -0.2 95% CI:-0.08--56.49, p = 0.049). We conclude that in mild-to-moderate ID regions, insufficient maternal iodine status may increase LGA risk. Iodine status and ICS intake may modify the effect that maternal dysglycemia has on offspring weight.

Can Mild-to-Moderate Iodine Deficiency during Pregnancy Alter Thyroid Function? Lessons from a Mother-Newborn Cohort.

Severe iodine deficiency during pregnancy has substantial hormonal consequences, such as fetal brain damage. Data on the potential effects of mild-to-moderate iodine deficiency on the thyroid function of pregnant women and their newborns are scarce and divergent. We investigated the association between iodine intake in pregnancy and maternal and neonatal thyroid function in a region with mild-to-moderate iodine deficiency. Pregnant women's iodine status was evaluated using an iodine food frequency questionnaire, serum thyroglobulin (Tg), and urinary iodine concentration (UIC). Neonatal thyrotropin (nTSH) values were measured after birth. Obstetrics and anthropometric data were also collected. Among the 178 women (median age 31 years) included in the study, median (interquartile range) estimated dietary iodine intake, Tg and UIC were 179 (94−268) µg/day, 18 (11−33) µg/L, and 60 (41−95) µg/L, respectively. There was a significant inverse association of iodine intake with Tg values among the study population (ß = −0.2, F = 7.5, p < 0.01). Women with high free triiodothyronine (FT3) values were more likely to exhibit an estimated iodine intake below the estimated average requirement (160 µg/day, odds ratio [OR] = 2.6; 95% confidence interval [CI], 1.1−6.4; p = 0.04) and less likely to consume iodine-containing supplements (OR = 0.3, 95% CI, 0.1−0.8; p = 0.01). It is possible that thyroid function may be affected by iodine insufficiency during pregnancy in regions with mild-to-moderate iodine deficiency. The relatively small sample size of the studied population warrants further investigation.

Maternal iodine deficiency: a newborns' overweight risk factor? A prospective study.

OBJECTIVES: Childhood obesity and iodine deficiency are global public health concerns. Whether maternal iodine status mediates overweight in infancy has yet to be explored. We aimed to assess the relationship between maternal iodine status and infant birth weight, including small and large for gestational age (SGA and LGA, respectively). METHODS: A prospective study was carried out among 134 mother-infant pairs from Israel. Maternal iodine intake and status were estimated via questionnaire and serum thyroglobulin (Tg), respectively. Estimated iodine intake below the Recommended Daily Allowance for iodine sufficiency in pregnancy (220 µg/d) considered Inadequate. Maternal and neonatal thyroid function and anthropometric measurements, as well as maternal thyroid antibodies were also tested. RESULTS: After screening, 118 participants met the inclusion criteria (distributed trimesters I, II and III: n = 3, n = 21, and n = 94, respectively). There was a negative association of iodine intake with Tg values among the study population. Maternal median Tg value was higher than the sufficiency cutoff (16.5 vs 13 µg/L), indicating insufficient iodine status. No SGA cases were found. Inadequate iodine intake was associated with maternal isolated hypothyroxinemia (OR = 3.4; 95% CI 1.2, 9.9) and higher birthweight (including macrosomia and LGA) rates. A suggestive association of elevated Tg with a greater risk of LGA was observed. Offsprings' birth weight percentiles were associated with Tg values in pregnant women with suggestive sufficient iodine status (n = 62, R2 = 0.11, p < 0.05). CONCLUSIONS: Iodine status during pregnancy can be associated with newborn anthropometric index. Maternal inadequate iodine intake may alter fetal growth and might increase the risk of LGA among newborns. These initial findings support the need to further study the impact of iodine deficiency on newborns overweight in Israel and elsewhere.

Local cerebroplacental ratio reference ranges are better predictors for adverse delivery outcomes in normal weight fetuses during pregnancy.

OBJECTIVE: To evaluate the predictive value of local versus external cerebroplacental ratio (CPR) reference ranges for delivery outcomes in low-risk pregnancies. METHODS: A retrospective analysis of all feto-maternal demographic and biometric data in fetuses with normal estimated fetal weight (EFW) and a CPR examination between the years 2014-2019, in a university medical center. The study group included healthy singleton pregnancies from 32-week gestation, with an examination-to-delivery interval of <31 days. The three models compared two thresholds: <5th percentile (CPR 1, CPR 3) and <10th percentile (CPR2). The CPR1 and CPR2 models both use local CPR reference ranges, while the CPR3 model uses an external CPR reference range. The main outcome was predictive accuracy for urgent cesarean delivery (CD), operative delivery (OD), and composite outcome (CO), defined as an Apgar score of <7, fetal blood pH < 7.1 or admission to the neonatal intensive care unit (NICU). RESULTS: Overall, 410 low-risk pregnancies with normal weight fetuses were enrolled in the study. All three CPR models turned out to be significant predictors of CD, with an odds ratio (OR) of 9, 95% CI (2.7-27), p < .001 for CPR1, and an OR of 2.9, 95% CI (1.1-7.4), p < .04 for CPR2, and an OR of 3.4, 95% CI (1.7-6.8), p < .001 for CPR3. All the three models were also found to be predictors of OD, and an OR of 6.9, 95% CI (2.1-22) p < .04 for CPR1, and an OR of 2.8, 95% CI (1.2-6.7), p < .04 for CPR2, and an OR of 2.8, 95% CI (1.4-5.3) p < .01 for CPR3. The positive predictive values (PPV) for CD and OD were both 50% for CPR1, versus 28% and 26% in CPR2, and 24% and 25% in CPR3. The negative predictive value (NPV) was similar, around 88% in all three models. None of the models were found to be significant predictors for CO. CONCLUSIONS: A CPR model based on local reference ranges and <5th percentile cutoffs showed the highest PPV for CD and OD. The calculation of local references for CPR should be encouraged.

Low intake of iodized salt and iodine containing supplements among pregnant women with apparently insufficient iodine status - time to change policy?

BACKGROUND: Iodine is an essential nutrient for human health throughout the life cycle, especially during early stages of intrauterine life and infancy, to ensure adequate neurocognitive development. The growing global reliance on desalinated iodine-diluted water raises the specter of increased iodine deficiency in several regions. The case of Israel may be instructive for exploring the link between iodine status and habitual iodine intake in the setting of extensive national reliance on desalinated water. The aim of this study was to explore the relationship between iodine intake, including iodized salt and iodine-containing supplements intake, and iodine status among pregnant women residing in a sub-district of Israel that is highly reliant on desalinated iodine-diluted water. METHODS: A total of 134 consecutive pregnant women were recruited on a voluntary basis from the obstetrics department of the Barzilai University Medical Center during 2018. Blood was drawn from participants to determine levels of serum thyrotropin (TSH), thyroid peroxidase antibodies (TPOAb), thyroglobulin antibodies (TgAb) and thyroglobulin (Tg). An iodine food frequency questionnaire (sIFFQ) was used to assess iodine intake from food, IS and ICS. A questionnaire was used to collect data on demographic and health characteristics. RESULTS: A total of 105 pregnant women without known or reported thyroid disease were included in the study. Elevated Tg values (≥ 13 µg/L), were found among 67% of participants, indicating insufficient iodine status. The estimated iodine intake (median, mean ± SD 189, 187 ± 106 µg/d by sIFFQ) was lower than the levels recommended by the World Health Organization and the Institute of Medicine (250 vs. 220 µg/day respectively). The prevalence of iodized salt intake and iodine containing supplement intake were 4 and 52% (respectively). Values of Tg > 13 µg/L were inversely associated with compliance with World Health Organization and Institute of Medicine recommendations. CONCLUSIONS: While the Israeli Ministry of Health has recommended the intake of iodized salt and iodine containing supplements, this is apparently insufficient for achieving optimal iodine status among Israeli pregnant women. The evidence of highly prevalent probable iodine deficiency in a sample of pregnant women suggests an urgent need for a national policy of iodized salt regulation, as well as guidelines to promote iodine containing supplements and adherence to them by caregivers. In addition, studies similar to this one should be undertaken in additional countries reliant on desalinated iodine-diluted water to further assess the impact of desalinization on maternal iodine status.

Third-trimester Reference Ranges for Cerebroplacental Ratio and Pulsatility Index for Middle Cerebral Artery and Umbilical Artery in Normal-growth Singleton Fetuses in the Israeli Population.

BACKGROUND: The ratio between the fetal umbilical artery pulsatility index (UA-PI) and the middle cerebral artery pulsatility index (MCA-PI) is termed the cerebroplacental ratio (CPR). The CPR represents fetal blood flow redistribution at the early stages of placental insufficiency; moreover, it has predictive value for adverse intrapartum and neonatal outcomes. However, internationally accepted reference ranges for CPR are lacking. OBJECTIVE: This study sought to establish UA-PI, MCA-PI, and CPR reference ranges in low-risk, normal-growth singleton fetuses during the third trimester of pregnancy. METHODS: A retrospective cohort cross-sectional study was performed in the obstetrics ultrasound unit of a university hospital in Israel. We reviewed all fetal and maternal electronic records of pregnant women referred for ultrasound assessment during the third trimester between January 2014 and January 2019. We included only singleton pregnancies with normal anatomy scans and a normal third-trimester estimated fetal weight. The UA-PI, MCA-PI, and CPR reference ranges were reconstructed for each of the vessels for each gestational age between 29 and 41 weeks. RESULTS: A total of 560 pregnancies met the inclusion criteria. Satisfactory waveforms and measurements were obtained in all cases. At least 18 women enrolled at each gestational week. The MCA-PI and CPR values showed a similar parabolic curve during the third trimester of pregnancy, with a peak value at 32 and 33 gestational weeks, respectively. The UA-PI showed a linear and gradual decrease over the gestational age. CONCLUSIONS: In this study we established UA-PI, MCA-PI, and CPR reference ranges in low-risk, normal-growth singleton fetuses during the third trimester based on the Israeli population.

Low Iodine Intake from Dairy Foods Despite High Milk Iodine Content in Israel.

BACKGROUND: Milk is a major source of iodine in human nutrition. Because both iodine content and the consumption of milk and dairy vary widely over time and populations, their contribution to iodine intake must be evaluated regularly. A recent national iodine survey found Israel's population to be mildly iodine deficient, possibly due to unmonitored changes in the food content of dietary iodine. Accounting for dairy iodine content can help guide efforts to prevent iodine deficiency. OBJECTIVES: This study aimed to determine the iodine concentration of dairy products typically consumed in the Israeli diet, and to estimate iodine intake from dairy products among Israeli adults. METHODS: Iodine was analyzed in 33 selected dairy products that account for 89% of the total population's dairy intake according to the "MABAT" Israeli National Health and Nutrition survey. Based on these data, the distribution of iodine intake from milk, dairy, and dairy-based foods in the adult population was calculated. RESULTS: Israeli milk is rich in iodine, with a mean concentration of 22 µg/100 g. However, due to low dairy consumption, the mean iodine intake from milk and dairy was only 34 µg/day (median 23 µg/day; range: 0-337 µg/day) or 22% of the recommended daily allowance. Self-reported intake among poor, male, and Arab subgroups was even lower. CONCLUSIONS: Because Israeli milk and dairy products are iodine rich, their contribution to the population's iodine intake would increase if they were consumed in greater amounts, particularly by high-risk groups. Dairy's potential contribution to iodine nutrition should be considered in recommendations for dairy consumption and iodine prophylaxis.

First Israeli National Iodine Survey Demonstrates Iodine Deficiency Among School-Aged Children and Pregnant Women.

BACKGROUND: National data on iodine status in Israel are lacking. Reliance on iodine-depleted desalinated water, the absence of a salt iodization program, and reports of increased use of thyroid medication in Israel suggest that the population's iodine intake is likely inadequate. The aims of this study were therefore to determine the iodine status of Israeli school-age children (SAC) and pregnant women (PW) in a nationally representative sample obtained by a novel approach of using pre-discard urinalysis samples collected from a centralized national laboratory. METHODS: Spot urine samples from 1023 SAC and 1074 PW, representing all regions and major sectors in Israel, were collected during 2016 at the Maccabi Healthcare Services central laboratory. Urinary iodine concentration (UIC) was measured, and the results were analyzed by trimester, sex, region, and sector. RESULTS: SAC were iodine deficient, with a median (interquartile range [IQR]) UIC of 83 µg/L (52-127 µg/L); 62% of SAC UICs were below the World Health Organization adequacy range for SAC (100-199 µg/L). PW were also iodine deficient, with a median (IQR) UIC of 61 µg/L (36-97 µg/L); 85% of PW UICs were below the adequacy range for PW (150-249 µg/L). For both SAC and PW, the median UIC was below the World Health Organization's adequacy range across all sectors, sexes, and districts. Among SAC, the median (IQR) UIC was lower among females (75 µg/L; 48-119 µg/L) than males (92 µg/L; 59-133 µg/L; p < 0.05). Median UIC values of PW correlated significantly with the median UIC for SAC by sub-district (R2 = 0.3, p < 0.05). CONCLUSIONS: Urine sampling via a centralized national laboratory was efficient and cost-saving. Iodine deficiency in Israeli SAC and PW is a serious public-health concern. A national program of salt iodization and iodine supplementation of PW should be urgently considered.

Can desalinated seawater contribute to iodine-deficiency disorders? An observation and hypothesis.

OBJECTIVE: Over 300 million people rely on desalinated seawater and the numbers are growing. Desalination removes iodine from water and could increase the risk of iodine-deficiency disorders (IDD). The present study assessed the relationship between iodine intake and thyroid function in an area reliant on desalination. DESIGN: A case-control study was performed between March 2012 and March 2014. Thyroid function was rigorously assessed by clinical examination, ultrasound and blood tests, including serum thyroglobulin (Tg) and autoimmune antibodies. Iodine intake and the contribution made by unfiltered tap water were estimated by FFQ. The contribution of drinking-water to iodine intake was modelled using three iodine concentrations: likely, worst-case and best-case scenario. SETTING: The setting for the study was a hospital located on the southern Israeli Mediterranean coast. SUBJECTS: Adult volunteers (n 102), 21-80 years old, prospectively recruited. RESULTS: After screening, seventy-four participants met the inclusion criteria. Thirty-seven were euthyroid controls. Among those with thyroid dysfunction, twenty-nine were classified with non-autoimmune thyroid disease (NATD) after excluding eight cases with autoimmunity. Seventy per cent of all participants had iodine intake below the Estimated Average Requirement (EAR) of 95 µg/d. Participants with NATD were significantly more likely to have probable IDD with intake below the EAR (OR=5·2; 95 % CI 1·8, 15·2) and abnormal serum Tg>40 ng/ml (OR=5·8; 95 % CI 1·6, 20·8). CONCLUSIONS: Evidence of prevalent probable IDD in a population reliant on desalinated seawater supports the urgent need to probe the impact of desalinated water on thyroid health in Israel and elsewhere.

[SERUM THYROGLOBULIN LEVELS AND ESTIMATED IODINE INTAKE IN ADULTS EXPOSED TO IODINE­DILUTED DESALINATED DRINKING WATER].

AIMS: The aim of this study was to describe thyroglobulin levels and iodine intake estimations in a convenience sample of Israeli adults without TD in the Ashkelon District, where SWRO desalination has become the major source of drinking water. BACKGROUND: Iodine deficiency (ID) is a significant risk factor for thyroid disease (TD). Recently, there were increases in both selfreported use of TD medication among Israeli adults and the national use of sea water reverse osmosis (SWRO) desalinated water. METHODS: Iodine concentrations in tap water (supplied by Mekorot Israel National Water Co.) were estimated before and after SWRO desalination was implemented in the Ashkelon District. Volunteers were recruited at the Barzilai Medical Center Ashkelon between January 2012 and October 2013. Data regarding residency, BMI and use of iodine-containing or steroidal drugs were obtained for all volunteers. Blood was drawn from matching participants for determination of serum thyrotropin, thyroid peroxidase antibodies, thyroglobulin (Tg) antibodies and Tg. A semi-quantitative iodine food frequency questionnaire (sIFFQ) was administered. RESULTS: Iodine concentration estimation in tap water declined from 52 µg/L to 27 µg/L after SWRO desalination was implemented in the Ashkelon District. A total of 50 participants without reported or known TD were included in the study after screening 92 volunteers. The median serum Tg was 21 ng/mL, and 76% (35 participants) had elevated values (Tg ≥ 10 ng/mL), indicating a high prevalence of apparent ID. Iodine intake estimation (median 99 µg/d by sIFFQ) was lower than the Recommended Dietary Allowance (150 µg/d). Unfiltered tap water was estimated to provide 16% of the mean daily iodine intake. CONCLUSIONS: The finding of apparent ID in this sample, underscores the need to obtain further data regarding many other regions across Israel. This is particularly urgent in the context of Israel's increased dependence on SWRO desalination.

Elevated Serum Thyroglobulin and Low Iodine Intake Are Associated with Nontoxic Nodular Goiter among Adults Living near the Eastern Mediterranean Coast.

Background. Information about iodine intake is crucial for preventing thyroid diseases. Inadequate iodine intake can lead to thyroid diseases, including nontoxic nodular goiter (NNG). Objective. To estimate iodine intake and explore its correlation with thyroid diseases among Israeli adults living near the Mediterranean coast, where iodine-depleted desalinated water has become a major source of drinking water. Methods. Cross-sectional study of patients attending Barzilai Medical Center Ashkelon. Participants, who were classified as either NNG (n = 17), hypothyroidism (n = 14), or control (n = 31), provided serum thyroglobulin (Tg) and completed a semiquantitative iodine food frequency questionnaire. Results. Elevated serum Tg values (Tg > 60 ng/mL) were significantly more prevalent in the NNG group than in the other groups (29% versus 7% and 0% for hypothyroidism and controls, resp., P < 0.05). Mean estimated iodine intake was significantly lower in the NNG group (65 ± 30 µg/d) than in controls (115 ± 60 µg/d) (P < 0.05) with intermediate intake in the hypothyroid group (73 ± 38 µg/d). Conclusions. Elevated serum Tg values and low dietary iodine intake are associated with NNG among adult patients in Ashkelon District, Israel. Larger studies are needed in order to expand on these important initial findings.