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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.

Lumbar puncture opening pressure (LPOP) exceeding 250mmH 2 O is key in diagnosing idiopathic intracranial hypertension (IIH), per revised Friedman’s criteria. Some patients do not meet LPOP criteria (with or without papilledema), despite having IIH-related symptoms and neuroimaging findings. This study aimed to investigate the radiological findings and clinical symptoms in patients suspected of having IIH without meeting the LPOP criteria. We retrospectively evaluated cerebral venous sinus stenosis using the conduit Farb score (CFS) and other radiological findings suggestive of IIH by computed tomography venography and magnetic resonance venography in females ≥ 18 years-old with chronic headaches, suspected IIH, and LPOP < 250 mm. Eighty-eight women (56 with LPOP < 200 mm H 2 O and 32 with LPOP ranging between 200 and 250mmH 2 O) were included. Among patients with LPOP 200–250mmH 2 O, 40% (12) exhibited three or more radiological findings supporting IIH, compared to 17% (8) in the LPOP < 200 mmH 2 O group ( p  = 0.048). Cerebral venous stenosis (CFS ≤ 5) was observed in 80% (24) of those with LPOP 200–250 mmH 2 O, contrasting with 40% (19) of those with LPOP < 200 mmH 2 O (p < 0.001). Cerebral venous stenosis was significantly more common in patients with LPOP 200–250 mmH 2 O than < 200 mmH 2 O, suggesting that they may benefit from IIH treatment.

Background Providing emergency care during conflict poses unique challenges for frontline hospitals. Barzilai Medical Center (BUMCA) in Ashkelon, Israel is a Level I trauma center located close to the Gaza border. During the November 2023 escalation of conflict, BUMCA experienced surging numbers of civilian and military trauma patients while also coming under rocket fire. Methods We conducted a retrospective review of BUMCA operational records and 827 de-identified patient records from October 7–14, 2023. Records provided data on daily patient volumes, injury patterns, resource constraints, and impacts of rocket attacks on hospital function. Basic demographic data was obtained including age, gender, injury severity scores, and disposition. Results Of the 827 patients brought to BUMCA, most ( n  = 812, 98.2%) presented through the emergency department. Tragically, 99 individuals were pronounced dead on arrival. Injury severity assessments found nearly half (47%) had minor injuries such as lacerations, contusions and sprains, while 25% exhibited moderate injuries like deep lacerations and fractures. 15% sustained severe or critical injuries including severe head injuries. The largest age group consisted of adults aged 19–60 years. No pediatric patients were admitted despite proximity to residential neighborhoods. The majority of cases (61%) involved complex polytrauma affecting multiple body regions. BUMCA served as both the primary treatment facility and a triage hub, coordinating secondary transports to other trauma centers as needed. Patient volumes fluctuated unpredictably from 30 to an overwhelming 125 daily, straining emergency services. Resources faced shortages of beds, medical staff, supplies and disruptions to power from nearby missile impacts further challenging care delivery. Conclusion Despite facing surging demand, unpredictable conditions and external threats, BUMCA demonstrated resilience in maintaining emergency trauma services through an adaptive triage approach and rapid surges in capacity. Their experience provides insights for improving frontline hospital preparedness and continuity of care during conflict through advance contingency planning and surge protocols. Analysis of patient outcomes found a mortality rate of 15% given the complex, multi-region injuries sustained by many patients. This study highlights the challenges faced and strengths exhibited by medical professionals operating under hazardous conditions in minimizing loss of life. Patient and public involvement in research Given that the study analyzed patient data from a hospital treating casualties of an ongoing armed conflict, directly engaging patients or the public during the sensitive research process could have posed risks. The volatile security situation and restrictions and protections in place amidst the crisis made it not feasible or appropriate to involve them in the study’s design, methods, reporting of results, or dissemination plans. Our aim was to conduct this retrospective analysis in a way that did not endanger those affected or compromise the hospital’s emergency response operations.

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Gender F F F F F F F F Age 80 75 76 53 81 49 60 38 Smoking No No Yes Yes No No No No Diabetes mellitus No No No No Yes No Yes No Hypertension Yes Yes No No Yes No Yes No Dyslipidaemia Yes Yes Yes No Yes No Yes No Obesity No No No No Yes No Yes Yes COPD No No Yes No No No No No Psychiatric and/or neurologic disorders No Dementia No No No Anxiety, epilepsy Schizophrenia Wernicke's encephalopathy Ischaemic heart disease No No No No No No No No Other No No No No CAVB, PM No No No Table 2 Patients' clinical characteristics. Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Trigger Emotional Emotional Emotional Emotional Emotional Emotional Emotional Emotional Presenting symptom Pre-syncope Dyspnoea Chest pain Chest pain Chest pain Syncope Chest pain Chest pain ECG at presentation ST-segment STE lateral leads STE antero-lateral leads STE antero-lateral leads; hyperacute T TWI in lateral leads Ventricular pacing TWI antero-lateral leads No ST-T changes STE antero-lateral leads QTc (ms) 450 449 456 513 500 520 520 532 ECG at 48 h ST-segment Diffuse TWI Diffuse Subtle STE and TWI Diffuse subtle STE and bi-phasic T waves Diffuse TWI Ventricular pacing Diffuse TWI No ST-T STE antero-lateral leads QTc (ms) 512 589 501 507 520 419 460 506 Echocardiography at presentation EF Simpson % 23 28 30 30 15–20 20 35 30 Functional MR grade Mild–moderate Moderate Moderate–severe Mild–moderate Mild Mild–moderate Moderate–severe Moderate LVOTO (rest gradient, mmHg) No Yes (46) Yes (53) No No No No Yes (44) Hypokinesis pattern Mid-apical Mid-apical Mid-apical Mid-apical Mid-apical Mid-apical Mid-apical Mid-apical Echocardiography at follow-up EF Simpson % 45 39 45 44 55 55–60 40–45 65 Functional MR grade Mild Mild Moderate Mild No No No No Cardiac magnetic resonance imaging N/A N/A N/A N/A N/A No myocardial LGE No myocardial oedema N/A Initial Hs-TnT ng/L 109 106 346 348 484 49 37 200 Peak Hs-TnT ng/L 830 611 445 372 1120 59 70 200 CK U/L 224 176 231 218 119 68 54 48 Pro BNP pg/mL — 8486 — 2595 >35 000 145 1925 10 800 CRP-s-B mg/L 12.90 2.3 7.40 8.2 275 6.8 6.8 8.1 Coronary artery disease NOCa Normal coronary arteries RCA 80% stenosis Normal coronary arteries Normal coronary arteries Normal coronary arteries Normal coronary arteries Normal coronary arteries Ballooning on angiography — — — — Yes — — — Revascularization during admission — — Yes — No — — — Length of hospital stay, days 7 4 7 5 9 14 5 11 Remarkably, between 7 October and 25 November 2023, patients diagnosed with TCM made up approximately 8.5% of all acute coronary syndrome (ACS) cases admitted to Barzilai Medical Center. Patients with emotionally triggered TCM had higher LVEF at presentation, lower rate of in-hospital complications, shorter hospital stay and lower long-term mortality rate compared with patients with TCM triggered by physical stressor or without an apparent preceding stressor.2,5,6 However, among emotionally triggered cases, the effect on clinical presentation and outcomes of the intensity of the emotional stressor remains largely unknown. Compared with patients >50 years of age, younger individuals have an increased prevalence of coexisting neurological and/or psychiatric disorders, present more commonly with atypical forms of TCM and have higher rate of cardiogenic shock.9 In our cohort, 25% of individuals were under 50 years of age and 4 patients

Background: SARS-CoV-2 is a novel human pathogen causing Coronavirus Disease 2019 that has caused widespread global mortality and morbidity. Since health workers in Israel were among the first to be vaccinated, we had a unique opportunity to investigate the post-vaccination level of IgG anti-S levels antibodies (Abs) and their dynamics by demographic and professional factors. Methods: Prospective Serological Survey during December 2020–August 2021 at Barzilai Medical Center among 458 health care workers (HCW) followed for 6 months after the second BNT162b2 vaccine dose. Results: Antibody levels before the second dose, and 30, 90 and 180 days after were 57.1 ± 29.2, 223 ± 70.2, 172.8 ± 73.3 and 166.4 ± 100.7 AU/mL, respectively. From GEE analysis, females had higher Abs levels (β = 26.37 AU/mL, p = 0.002). Age was negatively associated with Abs, with a 1.17 AU/mL decrease for each additional year (p < 0.001). Direct contact with patients was associated with lower Abs by 25.02 AU/mL (p = 0.009) compared to working with no such contact. The average decline rate overall for the study period was 3.0 ± 2.9 AU/mL per week without differences by demographic parameters and was faster during the first 3 months after vaccination than in the subsequent 3 months. Conclusions: All demographic groups experienced a decline in Abs over time, faster during the first 3 months. Findings of overall Abs lower in males, workers with direct contact with patients, and older workers, should be considered for policy-making about choosing priority populations for additional vaccine doses in hospital settings.

Contrary to some reports, 2,3 BUMCA is considered a medium-sized community hospital and is not designated as a specialised trauma centre. By innovation and cooperation with other Israeli hospitals, BUMCA has doubled the capacity of its emergency room to help triage and stabilise the extensive volume of patients requiring immediate care from the surrounding residential zones that are under heavy bombardment. Despite more than 250 rockets shot by Hamas being launched at Ashkelon in the past 7 days, 5 some hitting BUMCA itself, health workers have maintained constant functioning of the facility, including establishing a coordinated ambulance rapid response network and leveraging military-grade vehicles to ferry high acuity cases through the risky journey to reach care.

The largest cluster of E200K familial Creutzfeldt–Jakob disease (fCJD) which occurs is in Jews of Libyan origin in Israel. Insomnia is a very common early complaint in those patients and may even be the presenting symptom. The aim of this study was to assess and characterize sleep pathology in E200K fCJD patients. To do so, sleep studies of 10 consecutive fCJD patients were compared with those of 39 age and gender-matched controls. All patients presented pathological sleep characterized by fragmentation of sleep, loss of sleep spindles and reduced REM sleep amount. Respiration was characterized by irregular rhythm, periodic breathing, apneas and hypopneas, either central or obstructive. EMG recordings revealed repeated movements in sleep, with loss of REM atonia. Comparing to controls, a significant decrease of total sleep time, sleep efficacy and slow-wave sleep as well as a significant increase in the number of awakenings, apnea–hypopnea index and mixed and central apneas were evident in CJD patients. Comparison of two sequential sleep studies in one patient revealed a 40 % reduction of the total sleep time, a 40 % reduction in sleep efficacy and a 40-fold increase of the number of arousals in the second study. A significant correlation was found between the disease severity, as reflected by the CJD Neurological Scale and Periodic leg movement index. These definite and characteristic sleep pathologies in patients with fCJD associated with the E200K mutation may serve as a new diagnostic tool in the disease.