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COVID-19, the illness caused by the SARS-CoV-2 virus, has reached pandemic proportions. Although the virus can cause disease in anyone, it is particularly dangerous for those with various “co-morbidities” such as heart disease, hypertension, diabetes, obesity and others. Furthermore, advancing age (from about 60 on), even in those older persons without any accompanying illnesses, is a strong and independent risk factor for pneumonia, need for an ICU bed and death from the virus. It is therefore essential to find ways to protect all at-risk persons (old or young) from the virus but at the same time not harming, more than absolutely necessary their essential freedoms as well as taking into account their social/psychological needs. Compared with other OECD countries, Israel’s population is still relatively young, with only 11.5% being over 65+ with a smaller proportion of older persons in long-term institutions than that found in most other comparable jurisdictions. These factors might explain a part of the country’s (so far) relatively low rates of serious disease and mortality compared to those seen in other developed countries. However there are still over a million older citizens at risk and the numbers of infected, hospitalized and seriously ill persons are rising once again. This is no time for complacency. An analysis of the effect of age on the disease as seen through the principles of medical ethics is followed by a proposal as to how best to balance these sometimes conflicting goals. This paper relates mainly to older persons in the community since the Ministry of Health early on in the pandemic initiated an effective program (Magen Avot) meant to protect those older persons in long-term care institutions. Recommendations include the Ministry of Health publishing clear guidelines as to risk factors and offering sensible advice on how to practice physical (not “social”) distancing without exacerbating an older person’s sense of social isolation. In order to reduce the incidence of influenza (which can clinically be confused with COVID-19) and the potentially disastrous consequences of a “double pandemic” this coming winter, a robust flu vaccination program needs immediate implementation. Persons at all ages (but especially those 60+) should be encouraged and assisted to sign advance directives, especially those who do not wish to undergo invasive therapy. An individual older person’s wish to “make way” for younger people should be respected as an expression of his/her autonomy. As we enter the second wave, triage mechanisms and protocols need to be circulated in readiness for and well before a situation in which an acute imbalance develops between the availability for acute resources and the population’s need for them. The Ministry of Health, in cooperation with other relevant ministries and NGOs, should take the lead in developing plans, ensuring that they are carried out in an orderly, timely and transparent manner. The blanket is indeed not large enough but we must place it as judiciously as possible in order as much as possible to protect, cover and keep warm the body politic. Supplementary information Supplementary information accompanies this paper at 10.1186/s13584-020-00416-y.

OBJECTIVES Much of the research previously done on diabetic ketoacidosis (DKA) was based on a young population with type 1 diabetes mellitus (type 1 DM). But substantial numbers of DKA episodes occur in patients with a prior history of type 2 diabetes mellitus (type 2 DM). There is a lack of Data are lacking about DKA in older adults. The aims of this study were to analyze the clinical characteristics and outcomes of older adult patients with DKA. DESIGN Retrospective matched cohort study of adult patients hospitalized with DKA between 2004 and 2017. SETTING Soroka University Medical Center, Be'er Sheva, Israel. PARTICIPANTS The clinical characteristics of DKA patients 65 years and older were compared with patients younger than 65 years. MEASUREMENTS The primary outcome was in-hospital mortality. RESULTS The study cohort included 385 consecutive patients for whom the admission diagnosis was DKA: 307 patients (79.7%) younger than 65 years (group 1), and 78 patients (20.3%) older than 65 years (group 2). Patients in group 2 compared with group 1 had a significantly higher Charlson index (6 [6-6] vs 6 [6-7]; P < .0001) and DM with target organ damage (24.4% vs 6.2%; P < .0001). Patients in group 2 compared with group 1 had more serious disease according to results of laboratory investigations. The total in-hospital mortality rate of patients in group 2 was 16.7% compared with 1.6% in patients in group 1 in a sex and co-morbidities matched analysis (P = .001). CONCLUSIONS DKA in older adults is a common problem. The serious co-morbidities and precipitating factors such as infection/sepsis, myocardial infarction, and cerebrovascular accidents, may explain the severity of the problem of DKA in older adults and the high rate of mortality of these patients. DKA appears to be a lifethreatening condition in older adults. The alertness of physicians to DKA in older adults, timely diagnosis, proper treatment, and prevention are cornerstones of care. J Am Geriatr Soc 68:1256-1261, 2020.

Coronavirus disease-19 (COVID-19) impacted medical education and led to the significant modification or suspension of clinical clerkships and rotations.To describe a revised surgery clerkship curriculum, in which we divided in-person clinical teaching into smaller groups of students and adopted online-based learning to foster student and patient safety while upholding program standards.The third-year surgery core clerkship of a 4-year international English-language program at the Medical School for International Health at Ben Gurion University of the Negev, Beer Sheva, Israel, was adapted by dividing students into smaller capsules for in-person learning and incorporating online learning tools. Specifically, students were divided evenly throughout three surgical departments, each of which followed a different clinical schedule.National Board of Medical Examiners clerkship scores of third-year medical students who were returning to in-person clinical clerkships after transitioning from 8 weeks of online-based learning showed no significant difference from the previous 2 years.To manage with the restrictions caused by COVID-19 pandemic, we designed an alternative approach to a traditional surgical clerkship that minimized the risk of exposure and used online learning tools to navigate scheduling challenges. This curriculum enabled students to complete their clinical rotation objectives and outcomes while maintaining program standards. Furthermore, this approach provided a number of benefits, which medical schools should consider adopting the model into practice even in a post-pandemic setting.

Previous studies have shown a correlation between acute pancreatitis and several different risk factors that vary in different countries and ethnic groups. The aims of this study are to examine the clinical characteristics and outcomes of acute pancreatitis in patients of Jewish and Bedouin origin.We performed a retrospective cohort study of patients hospitalized with acute pancreatitis in the Soroka University Medical Center between the years 2012 and 2016 and compared two groups of patients: patients of Jewish and Bedouin origin. The primary outcome was a composite outcome consisting of 30-days mortality, ICU admission, complications (defined as necrotizing pancreatitis or pseudocyst formation), surgery due to these complications and 30-days re-admission due to pancreatitis.A total of 560 patients were included, 483 patients (86.3%) of Jewish origin and 77 patients (13.7%) of Bedouin origin. The most common cause in both groups was biliary pancreatitis: 49.7% among Jewish, 61% among Bedouin. In our study alcohol consumption, the most common worldwide risk factor of pancreatitis, accounts for only a small percentage of the disease in the Jewish population (5.6%) and does not exist in the Bedouin population. We found no significant differences in outcomes between the two groups.Biliary pancreatitis was the most common cause in both groups of patients. The important finding of our study is that alcohol use is a minor cause of acute pancreatitis in the Negev. Moreover, it is uncommon in the Jewish population and is completely non-existent among Bedouins. No differences were found in the primary outcomes between the two groups.

Diabetic ketoacidosis (DKA) during pregnancy is a life-threatening emergency for both the mother and the fetus. The pathophysiology of DKA in pregnancy has its own characteristics due to multiple factors, such as insulin resistance, accelerated starvation and respiratory alkalosis, thus creating ketosis-prone state, with DKA occurring at milder degrees of hyperglycemia, even in normoglycemic levels, which can result in delayed diagnosis and treatment with potential for adverse metabolic consequences.In this article, we presented 8 clinical cases of DKA during pregnancy. We discuss the spectrum of the clinical picture, the entity of euglycemic DKA vs hyperglycemic DKA, the period of pregnancy in appearance of episode of DKA and triggers of DKA.The treatment of DKA in pregnant women must be started immediately and must be accentuated on intravenous fluids, insulin and electrolyte replacement. DKA in pregnancy may be euglycemic. Prevention, early recognition, immediate hospitalization, and aggressive management remain the cornerstones in DKA management in pregnancy.

A 36‐year‐old male with diffuse large B‐cell lymphoma on maintenance rituximab therapy presented to the emergency department with high fever and fatigue. A chest X‐ray showed a lobar infiltrate, 40 days before admission the patient suffered from a mild coronavirus disease 2019 (COVID‐19) infection and fully recovered. PCR nasopharyngeal swab was negative for COVID‐19. Comprehensive biochemical, radiological, and pathological evaluation including 18‐fluorodeoxyglucose positron emission tomography with computed tomography and transbronchial lung biopsy found no pathogen or lymphoma recurrence. Treatment for pneumonia with antibiotic and antifungal agents was nonbeneficial. A diagnosis of secondary organizing pneumonia (OP) was made after pneumonia migration and a rapid response to corticosteroids. OP secondary to a viral respiratory infection has been well described. Raising awareness for post‐COVID‐19 OP has therapeutic and prognostic importance because those patients benefit from steroid therapy. We believe the condition described here is underdiagnosed and undertreated by doctors worldwide. Because of the ongoing global pandemic we are now encountering a new kind of patient, patients that have recovered from COVID‐19. We hope that this case may contribute to gaining more knowledge about this growing patient population.

The current COVID-19 pandemic has raised many questions and dilemmas for modern day ethicists and healthcare providers. Are physicians, nurses and other healthcare workers morally obligated to put themselves in harm’s way and treat patients during a pandemic, occurring a great risk to themselves, their families and potentially to other patients? The issue was relevant during the 1918 influenza epidemic and more recently severe acute respiratory syndrome epidemic in 2003. Since the risk to the healthcare workers was great, there was tension between the ethical duty and responsibility to treat and the risk to one’s own life. This tension was further noted during the 2014 Ebola outbreak in West Africa that left hundreds of healthcare workers dead. The AMA Code of Ethics states that physicians are to ‘provide urgent medical care during disasters…even in the face of greater than usual risk to physicians’ own safety, health or life.’1 Classic Jewish sources have dealt with this question as well. There is an obligation ‘to not stand by idly when your friends life is in danger’; however, the question arises as to whether there are limits to this obligation? Is one required to risk one’s own life to save another’s? There is a consensus that one is not required but the question open to debate is whether it is praiseworthy to do so. However, regarding healthcare workers, there is agreement for ethical, professional and societal reasons that they are required to put themselves in harm’s way to care for their patients.

The novel COVID-19 pandemic has placed medical triage decision-making in the spotlight. As life-saving ventilators become scarce, clinicians are being forced to allocate scarce resources in even the wealthiest countries. The pervasiveness of air travel and high rate of transmission has caused this pandemic to spread swiftly throughout the world. Ethical triage decisions are commonly based on the utilitarian approach of maximising total benefits and life expectancy. We present triage guidelines from Italy, USA and the UK as well as the Jewish ethical prospective on medical triage. The Jewish tradition also recognises the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making.

Purpose: To determine motives and attitudes towards life-sustaining treatments (LSTs) by clinical and preclinical medical students. Methods: This was a scenario-based questionnaire that presented patients with a limited life expectancy. The survey was distributed among 455 medical students in preclinical and clinical years. Students were asked to rate their willingness to perform LSTs and rank the motives for doing so. The effect of medical education was then investigated after adjustment for age, gender, religion, religiosity, country of origin, and marital status. Results: Preclinical students had a significantly higher willingness to perform LSTs in all cases. This was observed in all treatments offered in cases of a metastatic oncologic patient and an otherwise healthy man after a traumatic brain injury (TBI). In the case of an elderly woman on long-term care, preclinical students had higher willingness to supply vasopressors but not perform an intubation, feed with a nasogastric tube, or treat with a continuous positive air-pressure ventilator. Both preclinical and clinical students had high willingness to perform resuscitation on a twelve-year-old boy with a TBI. Differences in motivation factors were also seen. Discussion: Preclinical students had a greater willingness to treat compared to clinical students in all cases and with most medical treatments offered. This is attributed mainly to changes along the medical curriculum. Changes in reasons for supplying LSTs were also documented.

Context The COVID-19 pandemic led to shutting of education faculties, including clinical clerkships for medical students. Objective To review a selective for a course in diagnostic pathology geared toward undergraduate medical students, including its design, technical implementation, instructor and student evaluations, and suggestions for options for further adjusting and optimizing the selective. Design Whole slide images (WSI) were anonymized and students were given remote access to university computers, which were prepared with two freely available WSI viewers. Each topic was taught in a four-part module: Self-assigned reading, lecture via Zoom, quiz based on digital slide sets, and a frontal review of the slides via Zoom. Fifty-nine students participated in the selective. Following the course, students completed an anonymous questionnaire. Results Of the 59 participants, 42% (n = 25) responded. None of the respondents had any previous instruction in diagnostic pathology. Overall, the course was rated very favorably: 68% (n = 17) gave at least 3 points on a 4-point scale on questions relating to course interest, improvement in understanding of the covered diseases, and how strongly they would recommend a student take this course if given an option. The most significant disadvantage of the class, as reported by 80% (n = 20) were technical challenges in accessing the slides. Conclusion We believe the course was a success and can be a model for future virtual pathology electives. Great effort should be done to provide technical support to the students. The selective demonstrated value for students and provided much-needed exposure to diagnostic pathology in clinical practice., Highlights • COVID-19 pandemic guidelines partially excluded medical students from their normal training. • A new pathology course, utilizing distance learning, was implemented. • Digital pathology slides enriched the undergraduate students' education.

Aims To identify risk factors for recurrent episodes of DKA that may allow the development of an effective prevention strategies. Methods Retrospective analysis of admissions for DKA in adult patients between 2004, and 2017 in a tertiary hospital. The clinical characteristics and outcomes of DKA of patients were stratified into an isolated episode of DKA (group 1) and recurrent episodes (group 2). Results: 385 patients were included in the study, 281 had a single admission of DKA, and 104 had recurrent admissions. There were no statistically significant differences between the two groups in demographic or clinical variables. Patients in the recurrent DKA group had a younger age at diabetes diagnosis, 32.1 ± 17.08 vs. 36.13 ± 19.52 (p = 0.05). Patients with A1C greater than 9.0% were associated with recurrent DKA in cox regression analysis (HR 2.023; 95% Cl 1.112–3.679; p = 0.021). Recurrent DKA was a significant predictor of one-year mortality in cox regression analysis (HR 0.172; 95% CI 0.04–0.742; p = 0.018). Conclusion High A1C levels, which account for poorly controlled diabetes, was identified as the strongest predictor of recurrent DKA. This patient population warrants particular attention and the development of intervention strategies in further studies.

Activity of NGO's supporting living donor kidney donations can affect the shortage of kidneys. Matnat Chaim is a Jewish orthodox organization active in Israel since 2009. This is a voluntary organization with aims to shorten and eliminate the waiting list for kidneys. Since the beginning of its activity, it has said to play a key role in 379 kidney transplantations. In 2015, out of 174 live donor kidney transplantations that took place in Israel, Matnat Chaim had a key role in 88 of them (50.6%). We found some ethical issues concerning the organization's activity. The donor can restrict his or her donation to specific characteristics of recipient which can result in organs transplanted in a homogeneous group of the population. Another issue is the question of whether nudging people to kidney donation takes place and whether it is valid to do so. We found that Matnat Chaim does a great deal for promotion and intermediation of kidney donations in Israel. This form of promotion can be implemented by other organizations and countries.

The increasing use of medical cannabis (MC) in the past decade raises several ethical considerations for the clinician. Regulatory issues stem from a gap between MC registration and certification in each country. Professional issues derive from the lack of sufficient knowledge of MC characteristics and the intersection between the physician, the patient and commercial interests. Finally, there are medical and psychological implications which are related to the use of MC regimens. We will discuss these issues in the light of the current era, in which policy has rapidly shifted toward legalization of cannabis, which influences the decisions of both clinicians and patients.

Due to its pharmacokinetic properties, it has been suggested that long-acting insulin analogues may have a role in facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA for prevention of rebound hyperglycemia, particularly if there are high insulin requirements. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycemia. Several studies have investigated the use of basal insulin in the management of DKA. Studies have been instituted on pediatric patients and adult patients. These studies reveal that co-administration of basal insulin in combination with an insulin infusion in the acute management of DKA is feasible. Basal insulin co-administration with regular insulin infusion was well tolerated, associated with faster resolution of acidosis without any adverse effects; patients required a shorter duration of intravenous insulin infusion and had a lower total dose of intravenous insulin and significantly decreased hyperglycemia after discontinuation of the intravenous insulin. This could potentially lead to a shorter ICU length of stay and reduced costs in the treatment of DKA. However, this approach may be associated with an increased risk of hypokalemia. The current literature on this management approach is incomplete, due to its many limitations (retrospective nature, small sample size, nonrandomized design). Additional prospective randomized studies are needed on this new therapeutic approach in the management patients with DKA.

Objective The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions. Materials and methods Review article. Results Recurrent diabetic ketoacidosis is a serious and not uncommon health problem. Diabetic ketoacidosis is associated with severe morbidity and mortality and hospital admissions due to this problem constitute a serious economic burden on the healthcare system. Younger age at diabetic ketoacidosis onset, poor baseline glycemic control and elevated HbA1C, patient comorbidities, depression, alcohol or substance abuse, particularly active cocaine use, have been associated with recurrent diabetic ketoacidosis. In addition, socioeconomic factors (such as ethnic minority status, use of public health insurance and underinsurance), psychosocial, economic, and behavioral factors (including financial constraint, stretching a limited insulin supply, and homelessness) have been all reported to be associated with readmission among diabetic ketoacidosis patients. Conclusions Identifying high-risk patients during the first diabetic ketoacidosis admission and performing relevant interventions (repeated instructions of insulin use, social help and involvement of family members in medical treatment, collaboration with the patient’s primary care physician in order to establish a close and frequent follow up program) may help prevent future admissions. Further studies need to take place to determine whether early interventions with those factors prevent future admissions.

Stress has extensively been shown to trigger fibromyalgia syndrome (FM). Nursing is associated with high levels of stress. Our hypothesis was that nurses suffer from an increased prevalence of FM symptoms, and that these symptoms correlate with the levels of stress to which they are exposed in the course of their occupation.The study was conducted as a targeted survey distributed to nursing staff in Soroka University Medical Centre, Beer-Sheva, Israel. Participants were asked to answer a questionnaire evaluating symptoms of FM, based on the current diagnostic criteria, which include the widespread pain index (WPI) and the symptom severity scale (SSS). Participants were further questioned regarding stressful experiences during their work and about post-traumatic symptoms as well as regarding work performance and motivation.206 participants completed the study questionnaire (84.5% females and 15.5% males). Twenty (9.7%) participants of the sample fulfilled criteria for diagnosis of FM reaching rates among females and males of 10.9% and 3.1% respectively. The prevalence of FM in our study was related to age with the highest prevalence in the older age groups (p=0.012). FM symptoms were strongly correlated with work related stress and were strongly correlated with Post Traumatic Stress Disorder (PTSD)-related symptoms. Work-performance parameters did not show a significant correlation with FM parameters.FM is highly prevalent among nursing staff. Our findings point towards the possibility that work-related stress and traumatic events may play a major role in the development of FM symptoms among nurses. With aging this association is more significant.

Euglycemic DKA (eu-DKA) is a life-threatening emergency. It may occur in patients with both type 1 and type 2 DM, and characterized by milder degrees of hyperglycemia with blood glucose level 200 mg/dl, which can result in delayed diagnosis and treatment with potential for adverse metabolic consequences. Following the wide introduction of the sodium glucose transporter 2 inhibitors (SGLT2i) in therapeutic practice for DM type 2 treatment the amount of eu-DKA increased and therefore, interest to this entity rose. Other causes associated with eu-DKA include pregnancy, decreased caloric intake, heavy alcohol use, insulin use prior to hospital admission, cocaine abuse, pancreatitis, sepsis, chronic liver disease and liver cirrhosis. Patients with eu-DKA as well as with DKA need immediate referral for emergency evaluation and treatment. The treatment includes rapid correction of dehydration, correction electrolyte abnormalities, and use of insulin drip until the anion gap, and bicarbonate levels normalize. Increased glucose administration using higher percentages of dextrose (10 or 20%) are required to facilitate the concomitant administration of the relatively large amounts of insulin that are needed to correct the severe acidosis in these patients.

Erythema nodosum (EN) is the most common type of panniculitis, commonly secondary to infectious diseases.To elucidate the causative factors and the clinical presentation of patients with EN (2004-2014) and to compare their data to those reported in a previous study.A retrospective study was conducted of all patients diagnosed with EN who were hospitalized at Soroka University Medical Center (2004-2014). The clinical, demographic, and laboratory characteristics of the patients were compared to those in a cohort of patients diagnosed with EN from 1973-1982.The study comprised 45 patients with a diagnosis of EN. The most common symptoms of patients hospitalized with EN were arthritis or arthralgia (27% of patients). Patients with EN, compared to those reported in 1987, has significantly lower rates of fever (18% vs. 62% P0.001), streptococcal infection (16% vs. 44%, P = 0.003), and joint involvement (27% vs. 66%, P0.001). In addition, fewer patients had idiopathic causes of EN (9% vs. 32%, P = 0.006).In the past decades, clinical, epidemiological, and etiological changes have occurred in EN patients. The lowering in rate of fever, streptococcal infection, and joint involvement in patients with EN are probably explained by improvements in socioeconomic conditions. The significantly decreasing rate of idiopathic causes of EN is possibly due to the greater diagnostic accuracy of modern medicine. The results of the present study demonstrate the impact of improvements in socioeconomic conditions and access to healthcare on disease presentation.

Cutaneous leishmaniasis (CL) is diverse in its clinical presentation but usually demonstrates an erythematous, infiltrated, ulcerated, and crusted papule or nodule in exposed areas of the body. Rare clinical features have been reported including lymphatic dissemination, usually with subcutaneous nodules along lymphatic channels. Herein, we present six patients suffering from Old World CL with lymphatic dissemination characterized by sporotrichoid subcutaneous nodules along the lymphatic channels draining the primary lesion. Patients' history, clinical and laboratory findings were collected and summarized. Lymphatic dissemination of CL in our patients manifested as subcutaneous nodules without epidermal involvement within the axis of lymphatic drainage toward the regional lymph node, at times accompanied by regional lymphadenopathy. In all patients, the lymphatic dissemination was not present at initial diagnosis of CL, appearing only after local (topical or intralesional) treatment was initiated. In three patients, the subcutaneous nodules resolved without systemic treatment. Lymphatic dissemination of Old World CL is not uncommon and may possibly be triggered by local treatment. It should be recognized by dermatologists, especially those working in endemic areas. Systemic treatment may be not necessary since spontaneous resolution may occur.

Background Anticoagulant induced renal injury has been previously described with Warfarin treatment. In the last decade direct oral anticoagulants (DOAC) were introduced. They include direct inhibitors of factor Xa (Rivaroxaban, Apixaban, Edoxaban) and a thrombin inhibitor (Dabigatran). There are isolated reports describing acute kidney injury (AKI) due to the use of DOACs. Case report We report a clinical case of an 80-year-old patient recently started on Dabigatran for new onset atrial fibrillation. She presented with AKI and hematuria, urine specimen showed RBC casts, and a working diagnosis of anticoagulant nephropathy due to Dabigatran was made. During hospitalization she was treated with Idarucizumab with a full recovery of renal function. To the best of our knowledge, there are 4 published case reports describing kidney injury produced by Dabigatran. Conclusion The use of DOACs is increasing rapidly, with increasing concern about its safety profile and, in particular, its potential harmful effect on renal function. As described in our case, treatment with Praxbind for Dabigatran induced kidney injury may be an acceptable management strategy that may obviate the need for urgent dialysis in selected cases by complete reversal of the AKI.

Background The 2009 pandemic influenza A/H1N1 developed as a novel swine influenza which caused more diseases among younger age groups than in the elderly. Severe hypoxemic respiratory failure from A/H1N1 pneumonia resulted in an increased need for ICU beds. Several risk groups were identified that were at a higher risk for adverse outcomes. Pregnant women were a particularly vulnerable group of patients The CDC reported on the first ten patients with severe illness and acute hypoxemic respiratory failure associated with A/H1N1 infection, none of whom were pregnant, but they noticed that half of the patients had a pulmonary embolism. Methods During a four-month period from September to December 2009, 252 patients were admitted to our hospital with confirmed pandemic influenza H1N1 by real-time reverse transcriptase-polymerase chain reaction test (rRT-PCR). We cared for twenty patients (7.9%) admitted to MICU with severe A/H1N1. Results on Thrombotic events were identified in five (25%) of our critically ill patients. Conclusions We recommend that patients with severe influenza A/H1N1 pneumonitis and respiratory failure be administered DVT prophylaxis in particular if there are additional risk factors for TVE. Further prospective studies on the relationship of influenza A/H1N1 and VTE are needed.

A health scare is an event characterized by fear of catastrophic consequences with little actual results. Regardless of these negligible results, the health, social and economic impacts of such events may be significant. Health scares are spread throughout four major groups: the media, relevant medical experts, policy makers and the public at large. In this review, we described two recent cases in Israel: the case of Eltroxin exchange that occurred in Israel as well as other countries, in addition to the polio virus spread in sewage, in the context of health scares. Furthermore, we summarized the interaction between these groups, focusing on their functioning in selected health scares from the previous two decades. There is increased need for creating a priori coordinating methods, in order to deal efficiently with such events in the future. In that way, the implications of health scares can be reduce to minimum.

The writings of Maimonides, the 12th-century physician, Talmudic and philosophic scholar, are remarkably relevant for modern medicine. Whereas the specific medical recommendations are obviously outdated, Maimonides' perceptive insights into professional responsibilities and medical ethics remain as useful guides even in our postmodern era.

Jehovah's witnesses oppose receiving blood transfusions based on religious grounds. This refusal raises complex medical, legal and ethical issues for the treating medical staff. In the past physicians attempted to force patients and children to accept transfusions when deemed medically necessary through the use of court orders. However, in recent years the threshold for blood transfusion has been gradually raised by medical experts as expressed in consensus guidelines, which means that Jehovah's witnesses' aversion to transfusion would have been partially justified medically. This article will further discuss these current trends.

The patient-psychiatrist relationship is a cornerstone of psychiatric professionalism and ethics. We discuss this topic along the axis of the Other and the Same, concepts defined by continental philosophy. The self of Anglo-American philosophy is typically described in individualistic terms. Individualism, autonomy and ideal self are valorized within the current model of care. These characteristics belong to the Lacanian Imaginary Order, which is the core of narcissism. Patients may yearn for another model of interaction. For Levinas, ethics should not involve a search for perfectionism and accomplishment but responsibility toward others. Ethics is, according to him, rooted in the calling into question of one’s Sameness by the other’s Otherness. The question of hospitality and of the welcoming of Otherness is central to his thought. Derrida further asks whether hospitality is not an interruption of the self. Hospitality may thus become a fundamental way of re-thinking clinical practices. A relationship to the Other as an-other is characterized as of Euclidian-type, establishing borders between the self and the Other, whereas a relationship to the Other as same is characterized as of fractal-type, emphasizing similarities between self and other as same and obliterating boundaries. Winnicott’s object-relating versus use of object and Buber’s I-you and I-it relations are also examined along the axis of Sameness and Otherness. Since psychiatric clinical practice requires to our view adequate and adaptive to and fro movements along this axis, the two forms of relating to the Other are discussed both theoretically and through a clinical case presentation.

Takotsubo cardiomyopathy is a left ventricular dysfunction that typically occurs after sudden intense emotional or physical stress and mimics myocardial infarction. We describe a case of a 60-year-old woman that presented to the emergency department with chest pain after she attended a wedding and ate a large amount of wasabi, assuming it to be an avocado. To the best of our knowledge, this is the first report of takotsubo cardiomyopathy triggered by wasabi consumption.

Placebos have been used extensively by vast numbers of physicians, in a majority of clinical trials. Placebo effects involve behavioural, psychological and genetic factors and have been subject to ethical controversies stemming from the use of deception in treating patients. The patient-physician encounter, endogenous pharmacological pathways, personality traits and genetic diversity have all been reported to be key players in placebo responses. In the last decade, a new methodological paradigm of placebo research has emerged, using open-label placebos to investigate their effects which showed promising results for various common medical conditions. In this review, we will summarize the current body of evidence on placebos in clinical practice, with a view to open-label placebo trials in particular. It is our view that future larger-scale randomized blinded open placebo trials will benefit physicians and improve patient outcomes.

Diabetic ketoacidosis (DKA) is one of the most common and serious acute complications of diabetes and is a significant cause of morbidity and mortality. In the last decade the mortality rate from DKA has declined because of greater recognition and improvements in its management. The current available guidelines state that the most effective means of insulin delivery during DKA is a continuous infusion of regular insulin, usually referred to as continuous low-dose insulin infusion. However, the cost of this treatment is usually quite high, because patients are required to be admitted to an intensive care unit in order to be monitored closely. New analogs of human insulin that have a rapid onset of action have become available in the past decade and represent potential alternatives to the use of regular insulin in the treatment of DKA. In several trials it has been demonstrated that the use of subcutaneous rapid-acting insulin analogs represents a safe, cost-effective and technically simpler treatment that precludes intensive care unit admission without significant differences in outcome in the management of patients with mild to moderate, uncomplicated DKA. The long-acting insulin analog may have a role in facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA. This avoids rebound hyperglycaemia and ketogenesis when intravenous insulin is stopped and may avoid excess length of stay.

The epidemiology of primary biliary cirrhosis (PBC) in Israel is unknown. We aimed to determine the epidemiology, long-term survival and outcomes of PBC in Southern Israel from 1990 to 2010.Case-finding methods and population-based administrative data were used to estimate and evaluate the incidence, prevalence and prognostic factors of outcome in our PBC cohort.138 cases of PBC were identified. The average annual prevalence of PBC was 255 cases per million. The overall age/sex-adjusted annual incidence of PBC was 10 cases per million from 1990 through 1999 and 20 cases per million from 2000 to 2010. Among 138 incident cases with a total follow-up of 960 persons-years from diagnosis, 30 patients (21.7%) died. Survival in PBC patients was significantly lower than that of the age/sex-matched Israeli population. Mortality was significantly increased in patients with an initial MELD score greater than 8 (P0.001), with portal hypertension (P0.001), and in non-responders to ursodeoxycholic acid (UDCA) therapy according to Barcelona criteria (P=0.005). Out of 138 patients, 95 patients (68.0%) responded to UDCA therapy according to Barcelona and Paris criteria. None of the responders died during the follow-up period as opposed to 30 out of 43 (69.8%) of non-responders. In multivariate analysis the factors associated with response to UDCA were: albumin levels above 3.5 g/dL (P0.001) and lower degree of fibrosis per liver biopsy (P=0.003).This study addresses the increasing burden of PBC in Israel and confirms the importance of some clinical and therapeutic factors as predictors of long-term prognosis.

Although only some medical students will choose cancer as their specialty, it is essential that all students have a basic understanding of cancer and its treatment. The purpose of this study was to evaluate the impact of an introductory clinical oncology course on first-year international medical students. Evaluation of the course involved a quantitative survey designed for this study that was given pre- and post-course completion. Participants included 29 first-year international medical students. Students reported that the course affected them emotionally more than they anticipated it would prior to beginning the course. By the end of the course, students felt more comfortable focusing on how to live with cancer, felt less afraid of dealing with death, and were better able to cope with uncomfortable emotional situations. The course had no significant effect on students' interest in specializing in oncology in the future. Our study provides evidence that an introductory oncology course can increase student comfort with issues related to living with cancer, with confronting and dealing with death and dying, and with coping with uncomfortable emotional situations as related to cancer care. In anticipation of growing shortages in oncology specialists in the coming years, the ability of an early course in oncology to attract more students to the field is of interest. Future research should examine ethnic and cultural differences in uptake of the clinical oncology courses across continents and should use direct observation in addition to self-report in evaluating outcomes.

Introduction Outbreaks of serious communicable infectious diseases remain a major global medical problem and force healthcare workers to make hard choices with limited information, resources and time. While information regarding physicians’ opinions about such dilemmas is available, research discussing students’ opinions is more limited. Methods Medical students were surveyed about their willingness to perform medical procedures on patients with communicable diseases as students and as physicians. Students were asked about their opinions regarding the duty to treat in such cases. Results 74% of respondents felt that by deciding to enter medical school they were morally obliged to treat any patient despite the risks. Students’ willingness to treat as physicians is significantly higher than their willingness to treat as students. HIV was significantly the most tolerated disease with respect to performing mouth to mouth resuscitation. Among preclinical students, we found that willingness to treat during the later years is significantly greater than during the earlier years. Among clinical students, the opposite was observed. Discussion Students’ greater willingness to treat as physicians is mostly attributed to perceptions of higher obligations as a qualified doctor. There is greater but not total willingness to perform resuscitation on patients with HIV relative to other diseases. The increased willingness of preclinical students and the decreased willingness of clinical students both emphasise the importance of patient–physician communication and ethics studies during medical school.

Background The importance of heart failure with preserved ejection fraction is being increasingly recognized. However, there is a paucity of data about effective treatment for this condition. The present study investigated the impact of beta blocker therapy for 3 months before admission on the two-year survival of patients with heart failure and preserved systolic function hospitalized due to decompensated heart failure. Methods We performed a retrospective cohort analysis of 345 consecutive patients with heart failure with preserved systolic function older than 18 years hospitalized due to decompensated heart failure. Two groups of patients were compared: those who received beta blockers within 3 months before admission (BB) and those who did not (NBB). The primary outcome was two year all cause mortality (maximal follow-up available in all subjects). To adjust for a potential misbalance between BB and NBB groups in baseline characteristics, a propensity score for beta blocker therapy was incorporated into the survival model. Results 154 patients (44.6%) received beta blockers prior to admission. Overall two year mortality rate in the BB group was 50% vs. 62.8% in the NBB group, log-rank test p = 0.016. Beta blockers showed protective effect on two-year survival after adjustment for comorbidities and propensity score (hazard ratio [HR], 0.69; 95% CI 0.47–0.99). Conclusions Therapy with beta blockers may have protective effect on survival of patients with heart failure with preserved systolic function.

Anne Jones has pointed out that over the last three decades, stories have been important to medical ethics in at least three ways: (1). Stories as cases for teaching principle-based medical ethics (2). Narratives for moral guides on what is considered living a good life (3). Stories as testimonials written by both patients and physicians. A pioneer in this effort, particularly in regard to using narratives as moral guides, has been the ethicist and philosopher Stanley Hauerwas. Heavily influenced by virtue ethics, Hauerwas believes that it is a person's particular narrative tradition that provides one with convictions that form the basis of one's morality. Befitting a Protestant theologian, he is particularly concerned with the Christian narrative. From a Jewish perspective, there has been much less written on the use of narrative in medical ethics. However, it is a mistake to think that narrative has little, if any, role in Rabbinic ethical decision making. The purpose of this article is to demonstrate the centrality of narrative in the thought of Orthodox Jewish decisors and the problems inherent in this methodology.

Background Exertional heat stroke (EHS) is a life threatening disease characteristically affecting young adults involved in strenuous physical activity. Delay in diagnosis and management may adversely affect outcome. The aim of this study was to summarize our experience with this syndrome and to identify factors associated with poor outcome. Methods In this retrospective cohort study we enrolled thirty two patients who met the case definition of exertional heat stroke. Results Of the 32 patients, 27 (84%) were male and their median age was 19 years. 26 patients were residents of the northern parts of the country spending less than 10 days in the area. Only 10 patients (31%) were correctly diagnosed and treated in the prehospital setting. Those in whom treatment was delayed had higher rates of multi-organ failure and longer hospitalizations. In 7 patients protracted systemic inflammatory response (SIRS) was observed. Of the 14 patients that had moderate to severe disease requiring ICU admission, eight (25%) were mechanically ventilated, two (6.3%) were dead on arrival. The other half of the cohort had a mild disease managed by the general wards. Conclusions Exertional heat stroke is a life threatening disease. Early diagnosis and appropriate management may improve outcome. Protracted SIRS may complicate the course of EHS.

The ‘ferrule effect’ is a long standing, accepted concept in dentistry that is a foundation principle for the restoration of teeth that have suffered advanced structure loss. A review of the literature based on a search in PubMed was performed looking at the various components of the ferrule effect, with particular attention to some of the less explored dimensions that infl uence the effectiveness of the ferrule when restoring severely broken down teeth. These include the width of the ferrule, the effect of a partial ferrule, the infl uence of both, the type of the restored tooth and the lateral loads present as well as the well established 2 mm ferrule height rule. The literature was collaborated and a classifi cation based on risk assessment was derived from the available evidence. The system categorises teeth according to the effectiveness of ferrule effect that can be achieved based on the remaining amount of sound tooth structure. Furthermore, risk assessment for failure can be performed so that the practitioner and patient can better understand the prognosis of restoring a particular tooth. Clinical recommendations were extrapolated and presented as guidelines so as to improve the predictability and outcome of treatment when restoring structurally compromised teeth. The evidence relating to restoring the endodontic treated tooth with extensive destruction is defi cient. This article aims to rethink ferrule by looking at other aspects of this accepted concept, and proposes a paradigm shift in the way it is thought of and utilised.

Samuel Golubchuk was unwittingly at the center of a medical controversy with important ethical ramifications. Mr. Golubchuk, an 84-year-old patient whose precise neurological level of function was open to debate, was being artificially ventilated and fed by a gastrostomy tube prior to his death. According to all reports he was neither brain dead nor in a vegetative state. The physicians directly responsible for his care had requested that they be allowed to remove the patient from life support against the wishes of the patient's family. Concurrently the Manitoba College of Physicians and Surgeons released a statement which states that the final decision to withdraw life support lies with the physician. In our opinion the statement is ethically problematic for a number of reasons. 1. It is an affront to the guiding principles of Western medical ethics: patient autonomy and human freedom. 2. The position of Samuel Golubchuk's physicians and the new statement lack cultural sensitivity towards other traditions. 3. In modern society there exists an erosion of a basic attitude towards the value of life. 4. The ability of physicians to predict life expectancy in terminally ill patients has been shown repeatedly to be quite limited.

Palliation of pain is universally regarded as a cardinal aspect of end-of-life care. In the early days of the palliative care and hospice movement there was concern that aggressive pain control with opioids could potentially hasten the death of the patient primarily through respiratory depression. For many ethicists and theologians who were opposed to active euthanasia, this raised the difficult question of whether it is permissible to use these potentially harmful medications. Traditional Jewish decisors also addressed this question and their writings can shed light on their attitudes toward terminal care. The purpose of this article is to analyze the view of three highly respected authorities on the use of pain medications with potentially significant side effects in terminal patients. The Jewish position demonstrates how an ancient tradition struggles to develop an ethic consistent with modern sensibilities. Religious decisors scour the ancient sources to find precedents and then apply that wisdom to contemporary questions. Jewish medical ethics by its very nature is highly pluralistic because there is no central body that determines policy and a wide spectrum of opinions are usually found. However, regarding pain treatment there appears to be a broad consensus mandating its aggressive use even at the risk of significant side effects as long as the motivation is relief of suffering.

In the past 3 years, three landmark laws relating to bioethics have been passed in the Israeli parliament. These are the Terminally Ill Patient Law (in 2005) and the Organ Donation Law and the Brain Death/Respiratory Law (in 2008). To reach consensus on these difficult issues in a multicultural society such as Israel was not an easy undertaking. Using learning from previous failed attempts, compromise, dialogue and work done in the absence of hysteria and publicity were crucial to the process. In all three laws, compromises were obtained between the secular and religious factions, from which an acceptable law was developed. The Israeli experience is a model of a country working to synthesise an ancient tradition with the complexities of modern life and could serve as an example for other countries struggling with similar issues.

Objective.We evaluated the accuracy of diagnosis of fibromyalgia (FM) by family physicians.Methods.We performed a retrospective cohort analysis of 646 consecutive patients newly referred to the outpatient rheumatology clinic of Soroka University Medical Center from January 1, 2005, until December 31, 2007. The kappa statistic was used to measure agreement between family-physician and rheumatologist diagnoses for FM in the total patient cohort as well as in groups stratified by ethnicity. Sensitivity and specificity of family-physician diagnosis of FM were calculated using rheumatologist diagnosis as the gold standard. There were no exclusion criteria.Results.During the time period of the study, 646 new patients were seen in the rheumatology clinic. Of 196 patients referred with an initial diagnosis of FM, the consultant rheumatologist confirmed this diagnosis in 71% of cases. The overall kappa for FM diagnosis between family physicians and rheumatologists was 0.70 (p < 0.001), indicating a good level of agreement. Agreement was substantially lower among Bedouin patients (κ = 0.35, p = 0.003). All other patients in our study were Jewish Israelis. Using rheumatologist diagnosis as the gold standard, overall sensitivity and specificity of FM diagnosis by family physicians were 87.4% and 88.3%, respectively.Conclusion.Family physicians in our region are able to accurately diagnose FM. Future studies might focus on evaluating the factors and biases accounting for differences in level of diagnostic accuracy for FM among various ethnic groups.

Due to the worldwide shortage of organs for transplantation, there has been an increased use of organs obtained after circulatory death alone. A protocol for this procedure has recently been approved by a major transplant consortium. This development raises serious moral and ethical concerns. Two renowned theologians of the previous generation, Paul Ramsey and Moshe Feinstein, wrote extensively on the ethical issues relating to transplantation, and their work has much relevance to current moral dilemmas. Their writings relating to definition of death, organ transplantation and the care of the terminally ill are briefly presented, and their potential application to the moral problem of organ donation after circulatory death is discussed.

Background Hyperlipidemia remains a major cause of morbidity in Western countries. The objective of this study was to document the percentage of adults who underwent periodical LDL measurement, and the percentage of patients with diabetes and post-angioplasty who were treated to goal. Methods Using a national database, data were obtained on the percentage of adults who had an LDL performed and the percentage of adults with an LDL at pre-specified levels. We also assessed the attainment of target LDL levels in diabetic and post-angioplasty patients. Data were also collected from patients with an acute coronary syndrome (ACS) admitted to seven hospitals within a 5 year period (2000–2004). Results Primary prevention: In 2005, 64.6% of the total population of 754,910 aged 35–44 had at least one record of LDL cholesterol measurement documented. This figure was 79.6% in the 717,617 adults aged 45–54. Secondary prevention: Of 253,233 diabetics in 2005, 220,023 (86.9%) have undergone at least one annual LDL measurement. The percentage of patients on statin therapy 3 and 12 months after an ACS admission increased significantly during the years 2000–2004 and reached 87%. Of the 42,292 patients who underwent PTCA during 2005, 34,346 (81.2%) have purchased at least 3 prescriptions of statins during 2005, 35,261 (83.4%) have performed at least one LDL measurement and 57.8% attained an LDL level of Conclusions We have shown an improvement in primary and secondary preventions of CV disease as documented by LDL measured and attainment of treatment goals, but further efforts are needed.

Objective. To estimate the impact of delays in surgery for hip fracture on short- and long-term outcomes. Design. Analysis of inpatient hospital data integrated with national health plan data and Central Bureau Statistics. Setting. Seven major tertiary hospitals. Patients. All consecutive elderly patients admitted with hip fracture during the years 2001 –2005. Main outcome measures. Time from the hospitalization to operation; one-year mortality. Main results. Study population comprise 4633 patients, older than 65 years. The conservative approach was chosen in 818 patients (17.7%), while 1350 patients (29.1%) waited .2 days from admission to the surgery. There was a substantial variation in median pre-operative stay among the hospitals (range 0 – 4 days). Patients who had surgery within 2 days had lower mortality (in-hospital, 1-month and 1-year) compared to those who waited for surgery .4 days (2.9%, 4.0%, 17.4% vs. 4.6%, 6.1%, 26.2%, respectively). A Cox proportional regression model of 1-year mortality in operated patients adjusted for background morbidity (Charlson index) showed that the length of operation delay has a gradual effect on increasing mortality (,2 days—reference group, 2– 4 days—OR ¼ 1.20, 5 days or longer, OR ¼ 1.50). The 818 (17.7%) non-operated patients suffered the highest 1-year mortality, 36.2%. Conclusions. Delays in surgery for hip fracture are associated with significant increase in short-term and 1-year mortality. Variation among the hospitals was substantial and calls for prompt quality improvement actions.

Background and Objectives: In 1998 Ben-Gurion University, in collaboration with Columbia University, inaugurated the first medical school with the express purpose of training students in International Health and Medicine (IHM). The highlight of the program is the two-month clerkship in IHM. The purpose of this paper is to describe the IHM clerkship and report the preliminary results of an evaluation. Methods: To evaluate the impact of the clerkship on the students' attitudes and knowledge of IHM, the students were asked to complete a previously validated self- assessment questionnaire before and after the clerkship. Results: Ninety-six students participated in the IHM clerkship in the first 3 years. The mean age of the students was 29.4+4 and 53% were female. Comparison of the student's answers before their departure and after their return showed a significant difference in 5 of 64 items on the questionnaire. There was also a significant increase in the overall scores of the female students but no change in the scores of the male students pre- and post-clerkship. Discussion and Conclusions: Our results show that students who completed the clerkship modestly increased their knowledge of some aspects of IHM as measured by the survey. Further studies on the long-term impact of IHM experiences are needed in parallel with efforts to increase medical students' exposure to IHM.

Until recently physicians have been reluctant to disclose a poor prognosis to patients for fear of harming them with the bad news and/or taking away their will to live. In the last decades we have seen a reversal of practice among Western physicians, and most doctors readily disclose to their patients the full extant of their disease. This change is probably due to the emphasis on patient autonomy in the doctor-patient relationship and the lack of evidence that hearing the bad news impacts significantly on patient outcomes. This emphasis on complete honesty with patients might not reflect the practice in non-Western cultures. In disclosing a poor prognosis to a patient the physician must do so with cultural sensitivity, compassion and letting the patient decide how much he or she wants to know.

Chronic migraine management almost always requires daily oral preventative medication with potential adverse effects. Daily oral preventative therapy may also not be effective in terminating chronic migraine. Chronic central sensitisation caused by repetitive migraine attacks in a young person may lower the threshold for future migraine episodes leading to an intractable and debilitating disease course. The objective was to determine if short–term parenteral dihydroergotamine, dexamethasone and hydroxyzine can terminate chronic migraine and be followed by a continuous respite or conversion to a more benign episodic form without the need for daily oral preventative medication (“carry–over effect”). We treated ten patients, seven adolescents and three adults, with parenteral dihydroergotamine, dexamethasone and hydroxyzine given once a week for a maximum of three weeks. No oral preventative daily medication was administered. The setting was a private practice. Chronic migraine was terminated in all 7 adolescents. Their post–treatment course was converted to a more benign episodic migraine course and no adolescent required daily oral migraine preventative therapy for significantly long carry–over post–treatment observational periods. None of the three adult chronic migraine cases could be terminated satisfactorily as they all required daily oral preventative therapy. In the adolescent group only, this strategy terminated chronic migraine and resulted in a significant carry–over effect that appeared to favourably modify the long–term course without the need for daily pharmacological, potentially toxic, preventive therapy. Although this is a very small study, which requires confirmation by a larger controlled study, our data suggest a significant carryover effect in the young migraineur by administering short–term parenteral dihydroergotamine, dexamethasone and hydroxyzine.

In modern warfare, civilian populations may find themselves under immediate personal danger with very little warning. While there are ways to minimize this danger, there is a paucity of literature discussing this modern dilemma, and it is therefore important to try to address these situations in advance both logistically and ethically. Discussion of this case includes several relevant ethical principles.

Ovum donation affords countless couples that under natural circumstances would not be able to produce offspring the ability to carry out natural pregnancies. With advancements in biotechnology including egg collection and in vitro fertilization (IVF), physicians can now successfully implant fertilized embryos. Due to Israel's tremendous involvement in IVF for its own citizens, the national laws that govern egg donation are of great importance. On September 5th 2010, the Israeli Parliament (Knesset) passed a law that allows young women between the ages of 21 and 35 to donate their eggs for paid financial compensation. The new law allows infertile women between the ages of 18 and 54 to request egg donation and IVF, which will partially be covered under state insurance plans. This article provides a description of the new Israeli law regulating ovum donation and the practical, moral and ethical debate surrounding the new system.

The past two decades have seen a dramatic increase in the use of telemedicine while the information technology revolution has contributed significantly to its popularity. In addition, there has been a recent increase in the use of telemedicine in the intensive care unit (ICU), partially driven by a critical shortage of intensivists. However, the ethical questions raised by the implementation of tele-ICUs have not been adequately considered. In this essay, we will discuss the development of tele-ICUs from the perspective of autonomy, beneficence/non-malificence, justice and professionalism.