Examination of Cognitive Function, Neurotrophin Concentrations, and both Brain and Systemic Inflammatory Markers Following a Simulated Game of American Football.

ABSTRACT: Hoffman, JR, Ostfeld, I, Zamir, A, Amedi, R, Fonville, TR, Horstemeyer, MF, and Gepner, Y. Examination of cognitive function, neurotrophin concentrations, and both brain and systemic inflammatory markers following a simulated game of American football. J Strength Cond Res 36(3): 686-694, 2022-This investigation examined the effect of a simulated American football game on cognitive function, neurotrophin concentrations, and markers of both systemic and brain inflammation. Members of the Israel national team (6 linemen and 9 skill position players) were examined 1 week before (PRE), immediately post (IP) and 24-hour post (24P) game. Blood was obtained, and cognitive function was measured at each assessment. No head injuries to any of the players participating in the study occurred. Significant (p < 0.001) decreases in acute memory, and a trend (p = 0.066) toward a decrease in delayed memory was noted at IP. Significant negative correlations were observed between playing time (number of plays) and concentration changes from PRE to IP (r = -0.801; p = 0.001) and from PRE to 24P (r = -0.549; p = 0.034). All cognitive function measures returned to PRE levels by 24P. Increases from PRE were noted in tumor necrosis factor-alpha (TNF-α) (p = 0.041) at IP and in brain-derived neurotrophic factor (p = 0.009) and C-reactive protein (CRP) (p = 0.019) concentrations at 24P. Circulating CRP concentrations and the cytokine markers, interleukin (IL)-4, IL-6, IL-10, and TNF-α, were significantly elevated in linemen compared with skill players. Brain inflammatory markers (S100B and glial fibrillary acidic protein) and total tau protein (a marker of brain injury) were not elevated from PRE. No change from PRE was noted in either myoglobin or creatine kinase-MM concentrations. In conclusion, muscle damage and inflammatory marker responses observed from the scrimmage game were consistent with muscle desensitization associated with football participation. In addition, the systemic inflammatory marker results observed in linemen were suggestive of chronic low-grade inflammation.

The Effect of 2 Weeks of Inactivated Probiotic Bacillus coagulans on Endocrine, Inflammatory, and Performance Responses During Self-Defense Training in Soldiers.

Hoffman, JR, Hoffman, MW, Zelicha, H, Gepner, Y, Willoughby, DS, Feinstein, U, and Ostfeld, I. The Effect of 2-Weeks of Inactivated Probiotic Bacillus coagulans on Endocrine, Inflammatory and Performance Responses During Self-Defense Training in Soldiers. J Strength Cond Res 33(9): 2330-2337, 2019-The effect of 2 weeks of inactivated Bacillus coagulans (iBC) ingestion on performance and inflammatory cytokines was examined during a self-defense course in soldiers. Sixteen male soldiers were randomly assigned to either iBC (n = 8) or placebo (PL; n = 8) in this double-blind study. Participants were garrisoned on base and participated in the same training tasks. Assessments were conducted in a single day before (PRE) and after the supplementation period (POST). During each testing session, participants were assessed for vertical jump power (VJP), muscle endurance, simulated casualty drag, and 2 100-m shuttle runs. Resting blood measures for testosterone, cortisol, creatine kinase, and inflammatory cytokines were also assessed. Mann-Whitney analysis of change (Δ) scores indicated no significant change (p's > 0.05) in any of the performance or blood variables. However, a trend (p = 0.089) was noted in the Δ score for VJP in iBC compared with PL. In addition, trends were observed in the change in IL-10 (p = 0.057) and IFNγ (p = 0.057). Magnitude based inferential analysis indicated that changes in VJP and simulated casualty drag were likely beneficial (90.7 and 80.4% likelihood effect, respectively) for iBC. In addition, iBC supplementation very likely augmented IL-10 concentrations, but was possibly negative for changes in IL-6, and likely negative for changes in TNFα and IFNγ. Changes in all other performance and blood markers were unclear. Results indicated that 2 weeks of iBC supplementation appeared to be beneficial for maintaining power and short-term speed performance, while attenuating the inflammatory response during intense training in a military self-defense course.

Effect of High-Dose, Short-Duration ß-Alanine Supplementation on Circulating IL-10 Concentrations During Intense Military Training.

Hoffman, JR, Gepner, Y, Hoffman, M, Zelicha, H, Shapira, S, and Ostfeld, I. Effect of high dose, short-duration ß-alanine supplementation on circulating IL-10 concentrations during intense military training. J Strength Cond Res 32(10): 2978-2981, 2018-This study examined the effect of ß-alanine as a potential anti-inflammatory agent during intense military training. Twenty soldiers (20.1 ± 0.6 years) from an elite combat unit were randomly assigned to either a ß-Alanine (BA) or placebo (PL) group. Soldiers were provided with 12 g·d of either BA or PL for 7 days between 2 intensive periods of navigational training and restricted sleep. During the initial training period, soldiers navigated on average 27.8 km·d with ∼50% of their body mass in their packs for 5 days. Soldiers returned to base and began a 7-day supplementation program before departing for an additional period of intense field training. During the second period of field training, soldiers navigated 10 km·d for an additional 5 days, carrying similar loading as the initial week, performed tactical missions, and slept approximately 5 hours per day. Blood samples were obtained after the initial training period and after the second training period and analyzed for IL-10. Magnitude-based inferences that were used to provide inferences on the true effect BA may have had on IL-10 concentrations compared with PL, calculated from 90% confidence intervals. Data analysis indicated that changes in circulating IL-10 concentrations (mean difference 0.86 pg·ml) were possibly greater (57%) for BA than PL. Results of this study suggest that 1 week of high-dose BA ingestion may enhance the anti-inflammatory response during intense military training, suggesting a potential therapeutic role of BA during intense training.

Lessons From Analyzing the Medical Costs of Civilian Terror Victims: Planning Resources Allocation for a New Era of Confrontations.

Policy Points: Across the globe, the threat from terrorist attacks is rising, which requires a careful assessment of long-term medical support. We found 3 major sources of costs: hospital expenditures, mental health services dedicated to acute stress reactions, and ambulatory follow-up. During the first year, most of the costs were related to hospitalization and support for stress relief. During the second year, ambulatory and rehabilitation costs continued to grow. Public health specialists should consider these major components of costs and their evolution over time to properly advise the medical and social authorities on allocating resources for the medical and nonmedical support of civilian casualties resulting from war or terror. CONTEXT: Across the globe, the threat from terrorist attacks is rising, which requires a careful assessment of long-term medical support. Based on an 18-month follow-up of the Israeli civilian population following the 2014 war in Gaza, we describe and analyze the medical costs associated with rocket attacks and review the demography of the victims who filed claims for disability compensation. We then propose practical lessons to help health care authorities prepare for future confrontations. METHOD: Using the National Insurance Institute of Israel's (NII) database, we conducted descriptive and comparative analyses using statistical tests (Fisher's Exact Test, chi-square test, and students' t-tests). The costs were updated until March 30, 2016, and are presented in US dollars. We included only civilian expenses in our analysis. FINDINGS: We identified 5,189 victims, 3,236 of whom presented with acute stress reactions during the conflict. Eighteen months after the conflict, the victims' total medical costs reached $4.4 million. The NII reimbursed $2,541,053 for associated medical costs and $1,921,792 for associated mental health costs. A total of 709 victims filed claims with the NII for further support, including rehabilitation, medical devices, and disability pensions. CONCLUSION: We found 3 major sources of costs: hospital expenditures, mental health services dedicated to acute stress reactions, and ambulatory follow-up. During the first year, most of the costs were related to hospitalization and support for stress relief. During the second year, ambulatory and rehabilitation costs continued to grow. Public health specialists should consider these major components of costs and their evolution over time to properly advise the medical and social authorities on allocating resources for the medical and nonmedical support of civilian casualties resulting from war or terror.

Behavioral and inflammatory response in animals exposed to a low-pressure blast wave and supplemented with ß-alanine.

This study investigated the benefit of ß-alanine (BA) supplementation on behavioral and cognitive responses relating to mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) in rats exposed to a low-pressure blast wave. Animals were fed a normal diet with or without (PL) BA supplementation (100 mg kg-1) for 30-day, prior to being exposed to a low-pressure blast wave. A third group of animals served as a control (CTL). These animals were fed a normal diet, but were not exposed to the blast. Validated cognitive-behavioral paradigms were used to assess both mTBI and PTSD-like behavior on days 7-14 following the blast. Brain-derived neurotrophic factor (BDNF), neuropeptide Y, glial fibrillary acidic protein (GFAP) and tau protein expressions were analyzed a day later. In addition, brain carnosine and histidine content was assessed as well. The prevalence of animals exhibiting mTBI-like behavior was significantly lower (p = 0.044) in BA than PL (26.5 and 46%, respectively), but no difference (p = 0.930) was noted in PTSD-like behavior between the groups (10.2 and 12.0%, respectively). Carnosine content in the cerebral cortex was higher (p = 0.048) for BA compared to PL, while a trend towards a difference was seen in the hippocampus (p = 0.058) and amygdala (p = 0.061). BDNF expression in the CA1 subregion of PL was lower than BA (p = 0.009) and CTL (p < 0.001), while GFAP expression in CA1 (p = 0.003) and CA3 (p = 0.040) subregions were higher in PL than other groups. Results indicated that BA supplementation for 30-day increased resiliency to mTBI in animals exposed to a low-pressure blast wave.

Critical Velocity Is Associated With Combat-Specific Performance Measures in a Special Forces Unit.

The purpose of this study was to examine the relationship between critical velocity (CV) and anaerobic distance capacity (ADC) to combat-specific tasks (CST) in a special forces (SFs) unit. Eighteen male soldiers (mean ± SD; age: 19.9 ± 0.8 years; height: 177.6 ± 6.6 cm; body mass: 74.1 ± 5.8 kg; body mass index [BMI]: 23.52 ± 1.63) from an SF unit of the Israel Defense Forces volunteered to complete a 3-minute all-out run along with CST (2.5-km run, 50-m casualty carry, and 30-m repeated sprints with "rush" shooting [RPTDS]). Estimates of CV and ADC from the 3-minute all-out run were determined from data downloaded from a global position system device worn by each soldier, with CV calculated as the average velocity of the final 30 seconds of the run and ADC as the velocity-time integral above CV. Critical velocity exhibited significant negative correlations with the 2.5-km run time (r = -0.62, p < 0.01) and RPTDS time (r = -0.71, p < 0.01). In addition, CV was positively correlated with the average velocity during the 2.5-km run (r = 0.64, p < 0.01). Stepwise regression identified CV as the most significant performance measure associated with the 2.5-km run time, whereas BMI and CV measures were significant predictors of RPTDS time (R(2) = 0.67, p ≤ 0.05). Using the 3-minute all-out run as a testing measurement in combat, personnel may offer a more efficient and simpler way in assessing both aerobic and anaerobic capabilities (CV and ADC) within a relatively large sample.

[BEHAVIORAL, PHYSIOLOGICAL AND MORPHOLOGICAL CHARACTERISTICS ASSOCIATED WITH POST-TRAUMATIC RESPONSE TO CONTINUOUS EXPOSURE VERSUS ALTERNATE EXPOSURE IN AN ANIMAL MODEL OF POST-TRAUMATIC STRESS DISORDER].

AIMS: The aim of this study was to approximate these conditions in an animal model of post-traumatic stress disorder (PTSD). More specifically, the neurobiological basis of these conditions, focusing on stress-related behavioral changes, HPA-axis and morphological were evaluated. The intention was to employ this well-validated, reproducible and reliable model for PTSD, to elicit data which will provide some guidance in the planning of a prospective study involving military personal. BACKGROUND: Combat personnel are exposed to significant stress and hardship, both physical and emotional, during their service and especially during active combat. Military forces are increasingly involved in conflicts involving nonmilitary or paramilitary adversaries in which they are exposed not to battles but to sporadic events, in what has come to be labeled "low intensity conflict". "Low intensity conflict" refers to a level of hostilities or use of military power that falls short of a full scale conventional or general war. These are characterized by brief periods of extreme stress and tangible danger interspersed by prolonged periods of siege. Whereas the potentially traumatizing effect of battle conditions is well documented, the risks of the sporadic highly stressful nature of "low intensity conflict" have not been studied. Furthermore, in recent years, soldiers commonly receive "relaxation periods" before re-engaging in battle. This new policy may possibly contradict the traditional treatment principles, focusing on "proximity" and "continuity" to the battlefield and its effects have not been studied. METHODS: Continuous and sporadic stresses, representing battlefield conditions, were induced in a validated rat animalmodel for PTSD and behavioral changes, hormonal levels and brain morphology were evaluated. RESULTS: Behavioral response, hormonal levels and brain morphological changes suggest that PTSD-like reactions were significantly higher in rats exposed to continuous stress compared to those exposed to intermittent stress and the control group. CONCLUSIONS: The results support the assumption that "refreshing" during warfare may reduce the incidence of PTSD. Since this study is based on an animal model, its conclusions should also be validated in human observation studies.

ß-Alanine supplemented diets enhance behavioral resilience to stress exposure in an animal model of PTSD.

This study investigated the effects of ß-alanine (BA) ingestion on the behavioral and neuroendocrine response of post-traumatic stress disorder (PTSD) in a murine model. Animals were fed a normal diet with or without (PL) BA supplementation (100 mg kg(-1)) for 30 days. Animals were then exposed to a predator-scent stress (PSS) or a sham (UNEX). Behaviors were evaluated using an elevated plus maze (EPM) and acoustic startle response (ASR) 7 days following exposure to the PSS. Corticosterone concentrations (CS), expression of brain-derived neurotrophic factor (BDNF), and brain carnosine concentrations were analyzed a day later. Animals in PSS+PL spent significantly less time in the open arms and in the number of entries in the EPM than PSS+BA, UNEX+BA, or UNEX+PL. Animals in PSS+BA had comparable scores to UNEX+BA. Anxiety index was higher (p < 0.05) in PSS+PL compared to PSS+BA or animals that were unexposed. ASR and freezing were greater (p < 0.05) in animals exposed to PSS compared to animals unexposed. CS expression was higher (p < 0.05) in animals exposed to PSS compared to unexposed animals. Brain carnosine concentrations in the hippocampus and other brain sections were significantly greater in animals supplemented with BA compared to PL. BDNF expression in the CA1 and DG subregions of the hippocampus was lower (p < 0.05) in animals exposed and fed a normal diet compared to animals exposed and supplemented with BA, or animals unexposed. In conclusion, BA supplementation in rats increased brain carnosine concentrations and resulted in a reduction in PTSD-like behavior, which may be mediated in part by maintaining BDNF expression in the hippocampus.

ß-Alanine ingestion increases muscle carnosine content and combat specific performance in soldiers.

The purpose of this study was to examine the effect of ß-alanine (BA) ingestion on tissue carnosine levels and the impact such changes would have on combat specific activity. Eighteen soldiers (19.9 ± 0.8 year) from an elite combat unit were randomly assigned to either a BA or placebo (PL) group. Before and following a 30-day supplementation period carnosine content of the gastrocnemius muscle and brain was determined by proton magnetic resonance spectroscopy. During each testing session, participants performed military relevant tasks that included a 2.5 km run, a 1-min sprint, 50-m casualty carry, repeated 30-m sprints with target shooting, and a 2-min serial subtraction test (SST) to assess cognitive function under stressful conditions. A significant elevation (p = 0.048) in muscle carnosine content was noted in BA compared to PL. Changes in muscle carnosine content was correlated to changes in fatigue rate (r = 0.633, p = 0.06). No changes (p = 0.607) were observed in brain carnosine content. Following supplementation, no differences were noted in 2.5 km run, 1-min sprint, repeated sprint, or marksmanship performance, but participants in BA significantly (p = 0.044) improved their time for the 50-m casualty carry and increased their performance (p = 0.022) in the SST compared to PL. In summary, 30-days of BA ingestion can increase muscle carnosine content and improve aspects of military specific performance. Although cognitive performance was significantly greater in participants consuming BA compared to placebo, current study methods were unable to detect any change in brain carnosine levels, thus, the precise mechanism underlying these effects remains elusive.

ß-Alanine supplementation improves fractional anisotropy scores in the hippocampus and amygdala in 60-80-year-old men and women.

Recently, ß-alanine (BA) supplementation was shown to improve cognitive function in older adults with decreased cognitive function. Mechanisms supporting these improvements have not been well defined. This study examined the effects of 10-weeks of BA supplementation on changes in circulating brain inflammatory markers, brain derived neurotrophic factor (BDNF), and brain morphology. Twenty participants were initially randomized into BA (2.4 g·d-1) or placebo (PL) groups. At each testing session, participants provided a resting blood sample and completed the Montreal cognitive assessment (MoCA) test and magnetic resonance imaging, which included diffusion tensor imaging to assess brain tissue integrity. Only participants that scored at or below normal for the MoCA assessment were analyzed (6 BA and 4 PL). The Mann-Whitney U test was used to examine Δ (POST-PRE) differences between the groups. No differences in Δ scores were noted in any blood marker (BDNF, CRP, TNF-α and GFAP). Changes in fractional anisotropy scores were significantly greater for BA than PL in the right hippocampus (p = 0.033) and the left amygdala (p = 0.05). No other differences were noted. The results provide a potential mechanism of how BA supplementation may improve cognitive function as reflected by improved tissue integrity within the hippocampus and amygdala.

The Effect of ß-Alanine Supplementation on Performance, Cognitive Function and Resiliency in Soldiers.

ß-alanine is a nonessential amino acid that combines with the amino acid histidine to form the intracellular dipeptide carnosine, an important intracellular buffer. Evidence has been well established on the ability of ß-alanine supplementation to enhance anaerobic skeletal muscle performance. As a result, ß-alanine has become one of the more popular supplements used by competitive athletes. These same benefits have also been reported in soldiers. Evidence accumulated over the last few years has suggested that ß-alanine can result in carnosine elevations in the brain, which appears to have broadened the potential effects that ß-alanine supplementation may have on soldier performance and health. Evidence suggests that ß-alanine supplementation can increase resilience to post-traumatic stress disorder, mild traumatic brain injury and heat stress. The evidence regarding cognitive function is inconclusive but may be more of a function of the stressor that is applied during the assessment period. The potential benefits of ß-alanine supplementation on soldier resiliency are interesting but require additional research using a human model. The purpose of this review is to provide an overview of the physiological role of ß-alanine and why this nutrient may enhance soldier performance.

Role of ß-Alanine Supplementation on Cognitive Function, Mood, and Physical Function in Older Adults; Double-Blind Randomized Controlled Study.

This study investigated 10 weeks of ß-alanine (BA) supplementation on changes in cognitive function, mood, and physical performance in 100 older adults (70.6 ± 8.7 y). Participants were randomized into a BA (2.4 g·d-1) or placebo (PL) group. Testing occurred prior to supplementation (PRE), at the midpoint (MID), and at week-10 (POST). Participants completed cognitive function assessments, including the Montreal cognitive assessment (MOCA) and the Stroop pattern recognition test, at each testing session. Behavioral questionnaires [i.e., the profile of mood states, geriatric depression scale (GDS), and geriatric anxiety scale (GAS)] and physical function assessments (grip strength and timed sit-to-stand) were also conducted. No difference between groups was noted in MoCA scores (p = 0.19). However, when examining participants whose MOCA scores at PRE were at or below normal (i.e., ≤26), participants in BA experienced significant improvements in MOCA scores at MID (13.6%, p = 0.009) and POST (11.8%, p = 0.016), compared to PL. No differences were noted in mood scores, GAS, or any of the physical performance measures. A significant decrease was observed in the GDS for participants consuming BA but not in PL. Results suggested that BA supplementation can improve cognitive function in older adults whose cognitive function at baseline was at or below normal and possibly reduce depression scores.

Examination of Amorphous Calcium Carbonate on the Inflammatory and Muscle Damage Response in Experienced Resistance Trained Individuals.

The effect of 3 weeks of amorphous calcium carbonate (ACC) supplementation (2000 mg per day) was examined on the recovery response to resistance exercise. Thirty men were randomized into a supplement (ACC) or placebo (PL) group. Following supplementation, participants performed six sets of 10 repetitions in the bench press (BP) and incline BP exercises, using 80% of maximal strength. Participants returned 24 (T4) and 48 h (T5) later and performed six sets of the BP exercise. Significant decreases in the number of repetitions (p < 0.001), peak power (p < 0.001), and mean power (p = 0.009) were noted over time, but no significant interactions were observed (p > 0.05). Magnitude-based inference analysis (MBI) indicated that the change in repetitions was possibly beneficial for ACC at T4 and likely beneficial at T5. No significant interaction was noted for general soreness (p = 0.452), but a trend toward an interaction was observed in upper body soreness (p = 0.089). Confidence intervals for mean percent change scores indicated significant differences between the groups at T4 and T5, and MBI analysis indicated that ACC was very likely or likely to be beneficial for reducing soreness at those time points. In conclusion, ACC supplementation may have a potential beneficial effect in attenuating the decline in performance, which is possibly due to the carbonate component.

The Direct and Indirect Costs of Treating the Victims of the 2016 Nice Terror Attacks in a Single Pediatric Hospital.

OBJECTIVE: To analyze the cost of the terror attack in Nice in a single pediatric institution. METHODS: We carried out descriptive analyses of the data coming from the Lenval University Children's Hospital of Nice database after the July 14, 2016 terror attack. The medical cost for each patient was estimated from the invoice that the hospital sent to public insurance. The indirect costs were calculated from the hospital's accounting, as the items that were previously absent or the difference between costs in 2016 versus the previous year. RESULTS: The costs total 1.56 million USD, corresponding to 2% of Lenval Hospital's 2016 annual budget. Direct medical costs represented 9% of the total cost. The indirect costs were related to human resources (overtime, sick leave), revenue shortfall, and security and psychiatric reinforcement. CONCLUSION: Indirect costs had a greater impact than did direct medical costs. Examining the level and variety of direct and indirect costs will lead to a better understanding of the consequences of terror acts and to improved preparation for future attacks.

Trends of stress fracture prevalence among Israel Defense Forces basic trainees.

Stress fractures (SFs) are a common type of overuse injury encountered in training soldiers. High rates of SF may cause a tremendous negative effect on the military unit capability to perform its missions. In this study, we reviewed the medical registry of Israel Defense Forces (IDF) soldiers assigned to combat basic training programs between the years 1998 and 2007. SF rates among IDF combat basic trainees were as high as 20% in several companies during the first years of the study. Amendments in training programs were targeted to fit the different capability and the qualifications required from combat soldiers. As a result, a steady decline of SF rates was observed, with a yearly average of 5% in the later years of the study. Increasing awareness of both medical and commanding personnel to SF and their prevention led to the gradual decline in their frequency observed in IDF basic training programs during recent years.

Naturalistic Study of Posttraumatic Stress Disorder Among Israeli Civilians Exposed to Wartime Attacks.

OBJECTIVE: Civilians who survive wartime attacks commonly experience substantial psychological distress, including acute stress reactions (ASRs) and posttraumatic stress disorder (PTSD). The authors sought to determine the level of Israeli civilian exposure to wartime attacks, prevalence of posttraumatic stress disorder (PTSD) and physical injuries, and associated medical costs over a 7-year period. METHODS: Data from the National Insurance Institute of Israel on civilian survivors of wartime attacks in the 2009-2015 period were retrospectively examined. RESULTS: Overall, 11,476 civilians were affected by 243 wartime attacks during the study period. Of these individuals, 7,561 (65.9%) received early intervention (EI) psychological treatment for ASRs, 1,332 (11.6%) were subsequently adjudicated as having a disability (all causes), and 519 (4.5%) were adjudicated as disabled by PTSD through the end of 2016. Individuals who received immediate ASR treatment were less likely to be disabled by PTSD (p=0.001). Among those without physical injuries, the EI was associated with decreased PTSD disability (2.6% of those receiving the EI developed PTSD, whereas 7.2% of those who did not receive the EI developed PTSD); however, for those with physical injuries, the PTSD rate was higher among those who received the EI (30.4%) than among those who did not receive the EI (5.2%). Individuals having a disability other than PTSD incurred higher medical costs ($7,153 in 2016 U.S. dollars) than individuals with PTSD ($1,960). CONCLUSIONS: An approach of providing case management, medical care, behavioral health screening, and EI for ASRs in the wake of wartime attacks on civilians minimized long-term PTSD-related disability.

The medical costs of terror: A review of the literature.

CONTEXT: The threat of terrorism is intensifying with a recent rise in the number of death and injuries. Nevertheless, few articles deal with the short and long-term medical costs of treating and assisting the civilian victims of terror. The objective of this article is to review the literature and describe the medical costs of supporting victims of terrorism. METHOD: The authors reviewed the literature on the medical costs following terror attacks in the PubMed/Medline and Google Web sites. Relevant scientific articles, textbooks, and global reports were included in the research. RESULTS: There was a scarcity of data related to the medical costs of terror. The authors review the few articles that describe the hospital and outpatient expenses. The terror attacks lead to increasing length of stay and the use of supplementary medical support. The authors detail the relevant global reports and working papers on terrorism that included the cost of injury and the over-all economic impact assessment. CONCLUSION: The medical costs result from hospital and outpatient treatment support. There is a clear need to track the long-term fate of the victims of terror. The authors recommend that future research should include all sectors of the healthcare system, including the whole rehabilitation process and have a precise tracking system for all victims.

The long-term consequences of 35 years of terror attacks against civilians in Israel: Medical and nonmedical costs, disability.

BACKGROUND: Terrorism is a major threat, which requires operative preparedness, principally for the emergency struc-tures. Similarly, its rising impact on the healthcare system should interest the researchers in health affairs and policy. The number and the nature of disabilities due to terror is insufficiently addressed in the civilian population. In this article, we described the type and number of disabilities in Israel due to war and terror attacks since 1980. METHODS: Descriptive analyses of the National Insurance Institute of Israel (NII) Civilian Victim of Terror database which embraces medical and social information including the number and severity of disabilities and their nonmedical costs (disability pensions) since 1980; the related medical costs (based on hospital and ambulatory invoices) and their principal International Classification of Diseases (ICD 9) diagnoses and comparison to the data coming from the START database (National Consortium for the Study of Terrorism and Responses to Terrorism) Results: There was a surge in the number of disabilities following the years of the second Intifada 2000-2006. Al-though the number of wounded decreased after the end of the Second Intifada, the number of disabled stayed high due to their ongoing care. The costs of disability pensions grew in parallel to the number of disabled and approached 140 M US$ for 2016. CONCLUSIONS: The different waves of terror attacks have an awful legacy as 4,000 disabled whom are supported to-day by the State of Israel. Because of the unique way Israel is tracking and following the -victims, including the number of disabled and their attendant social and medical costs we can assess the broad impact of terrorism in Israel. It is interest-ing to note that when a country supports the victims of terror with an efficient system and dedicated means and re-sources, the social (nonmedical) costs are far more significant than the medical costs.

Intersex patients in military service.

The term "intersex" describes a variety of medical conditions in which sex determination is atypical. One of its most severe forms is an inadequate response to androgens due to mutations in the androgen receptor gene, which may manifest as a complete androgen insensitivity syndrome (CAIS). In this form of intersex condition, genetically male individuals do not form masculine genitalia, but have a female phenotype. Officially, Israel Defense Forces policy does not prohibit intersex patients' draft. However, it is uncommon to encounter intersex patients in the military setting. In this report, we describe a case of a combat Israeli Defense Forces female soldier, whose CAIS diagnosis was not reported to the military health authorities before her recruitment, but was revealed only during active service. Medical and other professional issues were discreetly handled, permitting her to successfully fulfill her 2 years of duty service. Although CAIS is a rare entity, it should be appropriately addressed in medical, psychological, social, and command aspects in the unique military setting. Our recommendation is to allow intersex patients military service, but not in combat units.

Effect of Spearmint Extract Containing Rosmarinic Acid on Physical and Executive Functioning After a Tactical Operation.

We examined the effect of a proprietary spearmint extract containing rosmarinic acid (PSE) on physical, cognitive, and executive functioning of study participants after a high-risk tactical operation while sleep deprived for 24 hours. Ten Operators (mean ± standard deviation: age, 35.1 ± 5.2 years; height, 177.6 ± 5.3cm; weight, 81.3 ± 9.3kg) from an elite counterterrorism unit volunteered to participate in this randomized, double-blind, parallel-design study. Participants were randomly assigned into either the PSE or placebo (PL) group and ingested 900mg/day PSE or an equivalent amount of PL for 17 days. Physical, cognitive, and executive functioning was tested before PST supplementation (PRE) and within 1 hour of the operation's conclusion (POST). Magnitude-based inferences indicated that differences between PSE and PL in jump power, reactive agility, eye-hand coordination, and cognition were unclear. However, subjective feelings of energy, alertness, and focus were very likely, likely, and possibly better for PSE than PL, respectively. There was no difference (ρ = .64) between groups in identifying the correct target; however, all participants in the PSE group correctly identified the target, whereas 60% of participants in the PL group correctly identified the target at POST. Although the results of this study do not provide conclusive evidence regarding the efficacy of PSE, they do suggest additional research is warranted in a larger sample of participants.