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The goals of this study were to evaluate the effectiveness and physiological effects of alfaxalone-butorphanolmidazolam sedation in cats compared with the common sedation protocol used at our institution; medetomidine-butorphanol-midazolam. Thirty-one cats requiring sedation for various procedures were recruited randomly to receive intramuscular butorphanol (0.4 mg/kg) and midazolam (0.3 mg/kg) combined with alfaxalone (2 mg/kg) (ABM; n=16) or medetomidine (0.02 mg/kg) (MBM; n=15). Physiological variables and sedation quality (scale 7-28; 7=awake, 28=deeply sedated) were collected every 10 minutes until recovery. For medetomidine antagonism, the MBM cats received atipamezole intramuscularly. Induction and recovery times were recorded, and recovery quality was scored (1-4 scale: 1=poor, 4=excellent). Evaluations were performed by one blinded observer. Mann-Whitney U test, Fischer's exact and repeated measures mixedeffects were used for analysis, and p<0.05 was set for significance. Six cats (ABM) and three cats (MBM) required an additional dose. At 10-40 minutes sedation scores were significantly better in the MBM (21-24) compared with ABM group (19-20). Significant lower heart rate, higher blood pressure and respiratory frequency were recorded in the MBM group. Time to recovery was significantly faster (9±7 versus 26±21 minutes) and recovery of better quality (4 [1-4] versus 3 [1-4]) in the MBM compared with the ABM group. During recovery, cats in the ABM group showed opisthotonos, twitching, and paddling, which resolved within an hour. In conclusion, at the doses used, ABM was a viable alternative to MBM with less cardiovascular effects, however, sedation plane was inferior and recovery, longer, accompanied by adverse behaviors. [ABSTRACT FROM AUTHOR]

Cats exposed to permethrins, which are present in ectoparasite control products intended for dogs, may develop signs of toxicity. This retrospective study describes the clinical course of permethrin toxicosis in cats, and examines if methocarbamol treatment had improved its morbidity and outcome. The study included 61cats diagnosed with permethrin toxicosis presented to the Hebrew University Veterinary Teaching Hospital. In most cases (89%), the owners have inadvertently applied anti-flea spot-on products designated for dogs to their cats, resulting in toxicosis-related clinical signs. These most common signs included tremors and twitching (90%), hypothermia (39%), seizures (30%), tachypnea (25%), abnormal mentation (18%), ataxia (16%), ptyalism (11%) and mydriasis (10%). Treatments included whole body bathing (85%), along with supportive care, sedatives and muscle relaxants. Some cats (5%) required general anesthesia. The median hospitalization period was one day (range, 1-9). The survival rate was 100%. Methocarbamol (50-330 mg/kg, slow IV PRN) was administered to 41 cats (67%), which had a shorter (P=0.032) hospitalization period (median, 1 day) compared to that of cats untreated with methocarbamol (2 days). Cats with seizures treated with methocarbamol had a shorter (P=0.08) hospitalization period compared to that of cats untreated with methocarbamol. In conclusion, permethrin toxicosis occurs in cats, mainly by inadvertent application of canine flea insecticide spot-ons. The overall prognosis of such cases, when treated intensively was excellent. Herein, methocarbamol treatment of cats with this toxicosis, in general, as well as particularly in those presenting seizures, decreased their morbidity, as reflected by a shorter hospitalization period. [ABSTRACT FROM AUTHOR]

Background: Healthcare organizations attempt to address unwarranted fentanyl use, which often leads to increased risk of addiction and overdose., Objective: To assess the impact of a requirement for a specialist's approval on fentanyl initiation for non-oncological pain., Design: A retrospective cohort study based on observational data., Participants: All 4.4 million non-oncological members of Clalit Health Services were included, from July 20, 2021, to July 19, 2023., Main Measures: The rate of fentanyl initiation was assessed before and after the implementation of the requirement for specialist's approval, which was introduced on July 2022, and expanded 6 months later for continued use. A sub-group analysis by age group was performed, and patient characteristics and indications were assessed. We also compared total opioid dispensation in the 6th and 12th months after the implementation with the predicted rate based on pre-implementation rates., Key Results: Fentanyl initiation rate in the year before the requirement was 711 per million capita, which decreased following the requirement by - 81% (95% CI: - 77%; - 85%). The decrease attenuated with age. The prevalence of diagnosis with substance abuse disorders at the time of fentanyl initiation decreased from 6 to 3%. In the 6th and 12th months after the requirement was implemented, the morphine milligram equivalent (MME) from dispensation of total opioids was lower than predicted based on pre-implementation rates by 7% and 26%, respectively., Conclusions: Requiring specialist approval for fentanyl initiation for non-oncological chronic pain was associated with a decrease in fentanyl prescription initiations, especially among non-elderly patients. A decrease also occurred gradually in total opioid dispensations, further decreasing following the extension of the requirement to continuous fentanyl. The requirement for specialist approval upon fentanyl initiation and continuous fentanyl may present an effective tool for limiting the use of fentanyl and total opioids in healthcare systems., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Objectives: Previous research reported inconsistent results on the efficacy of molnupiravir in treating COVID-19. Moreover, efficacy was not assessed in the intended-use population (IUP), as defined by the FDA. Therefore, we aimed to evaluate the effectiveness and safety of molnupiravir for the treatment of COVID-19 in the IUP., Methods: We performed a retrospective cohort study on all IUP in Israel's Clalit Health Services from January 16, 2022, to February 16, 2023. The effectiveness outcome was the incidence of hospitalization or death due to COVID-19, and the safety outcome was the incidence of all-cause mortality within 35 days of SARS-CoV-2 infection. Cox-proportional hazard models were used to analyse the data after 1:5 propensity-score matching., Results: A total of 49 515 patients met the eligibility criteria. Of them, 3957 molnupiravir-treated patients were matched to 19 785 untreated patients. In molnupiravir-treated patients, 70 out of 3957 (5.1 per 10 000 person per day) experienced COVID-19-related hospitalization or death, compared with 699 out of 19 785 untreated patients (10.4 per 10 000 person per day); RR: 0.50 (95% CI, 0.39-0.64). All-cause mortality was also lower in the treated group, with 41 out of 3957 (3.0 per 10 000 person per day) experiencing mortality compared with 414 out of 19 785 untreated patients (6.1 per 10 000 person per day); RR: 0.50 (0.36-0.68)., Discussion: In a real-world cohort of IUP, molnupiravir therapy was associated with a significant reduction in hospitalizations or deaths due to COVID-19 and all-cause mortality., (Copyright © 2024 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Background: Several meta-analyses assessed the relationship between exposure to PM with aerodynamic diameter ≤ 2.5 μm (PM 2.5 ) during pregnancy and birth weight (BW), but results were inconsistent and substantial unexplained heterogeneity was reported. We aimed to investigate the above association and to explore sources of heterogeneity across studies., Methods: We systematically reviewed the current worldwide evidence examining the association between PM 2.5 and BW. The review protocol was registered on the PROSPERO website (CRD42020188996) and followed PRISMA guidelines. We extracted association measures for BW and low birth weight (LBW, BW < 2500 g) from each study to evaluate pooled summary measures and to explore sources of between-study heterogeneity., Findings: Of the 2677 articles identified, 84 met the inclusion criteria (~42 M births). Our random effects meta-analyses revealed substantial heterogeneity among included studies (I 2  = 98.4 % and I 2  = 77.7 %, for BW and LBW respectively). For LBW, the heterogeneity decreased (I 2  = 59.7 %) after excluding four outlying studies, with a pooled odds ratio 1.07 (95 % confidence interval, CI: 1.05, 1.09) per a 10-μg/m 3 increase in mean PM 2.5 exposure over the entire pregnancy. Further subgroup analysis revealed geographic heterogeneity with higher association in Europe (1.34, (1.16, 1.55)) compared to Asia (1.06, (1.03, 1.10)) and US (1.07, (1.04, 1.10))., Conclusion: The association between PM 2.5 and birth weight varied depending on several factors. The sources of heterogeneity between studies included modifiers such as study region and period. Hence, it is advisable not to pool summary measures of PM 2.5 -BW associations and that policy would be informed by local evidence., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

There is a potential link between cannabis and mental disorders. Cannabis exposure involves in many cases negative mental emotions, which are unpleasant sensations or thoughts. Whereas mild cases of negative mental emotions inflict patient's quality of life, more severe cases lead to therapy discontinuations, or even hospitalizations and death. This study characterizes cannabis users who experienced negative mental emotions after cannabis exposure. The Releaf App database was utilized to evaluate the association between personal and cannabis use characteristics on reporting a negative mental emotion during cannabis exposure. This global mobile lets individuals track real-time cannabis experience use with cannabinoid-based products, containing data points such as gender, age, reasons for use, product type, cannabis composition, and feelings and emotions experienced after cannabis use. Multivariable logistic regression models were constructed, adjusting for potential confounders such as gender and previous experience with cannabis use. The study population comprised 4,435 users, and 34,279 sessions were collected from various countries, mainly from North America, and included in the primary analysis. Reporting on negative mental emotions was associated with users in the age group of 18-30 years. Using cannabis for a mental purpose was associated with a small increase in reporting on negative mental emotions (OR = 1.10, 95%CI [1.03-1.19]). Oral products were associated with reporting on negative mental emotions. THC-dominant products were associated with reporting negative mental emotions compared to balanced products (OR = 1.21, 95%CI [1.06-1.38]). This study suggests that some characteristics of cannabis use, such as young age and oral consumption are associated with negative mental emotions. Further studies should examine the interface between cannabis consumption, characteristics of consumers, and negative emotional experience or even long-term mental disorders., (© 2024. The Author(s).)

Objectives: In equine glaucoma, topical treatment with carbonic anhydrase inhibitors (CAIs) is recommended. Oral acetazolamide, a systemic CAI, is used in horses with hyperkalemic periodic paralysis. Information regarding its effect on equine intraocular pressure (IOP) is scarce. The aim of the study was to determine the effect of oral acetazolamide treatment on IOP in horses, in a case-control study., Animals: Ten healthy horses., Procedures: Horses were treated with oral acetazolamide (4.4 mg/kg) BID for 1 week. Serum acetazolamide concentrations were determined by liquid chromatography/tandem mass spectrometry, and IOP were measured before treatment, daily during treatment, and at 48 and 72 h after treatment., Results: Acetazolamide serum levels reached steady state at 72 h after the first oral dose. In a mixed effect model logistic regression, there was a significant decrease in IOP on the third treatment day, of 2.4 mmHg (p = .012) and 2.7 mmHg (p = .006) in the left (OS) and right eye (OD), respectively. On the seventh day, there was a decrease in 2.5 mmHg (p = .008) and 2.7 mmHg (p = .007) OS and OD, respectively. A significant increase occurred 48 h following treatment discontinuation (3.6 mmHg, p < .001 and 3.5 mmHg, p < .001 OS and OD, respectively). The area under the concentration versus time curve (AUC (0-10h) ) was 1.1 ± 0.5 μg/mL*h, mean residence time 6.7 ± 4.3 h, peak plasma concentration (C max ) 0.4 ± 0.4 μg/mL and time to reach C max 1.8 h. There was a significant increase in serum concentrations 1, 2, 48, 72, and 156 h following the first drug administration (p < .05)., Conclusions: Further studies are required to determine whether acetazolamide is a potential treatment for equine glaucoma., (© 2024 The Author(s). Veterinary Ophthalmology published by Wiley Periodicals LLC on behalf of American College of Veterinary Ophthalmologists.)

Purpose: Previous studies have shown differences in baseline and stimulated cortisol levels between men and women. Whether this difference is secondary to sex hormones or to other factors, such as genetic or epigenetic changes, is unknown. We investigated the effect of gender-affirming hormone treatment (GAHT) on the hypothalamo-pituitary-adrenal axis of transgender subjects in an effort to throw light on this question., Methods: Ten transgender males (TM) and eight transgender females (TF) underwent a low-dose (1 µg) adrenocorticotropic hormone (ACTH) stimulation test before and 6 months after GAHT initiation. Serum total, free and salivary cortisol (SC) levels were measured at baseline and at 20, 30 and 40 min., Results: For the TM, all three levels were significantly lower at several time points after ACTH injection compared to pretreatment levels following 6 months of treatment (p < .05). Likewise, the overall SC response as calculated by the area under the curve was significantly lower (p = .0053). For the TF, the basal total cortisol (TC) level increased after 6 months of treatment (p < .01) while ACTH-stimulated SC levels decreased significantly. The basal ACTH levels were significantly lower following hormonal therapy (p < .001)., Conclusion: Stimulated salivary cortisol levels decreased significantly after 6 months of GAHT in both male and female transgender subjects, possibly reflecting a decreased state of anxiety associated with treatment initiation. Additionally, basal and stimulated serum TC levels increased after hormonal treatment in the TF, probably secondary to the effect of oestrogen on cortisol-binding globulin., (© 2023 John Wiley & Sons Ltd.)

Background and Objective: Pregabalin is steadily gaining popularity worldwide, with epidemiological studies indicating an increase in labeled, off-labeled, and recreational uses. In Israel, pregabalin prescriptions are not regulated by the controlled substances legislations, prompting a need to examine its usage trends for potential policy adjustments. The objective of this study was to assess trends in pregabalin prescribing during a 10-year period, to characterize demographic and clinical characteristics of individuals prescribed pregabalin, and to identify risk factors associated with high-intensity pregabalin use., Methods: This retrospective, longitudinal study examined trends in pregabalin prescribing from 2010 to 2019 based on data extracted from the Clalit Health Services (CHS) electronic database. Annual pregabalin prescribing rate was calculated individually for each reporting year. A univariable analysis was conducted to compare the demographic and clinical characteristics of pregabalin users in 2019 with those in 2010. Multivariable regression analysis was performed to assess dose-related patterns by specific demographic and clinical characteristics., Results: Pregabalin prescription rate more than doubled over 10 years [odds ratio (OR) 2.3, p = 0.001], reaching 7.2 [95% confidence interval (CI) 7.18-7.28] prescriptions per 100 CHS members in 2019. The highest prescription rates were observed among the elderly population (13.2 and 24.1 prescriptions per 100 CHS members for those aged 55-74 and over 75 years old, respectively). Same-year administration of pregabalin with opioids, benzodiazepines, and Z-drugs was common; however, the percentage of patients using these drugs together declined in 2019 compared with 2010 (p < 0.001). Males, patients with low socioeconomic status, patients aged 35-54 years, and those who consumed opioids, benzodiazepines, and Z-drugs received higher pregabalin doses., Conclusion: Pregabalin use has increased significantly in the Israeli adult-based CHS population, consistent with worldwide data. A growing use over time may indicate overprescription. More studies are needed on misuse patterns to identify populations most susceptible to high-dose and high-intensity pregabalin use., (© 2024. The Author(s).)

Prior studies found reduced incidences of cardiovascular diagnoses and treatments in the initial phase of the COVID-19 pandemic. However, these studies included a limited number of outcomes and did not consider pre-pandemic trends. This study aimed to describe trends in the incidence of cardiovascular diagnoses and treatments over the years 2012-2021 in Israel and to compare the two years of the COVID-19 period with the preceding 8 years. In this retrospective, population-based study, carried out within Clalit Health Services, the incidence rates of cardiovascular outcomes were calculated for individuals aged ≥ 25 (~2.7 million adults per year) during the first (Y1, 3/2020-2/2021) and second (Y2, 3/2021-2/2022) years of COVID-19 and the 8 years prior (3/2012-2/2020). Declines were observed in Y1 compared to 2019 in all diagnoses and treatments: STEMI (-16.3%; 95% CI: -16.6, -16.1), non-STEMI (-16.4%; -16.6, -16.2), AF (-14.1%; -14.2, -14.0), CHF (-7.8%; -7.9, -7.7), CVA (-5.0%; -5.0, -4.9), catheterization (-64.7%; -65.2, -64.2), CABG (-77.7%; -79.2, -76.2), ablation (-21.2%; -22.0, -20.4), pacemaker implantation (-39.3%; -40.7, -37.9), and defibrillator insertion (-12.5%; -13.1, -12.0). Compared with expected rates based on pre-pandemic trends, observed rates were within expected ranges (CHF, CVA, and ablation), less than expected (STEMI, non-STEMI, AF, catheterization, CABG, and pacemaker insertion), or more than expected (defibrillator insertion). In Y2, STEMI, catheterization, and CABG returned to expected rates; non-STEMI and AF were lower than expected; and CHF, CVA, ablation, and pacemaker and defibrillator implantations were higher than expected. Several cardiovascular diagnoses and treatment trends were interrupted by COVID-19. The long-term consequences of these changes should be considered by health policymakers.

Background: Hip fracture patients (HFPs) frequently have multiple underlying conditions, necessitating that agreed-upon goals take these complications into consideration. Communication regarding goals between medical-personnel and patients is not always effective. Patient-reported outcomes (PROs) can outline personal goals and help promote quality health care in HFPs. Few studies have been published on this topic. The study's aim was to outline the process of using PROs for goal-directed therapy among HFPs., Methods: This sequential controlled trial was conducted among HFPs from two medical centres. The control and the intervention group received integrative rehabilitation. PROs were measured in both groups using the SF36 questionnaire three times postsurgery: 24-48 hours, 2 weeks and 3 months. During the first round of questioning, only the intervention group was asked 'what matters most to you?' during the rehabilitative process. Accordingly, agreed-upon goals that were determined by the SF36's eight topics and were incorporated into the HFP's rehabilitative process. A Likert scale of 1-5, '1' indicating no-achievement and '5' full-achievement, was used to assess the goal achievement 4-6 months post-fracture., Results: 84 HFPs participated in the study: 40 and 44 in the intervention and control group, respectively. In both groups, PROs declined after the HF, then improved somewhat 3 months later, but did not return to prefracture scores. Among the intervention group, 39% reached their specific goals (Likert level 5). Patients who achieved their goals had better PROs in comparison to others. The intervention group indicated PROs helped them articulate their desires and introduced them to new areas of care., Conclusions: Shifting from asking 'what's the matter?' to 'what matters most to you?' can improve the understanding of HFPs' own priorities, promote quality outcomes and enhance patient-centred care. Using PROs as a guide for goal-directed therapy can create a more inclusive process that includes the patients' most important health determinants and needs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Osteoarthritis is a common disease in dogs resulting in chronic pain and decreased wellbeing. Common analgesics such as non-steroidal anti-inflammatories may fail to control pain and can produce major adverse effects. Study objectives were to evaluate pharmacokinetics, therapeutic efficacy, and safety of subcutaneous liposomal-cannabidiol (CBD) as an additional analgesic therapy in dogs suffering from naturally-occurring osteoarthritis., Methods: Six such dogs were recruited following ethics approval and owner consent. Dogs were administered a single subcutaneous injection of 5 mg/kg liposomal-CBD. Plasma concentrations of CBD, blood work, activity monitoring collar data, wellbeing questionnaire (owners) and pain scoring (veterinarian) were performed at baseline and monitored up to six weeks following intervention. Data overtime were compared with baseline using linear-regression mixed-effects. P -value was set at 0.05., Results: CBD plasma concentrations were observed for 6 weeks; median (range) peak plasma concentration (C max ) was 45.2 (17.8-72.5) ng/mL, time to C max was 4 (2-14) days and half-life was 12.4 (7.7-42.6) days. Median (range) collar activity score was significantly increased on weeks 5-6; from 29 (17-34) to 34 (21-38). Scores of wellbeing and pain evaluations were significantly improved at 2-3 weeks; from 69 (52-78) to 53.5 (41-68), and from 7.5 (6-8) to 5.5 (5-7), respectively. The main adverse effect was minor local swelling for several days in 5/6 dogs., Conclusion: Liposomal-CBD administered subcutaneously produced detectable CBD plasma concentrations for 6 weeks with minimal side effects and demonstrated reduced pain and increased wellbeing as part of multimodal pain management in dogs suffering from osteoarthritis. Further placebo-controlled studies are of interest., Competing Interests: DZ, AH, and AC are supported by Innocan Pharma™. AC and YB have a patent pending on the liposomal-CBD formulation used in this study. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Shilo-Benjamini, Lavy, Yair, Milgram, Zilbersheid, Hod, Barasch, Abu Ahmad, Cern and Barenholz.)

Objectives: The global supply of vaccines against mpox (previously called monkeypox virus infection) was significantly lower than the demand. Therefore, evidence-based vaccine prioritization criteria, based on risk assessment were needed. Our objective was therefore to identify the characteristics of individuals at the highest risk for mpox., Methods: This population-based cohort study included all Clalit Health Services (CHS) subjects assumed to be at risk for mpox. The eligibility criteria for inclusion were determined based on known characteristics of people with infection worldwide and insights of lesbian, gay, bisexual, transgender, queer+ (LGBTQ+) -specialized CHS clinicians. Cox hazards models were used to identify the risk factors for mpox within the study cohort. The study commenced on 6 June 2022, the date of the first known mpox in CHS members, until 31 July 2022, when the mpox vaccination campaign started., Results: A total of 8088 individuals of 4.7 million CHS members (0.18%) were identified according to the study inclusion criteria. Of those, 69 (0.85%) developed infection during the study period. Risk factors for mpox were birth in 1980 or later (hazard ratio, 5.04; 95% CI, 2.11-12.02), history of syphilis (2.62; 1.58-4.35), registration to primary healthcare clinics in the Tel Aviv district (2.82; 1.44-5.54), HIV-pre-exposure prophylaxis medication use (3.96; 2.14-7.31), PDE5 inhibitors use (2.92; 1.77-4.84), and recent sexually transmitted infections (STIs) within the last 18 months (2.27; 1.35-3.82). No infections were observed in individuals with none of the factors. Individuals with three or more risk factors had a 20.30-fold (10.39-39.69) higher risk for mpox compared with those with 0-2, with 85.5% (75.0-92.8%) sensitivity and 77.8% (76.9-78.7%) specificity., Discussion: Weighting individuals' risk levels based on validated risk factors against vaccine availability can assist health systems in the equitable prioritization of vaccine allocation in various future outbreaks, given supply-demand gaps., (Copyright © 2023 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Background: Previous studies have shown that more temporally regular primary care visits are associated with improved patient outcomes., Objective: To examine the association of temporal regularity (TR) of primary care with hospitalizations and mortality in patients with chronic illnesses. Also, to identify threshold values for TR for predicting outcomes., Design: Retrospective cohort study., Participants: We used data from the electronic health record of a health maintenance organization in Israel to study primary care visits of 70,095 patients age 40 + with one of three chronic conditions (diabetes mellitus, heart failure, chronic obstructive pulmonary disease)., Main Measures: We calculated TR for each patient during a two-year period (2016-2017), and divided patients into quintiles based on TR. Outcomes (hospitalization, death) were observed in 2018-2019. Covariates included the Bice-Boxerman continuity of care score, demographics, and comorbidities. We used multivariable logistic regression to examine TR's association with hospitalization and death, controlling for covariates., Key Results: Compared to patients receiving the most regular care, patients receiving less regular care had increased odds of hospitalization and mortality, with a dose-response curve observed across quintiles (p for linear trend < 0.001). For example, patients with the least regular care had an adjusted odds ratio of 1.40 for all-cause mortality, compared to patients with the most regular care. Analyses stratified by age, sex, ethnic group, area-level SES, and certain comorbid conditions did not show strong differential associations of TR across groups., Conclusions: We found an association between more temporally regular care in antecedent years and reduced hospitalization and mortality of patients with chronic illness in subsequent years, after controlling for covariates. There was no clear threshold value for temporal regularity; rather, more regular primary care appeared to be better across the entire range of the variable., (© 2023. The Author(s).)

Objectives: The aim of this study was to describe mothers' knowledge of infant fever management after birth and six months later and its association with sociodemographic characteristics, perceived support, sources of consultation and health education; and to assess determinants of change in mother's knowledge from birth to six months., Methods: Mothers (n = 2804) answered a self-reporting questionnaire after giving birth in maternity wards in six hospitals in Israel; six months later follow- up interviews were conducted by telephone., Results: The mothers' knowledge level of infant fever management was low after birth (mean = 50.5, range 0-100, SD = 16.1), and rose to a moderate level six months later (mean = 65.2, SD = 15.0). Mothers having their first born, with lower household income or education were less knowledgeable about infant fever management after birth. However, these mothers showed the largest improvement after six months. Mothers' perceived support or sources of consultation and health education (partner, family, friends, nurses, and physicians) were not associated with their knowledge at either time. Moreover, mothers stated self-learning from internet and other media as often as receiving health education by health professionals., Conclusions for Practice: Public health policy for health professionals in hospitals and community clinics is essential to promote clinical interventions promoting mothers' knowledge of infant fever management. Efforts should focus at first time mothers, those with non-academic education, and those with a moderate or low household income. Public health policy enhancing communication with mothers regarding fever management in hospitals and community health settings, as well as accessible means of self-learning is warranted., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The recent global outbreak of the monkeypox (mpox) virus in humans was declared a public health emergency by the World Health Organization in July 2022. The smallpox and mpox vaccine (JYNNEOS; Modified Vaccinia Ankara-Bavarian Nordic; MVA-BN), provided as a two-dose regimen, is currently the primary vaccine utilized against mpox. However, the efficacy of MVA-BN against mpox has never been demonstrated in clinical trials to date. Due to the limited supply of vaccines, the World Health Organization has recommended prioritizing the vaccination of high-risk groups. We evaluated the real-world effectiveness of a single, subcutaneous dose of MVA-BN in this observational, retrospective cohort study, which included the analysis of electronic health records of all members of Clalit Health Services eligible for the vaccine on 31 July 2022. We used a Cox proportional hazards regression model with time-dependent covariates to estimate the association between vaccination and mpox while adjusting for sociodemographic and clinical risk factors. In an analysis of 2,054 male individuals who met vaccine eligibility criteria, 1,037 (50%) were vaccinated during the study recruitment period and completed at least 90 d of follow-up. During the study period, 5 and 16 infections were confirmed in vaccinated and unvaccinated individuals, respectively. The adjusted vaccine effectiveness was estimated at 86% (95% confidence interval, 59-95%). Our results suggest that a single dose of subcutaneous MVA-BN in this high-risk cohort is associated with a significantly lower risk of MPXV infection., (© 2023. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Background: previous worldwide reports indicated a substantial short-term reduction in various respiratory infections during the early phase of the SARS-CoV-2 pandemic., Aims: exploring the long-term impact of the COVID-19 pandemic on respiratory pathogens., Methods: retrospective analysis of bacterial and viral positivity rate in respiratory samples, between 1 January 2017-30 June 2022 in a tertiary hospital in Jerusalem, Israel., Results: A decline in overall respiratory tests and positivity rate was observed in the first months of the pandemic. Respiratory isolations of Hemophilus influenza and Streptococcus pneumoniae were insignificantly affected and returned to their monthly average by November 2020, despite a parallel surge in COVID-19 activity, while Mycoplasma pneumoniae was almost eliminated from the respiratory pathogens scene. Each viral pathogen acted differently, with adenovirus affected only for few months. Human-metapneumovirus and respiratory-syncytial-virus had reduced activity for approximately a year, and influenza A virus resurged in November 2021 with the elimination of Influenza-B., Conclusions: After an immediate decline in non-SARS-CoV-2 respiratory infections, each pathogen has a different pattern during a 2-year follow-up. These patterns might be influenced by intrinsic factors of each pathogen and different risk reduction behaviors of the population. Since some of these measures will remain in the following years, we cannot predict the timing of return to pre-COVID-19 normalcy.

Objective: To compare the effect of propofol, alfaxalone and ketamine on intraocular pressure (IOP) in cats., Study Design: Prospective, masked, randomized clinical trial., Animals: A total of 43 ophthalmologically normal cats scheduled to undergo general anesthesia for various procedures., Methods: Following baseline IOP measurements using applanation tonometry, anesthesia was induced with propofol (n = 15), alfaxalone (n = 14) or ketamine (n = 14) administered intravenously to effect. Then, midazolam (0.3 mg kg -1 ) was administered intravenously and endotracheal intubation was performed without application of topical anesthesia. The IOP was measured following each intervention. Data was analyzed using one-way anova and repeated-measures mixed design with post hoc analysis. A p-value <0.05 was considered significant., Results: Mean ± standard error IOP at baseline was not different among groups (propofol, 18 ± 0.6; alfaxalone, 18 ± 0.7; ketamine, 17 ± 0.5 mmHg). Following induction of anesthesia, IOP increased significantly compared with baseline in the propofol (20 ± 0.7 mmHg), but not in the alfaxalone (19 ± 0.8 mmHg) or ketamine (16 ± 0.7 mmHg) groups. Midazolam administration resulted in significant decrease from the previous measurement in the alfaxalone group (16 ± 0.7 mmHg), but not in the propofol group (19 ± 0.7 mmHg) or the ketamine (16 ± 0.8 mmHg) group. A further decrease was measured after intubation in the alfaxalone group (15 ± 0.9 mmHg)., Conclusions and Clinical Relevance: Propofol should be used with caution in cats predisposed to perforation or glaucoma, as any increase in IOP should be avoided., (Copyright © 2022 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Background: antimicrobial resistance is a global problem in human and veterinary medicine. We aimed to investigate the extended spectrum β-lactamase-producing Enterobacterales (ESBL-PE) gut colonization in healthy community dogs in Israel., Methods: Rectal swabs were sampled from 145 healthy dogs, enriched, plated on selective plates, sub-cultured to obtain pure cultures, and ESBL production was confirmed. Bacterial species and antibiotic susceptibility profiles were identified. WGS was performed on all of the ESBL-PE isolates and their resistomes were identified in silico. Owners' questionnaires were collected for risk factor analysis., Results: ESBL-PE gut colonization rate was 6.2% ( n = 9/145, 95% CI 2.9-11.5). Overall, ten isolates were detected (one dog had two isolates); the main species was Escherichia coli (eight isolates), belonging to diverse phylogenetic groups-B1, A and C. Two isolates were identified as Citrobacter braakii , and C. portucalensis . A phylogenetic analysis indicated that all of the isolates were genetically unrelated and sporadic. The isolates possessed diverse ESBL genes and antibiotic-resistance gene content, suggesting independent ESBL spread. In a multivariable risk factor analysis, coprophagia was identified as a risk factor for ESBL-PE gut colonization ( p = 0.048, aOR = 4.408, 95% CI 1.014-19.169)., Conclusions: healthy community dogs may be colonized with ESBL-PE MDR strains, some of which were previously reported in humans, that carry wide and diverse resistomes and may serve as a possible source for AMR.

Objective: Newborns exhibit the lowest immediate respiratory morbidity rates when born at full term (39-40 completed weeks of gestation). We evaluated whether early-term deliveries (37 0/7 to 38 6/7 weeks of gestation) bear a substantial impact on overall and specific long-term respiratory outcomes of offspring up to the age of 18 years compared with full-term or later deliveries., Data Sources: We searched PubMed, Medline, Embase, and relevant reference lists from January 2012 to May 2020., Study Eligibility Criteria: This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews guidelines and was registered on International Prospective Register of Systematic Reviews. Any observational or randomized human trials addressing the association between early-term delivery and long-term respiratory outcomes in the offspring, restricted to studies published in English, were included. The search included terms relating to gestational age, pediatric morbidity, and respiratory outcomes. We included studies assessing long-term respiratory disease (1-18 years) of offspring born early term compared with offspring born full term and later., Methods: Here, 2 independent reviewers extracted data and assessed the risk of bias. Using a random-effect meta-analysis, pooled relative risk with their 95% confidence intervals and heterogeneity were determined. Publication bias was assessed using funnel plots with Egger regression line and contours, and sensitivity analyses were performed using Baujat plots., Results: Overall, 14 studies were included after screening nearly 2500 abstracts. These studies included nearly 8 million patients and were subjected to qualitative and quantitative analyses. Early-term delivery significantly increased the risk of total respiratory morbidity in the offspring (relative risk, 1.20; 95% confidence interval, 1.16-1.26) compared with full-term delivery. The increased respiratory morbidity was attributed to obstructive airway diseases (relative risk, 1.19; 95% confidence interval, 1.12-1.27) and infectious respiratory diseases (relative risk, 1.22; 95% confidence interval, 1.17-1.29). Most studies were of acceptable quality., Conclusion: This comprehensive meta-analysis suggested that early-term delivery poses a risk of long-term pediatric respiratory morbidity compared with full-term delivery. Other factors throughout the years cannot be accounted for. Our study has added an important perspective to be considered when balancing the fetal, maternal, and neonatal risks associated with delivery timing., (Copyright © 2022. Published by Elsevier Inc.)

We aimed to analyze rates and risk factors for carbapenemase-producing Enterobacterales (CPE) bloodstream infection (BSI) in CPE-colonized patients with malignancies or following hematopoietic cell transplantation. We retrospectively collected data on demography, underlying disease, colonizing CPE, treatment, intensive care unit (ICU) hospitalization, CPE-BSI, and mortality in CPE-colonized immunocompromised patients (2014-2020). Two hundred twenty-one patients were colonized with 272 CPE: 254 (93.4%) carried one carbapenemase [KPC (50.4%), NDM (34.6%), OXA-48-like (5.2%), and VIM (3.3%)]; 18 (6.6%) carried two carbapenemases. Twenty-eight (12.7%) patients developed CPE-BSI. Univariate analysis revealed CPE-BSI-associated factors: younger age, carbapenem or aminoglycoside exposure, ICU admission, neutropenia, carrying serine carbapenemase-producing, and specifically KPC-producing bacteria, colonization with several CPE, and detection of several carbapenemases. None of 23 auto-HSCT recipients developed CPE-BSI. In multivariate analysis, ICU hospitalization was significantly associated with CPE-BSI (odds ratio [OR] 2.82, 95% CI 1.10-7.20; p  = 0.042); solid tumor diagnosis was protective (OR 0.21, 95% CI 0.05-1.01; p  = 0.038). One-year crude mortality was 108/221 (48.8%), including 19/28 (67.9%) and 89/193 (46.1%) in patients with and without CPE-BSI, p  = 0.104. To conclude, CPE-BSI is rare in CPE-colonized patients with solid tumors and following auto-HSCT. ICU hospitalization increased CPE-BSI risk. These data can help to guide empirical anti-CPE antibiotic therapy in patients colonized with these bacteria.

Objectives: The maxillary nerve courses very close to the globe, rendering cats - with their large eyes - at risk of globe penetration during infraorbital or maxillary nerve blocks. Therefore, the goals of the study were to compare the distribution and potential complications of three infraorbital or maxillary regional injection techniques., Methods: Twenty-three bilateral maxillae of cat cadavers were used in a randomised blinded trial. Each maxilla was injected with a 0.2 ml 1:1 mixture of lidocaine 2% and a contrast medium by one of three injection techniques: infraorbital foramen (IOF; n = 14); infraorbital canal (IOC; n = 16); or maxillary foramen (MF; transpalpebral approach; n = 16) using a 25 G 1.6 cm needle. CT imaging of each cadaver head was performed before and after injections. A radiologist scored injectate distribution (none [0], mild [1], moderate [2], large [3]) in four locations: rostral, central and caudal IOC, and at the MF, for which the distribution side was also determined. Comparisons were performed with ordinal logistic mixed effects ( P <0.05)., Results: The median (range) total distribution score of the IOC and MF technique were significantly higher compared with the IOF technique (6.5 [4-12], 4 [2-8] and 0 [0-10], respectively). The total IOC score was also significantly higher compared with the MF technique. Injectate distribution at the MF was significantly more central following IOC injection compared with MF injection, which distributed centrolaterally. None of the techniques resulted in intraocular injection., Conclusions and Relevance: The IOC and MF techniques produced a satisfactory spread of the mixture that could result in effective maxillary anaesthesia in cats. Further studies are required to determine the effectiveness and safety of these techniques.

The aim of this study was to investigate the safety and pharmacokinetics of trimethoprim-sulphadiazine administered via intravenous regional limb perfusion (IVRLP) into the cephalic vein. According to the hypothesis, the drug could be administered without adverse effects and the synovial concentrations would remain above the minimum inhibitory concentration (MIC) for trimethoprim-sulphadiazine (0.5 and 9.5 µg/mL) for 24 h. Ten ( n = 10) horses underwent cephalic vein IVRLP with an Esmarch tourniquet applied for 30 min. Four grams (4 g) of trimethoprim-sulphadiazine (TMP-SDZ) were diluted at 0.9% NaCl for a total volume of 100 mL. Synovial fluid and blood samples were obtained immediately before IVRLP and at 0.25, 0.5, 2, 6, 12 and 24 h after the initiation of IVRLP. Trimethoprim and sulphadiazine concentrations were determined using a method based on liquid chromatography/tandem mass spectrometry. The C max (peak drug concentration) values were 36 ± 31.1 and 275.3 ± 214.4 µg/mL (TMP and SDZ). The respective t max (time to reach C max ) values were 20 ± 7.8 and 26.4 ± 7.2 min. The initial synovial fluid concentrations were high but decreased quickly. No horse had synovial concentrations of trimethoprim-sulphadiazine above the MIC at 12 h. Severe vasculitis and pain shortly after IVRLP, lasting up to one week post-injection, occurred in five out of 10 horses. In conclusion, IVRLP with trimethoprim-sulphadiazine cannot be recommended due to the low concentrations of synovial fluid over time and the frequent severe adverse effects causing pain and discomfort in treated horses. Thus, in cases of septic synovitis with bacteria sensitive to trimethoprim-sulphadiazine, other routes of administration should be considered.

Aim: To characterise the association between peripheral intravenous catheter (PIVC) gauge (G), the patient's age, insertion site and complication incidence., Methods: This prospective study was performed in Hadassah Medical Center, Jerusalem, Israel, between June 2018 and March 2019. Children with PIVC admitted to the paediatric departments were included. PIVCs were evaluated daily., Results: A total of 113 children with 132 PIVCs were included in the study. The most common site of insertion was the antecubital fossa (43.9%). PIVCs were most commonly used for intravenous (IV) antibiotics (46.6%). Complications were observed for 40.9% PIVCs. Dislodgement was the most common complication. The complication rate was higher for the lower limbs (60%) and external jugular veins (100%) p = 0.002. In infants younger than 12 months, the complication rate was higher for 22 G PIVCs or larger (58.7% versus 27.5%; p = 0.05). In contrast, for the 1-6 years age group, PIVCs smaller than 24 G had a higher complication rate (p = 0.004). Patients with comorbidities had a higher complication rate (p = 0.003)., Conclusion: Risk factors for complications are comorbidities and sites of insertion other than the upper limbs. In infants, 24 G PIVC or smaller should be inserted, whereas 22 G PIVC or larger are superior for 1- to 6-year-old children., (©2020 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background: We aimed to investigate the prevalence, molecular epidemiology and prevalence factors for Extended Spectrum β-Lactamase-producing Enterobacteriaceae (ESBL-E) shedding by race horses. A cross-sectional study was performed involving fecal samples collected from 169 Thoroughbred horses that were housed at a large racing facility in Ontario, Canada. Samples were enriched, plated on selective plates, sub-cultured to obtain pure cultures and ESBL production was confirmed. Bacterial species were identified and antibiotic susceptibility profiles were assessed. E. coli sequence types (ST) and ESBL genes were determined using multilocus sequence type (MLST) and sequencing. Whole genome sequencing was performed to isolates harboring CTX-M-1 gene. Medical records were reviewed and associations were investigated., Results: Adult horses (n = 169), originating from 16 different barns, were sampled. ESBL-E shedding rate was 12% (n = 21/169, 95% CI 8-18%); 22 ESBL-E isolates were molecularly studied (one horse had two isolates). The main species was E. coli (91%) and the major ESBL gene was CTX-M-1 (54.5%). Ten different E. coli STs were identified. Sixty-four percent of total isolates were defined as multi-drug resistant. ESBL-E shedding horses originated from 8/16 different barns; whereas 48% (10/21) of them originated from one specific barn. Overall, antibiotic treatment in the previous month was found as a prevalence factor for ESBL-E shedding (p = 0.016, prevalence OR = 27.72, 95% CI 1.845-416.555)., Conclusions: Our findings demonstrate the potential diverse reservoir of ESBL-E in Thoroughbred race horses. Multi-drug resistant bacteria should be further investigated to improve antibiotic treatment regimens and equine welfare.

Objective: This study aimed to assess area-level socioeconomic position (SEP) disparities in nutritional status, to determine whether disparities differed by sex and to assess whether nutritional status and disparities changed over time., Design: We used repeated cross-sectional data from a national programme that evaluates the quality of healthcare in Israel to assess children's nutritional status., Setting: The study included all Israeli residents aged 7 years during 2014-2018 (n=699 255)., Methods: SEP was measured based on the Central Bureau of Statistics' statistical areas, and grouped into categories, ranging from 1 (lowest) to 10 (highest). We used multivariable multinomial regression to assess the association between SEP and nutritional status and between year and nutritional status. We included interactions between year and SEP to assess whether disparities changed over time., Results: Children in SEP 1, comprised entirely of children from the Bedouin population from Southern Israel, had drastically higher odds of thinness compared with those in the highest SEP (Girls: OR 5.02, 99% CI 2.23 to 11.30; Boys: OR 2.03, 99% CI 1.19 to 3.48). Odds of obesity were highest in lower-middle SEPs (OR SEP 5 vs 10 1.84, 99% CI 1.34 to 2.54). Prevalence of overweight and obesity decreased between 2014 and 2018, normal weight increased and thinness did not change. SEP disparities in thinness decreased over time in boys but showed a reverse trend for girls. No substantial improvement was seen in SEP disparities for other weight categories., Conclusions: Our study demonstrates the need to consider initiatives to combat the considerable SEP disparities in both thinness and obesity., Competing Interests: Competing interests: YLW reports grants from Azrieli Foundation, during the conduct of the study., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Data on enterococcal bacteremia (EB) in immunocompromised children are scarce. We aimed to describe EB in children with hematologic malignancies (HM), solid tumors and/or following allogeneic hematopoietic stem cell transplantation (HSCT) and analyze their ampicillin and vancomycin resistance., Methods: We conducted an observational retrospective study in the tertiary-care Hadassah University Medical Center (2001-2015). We collected demographic, clinical and laboratory data on EB and compared ampicillin and vancomycin sensitive with resistant episodes., Results: Fifty-six of 1123 children developed 74 episodes of EB; 62.1% Enterococcus faecium, 36.5% Enterococcus faecalis; and 1.4% Enterococcus gallinarum. EB developed in 12.1% of HSCT patients, 5.1% of HM, 6.3% of neuroblastoma and 1.0% of other solid tumors patients. Of these episodes, 85.1% were nosocomial, and 71.6% developed while on antibiotic therapy. Resistance rates were: to ampicillin, 57.6%; to vancomycin (vancomycin-resistant enterococci), 21.6%; and higher rates among E. faecium. Among vancomycin-resistant enterococci, 1 of 16 was linezolid and 2 of 10 daptomycin resistant. Overall 7- and 30-day mortality rates were 2.7% and 5.4%, respectively. Thirty-day mortality was 18.2% in recurrent episodes and 0% in the first-time EB episodes (P = 0.006). In multivariate analysis, high treatment intensity was associated with ampicillin resistance [odds ratio (OR) = 3.18, 95% confidence interval (CI): 1.31-9.12], prior penicillin exposure (OR = 7.50, 95% CI: 1.41-39.81) and breakthrough on vancomycin (OR = 18.83, 95% CI: 3.31-101.14) with vancomycin resistance., Conclusions: EB occurs mainly as a nosocomial infection in children receiving high-intensity chemotherapy, especially in those with neuroblastoma, HM and following HSCT. Antibiotic resistance is common. Vancomycin resistance can occur regardless of previous vancomycin use. Prognosis in immunocompromised children with EB is better than previously reported. Recurrent EB is associated with increased mortality.

Food-animal welfare is a major ethical and social concern. Pork is the most consumed meat worldwide, with over a billion pigs slaughtered annually. Most of these pigs routinely undergo painful surgical procedures (surgical castration, tail docking, teeth clipping), which farmers often reluctant to avoid, claiming it would increase cost and reduce production efficiency. Herein, this study indicates that these procedures compromise pigs' health and condition. Replacing surgical castration with immunocastration, avoiding tail docking and teeth clipping, and providing environmental enrichment, resulted in significant increase in weight gain, lowered risks for injuries and death, and reduced saliva and hair cortisol, both biomarkers for stress. Testosterone and DHEA analyses confirmed that immunocastration was an effective alternative to surgical castration. Economic models for the entire US swine market revealed that following across-the-board acceptance of this management, pork meat price is expected to drop, while the total annual social welfare (combined consumer and producer surplus) is expected to increase by $US 1.48 to 1.92 billion. In conclusion, sustainable swine farming management can be beneficial for both animals and farmers. Applying such welfare-friendly management is expected to reduce stress, enhance piglet/pig welfare and production, and improve the economics of swine operations in the global agro-food system.

Extended spectrum beta-lactamases and AmpC-producing Enterobacteriaceae (ESBL/AmpC-E) have become a great concern in both human and veterinary medicine. One setting in which this risk could be particularly prominent is petting zoos, in which humans, especially children, directly and indirectly interact with the animals. Yet, while the zoonotic transmission of various Enterobacteriaceae has been reported previously in petting zoos, reports on ESBL/AmpC-E shedding in this setting is currently lacking, despite the high potential risk. To fill this knowledge gap, we conducted a prospective cross-sectional study to explore the prevalence, molecular epidemiology, and risk for shedding of ESBL/AmpC-E in petting zoos. We performed a prospective cross-sectional study in eight petting zoos. Altogether, we collected 381 fecal and body-surface samples from 228 animals, broth-enriched them, and then plated them onto CHROMagar ESBL-plates for ESBL/AmpC-E isolation. Next, we identified the isolated species and tested their susceptibility to various antibiotics using the Vitek-2 system, determined bacterial relatedness by multilocus sequence typing (MLST), and identified ESBL/AmpC genes by using PCR and sequencing. Finally, we asked petting zoo owners and veterinarians to complete questionnaires, which we then analyzed to evaluate risk factors for ESBL/AmpC-E shedding. We found that ESBL/AmpC-E shedding is an important, currently oversighted risk in petting zoos, as the overall shedding rate was 12% (35 isolates, including 29% ESBL-producers, 34% AmpC-producers, and 37% ESBL and AmpC-producers). The isolated bacteria included Enterobacter cloacae (55%), Escherichia coli (31%), and Citrobacter freundii (14%), with diverse ESBL genes. MLST revealed diverse sequence types (STs), including the highly virulent Enterotoxigenic ST656 and the Uropathogenic ST127 E. coli strains, indicating complex epidemiology with inter-animal bacterial transmission. Shedding was associated with petting permission and antibiotic treatment in the petting zoo (OR = 7.34), which were identified as risk factors for ESBL/AmpC shedding. Our findings highlight petting zoos as a source for antibiotic-resistant ESBL/AmpC-producing bacteria, including highly virulent, disease-associated MDR E. coli strains. As this risk has not been previously described in detail, it calls for the implementation of infection control and active surveillance programs in petting zoos and raises the need for a comprehensive guideline to restrain this emerging concern., (Copyright © 2019 Shnaiderman-Torban, Steinman, Meidan, Paitan, Abu Ahmad and Navon-Venezia.)

Objective: To evaluate the association of obstetric, maternal, and fetal variables with successful membrane sweeping and to develop a calculator that can predict spontaneous delivery within 24 hours of membrane sweeping., Methods: This secondary analysis of the STRIP-G Study included all singleton term parturients who underwent membrane sweeping in a tertiary center in October 2011 to July 2013. Primary end point was a 24-hour time interval from sweeping to delivery. Women who delivered without formal induction within the 24-hour interval were included in the "successful sweeping group". Stepwise logistic regression was used to calculate the adjusted odds ratio (aOR) for successful membrane sweeping and to create the calculator. The predictive power of the calculator was evaluated by area under the curve (AUC) of the receiver operating characteristic (ROC) curve and by Nagelkerke R-square. The model was validated by the Hosmer-Lemeshow test and by these validation measures: sensitivity, specificity, and positive and negative predictive value., Results: We analyzed data from 542 women. Parity (aOR = 1.66, 95% confidence interval [CI] 1.1-2.54), cervical dilation (aOR = 3.33, 95%CI 2.04-5.44), and gestational age (aOR = 1.44, 95%CI 1.21-1.72) were independent predictors of spontaneous delivery during the first 24 hours. A cross validation procedure showed that the calculator had a good accuracy (68%)., Conclusions: A simple calculator based on maternal age, parity, gestational age, cervical dilatation, effacement and station, can accurately predict the chances of delivery within 24 hours of membrane sweeping. This may assist physicians better counseling of women regarding the likelihood of successful membrane sweeping.

Aims: We sought to evaluate the extent of overall and second-line systemic antibiotic use in the Israeli community, to compare them to international data and to monitor temporal trends., Background: Antibiotic overuse is prevalent and has grave implications, primarily the emergence of resistant pathogens - an urgent public health concern worldwide., Methods: The Israel National Program for Quality Indicators in Community Healthcare (QICH) obtains data from electronic medical records from the 4 health-plans, covering the entire civilian population. We assessed 2 quality indicators, compatible with those of the OECD: 1. Overall volume of antibiotics for systemic use dispensed. 2. Volume of second-line antibiotics as a proportion of all systemic antibiotics. Analysis was stratified by gender, age and socio-economic position (SEP)., Results: The volume of systemic antibiotics dispensed in 2016 was 20.76 DDD/1000 person/day, with second-line antibiotics comprising 22.0% of the total. These values have been stable since 2014, and are higher compared with the OECD averages (20.61 DDD/1000 person/day, and 17.02% in 2015). Both overall volume and the proportion of second-line antibiotics rose with age and were higher among women especially in the 20-40 years age bracket (overall volume of 23.98 DDD/1000 person/day, proportion of second-line antibiotics of 23.98% VS 17.41 and 19.17% in men). Higher overall use was observed among patients of low SEP., Conclusions: The observed volume of systemic antibiotics and the proportion of second-line antibiotics dispensed in the Israeli community were stable and high. Higher use was observed among older individuals, women and patients of low SEP. Our results call for the implementation of a national-level, community-based antibiotic stewardship program. QICH might serve to monitor such a program.

Purpose:: To evaluate the outcome of second-line intravitreal ranibizumab treatment in eyes with diabetic macular edema having persistent edema following initial therapy with intravitreal bevacizumab., Methods:: Diabetic macular edema treated with ranibizumab following bevacizumab failure in Israel was a retrospective, multi-center study. Consecutive eyes with persistent diabetic macular edema following at least three previous intravitreal bevacizumab injections prior to intravitreal ranibizumab, at least three-monthly intravitreal ranibizumab injections and at least 12 months of follow-up were included. Data collected included demographics, ocular findings, diabetes control, details of intravitreal bevacizumab and ranibizumab injections, and visual and anatomical measurements before and after intravitreal ranibizumab treatment., Results:: In total, 202 eyes of 162 patients treated at 11 medical centers across Israel were included. Patients received a mean (±standard deviation) of 8.8 ± 4.9 intravitreal bevacizumab injections prior to the switch to intravitreal ranibizumab. A mean of 7.0 ± 2.7 intravitreal ranibizumab injections were given during the 12 months following the switch to intravitreal ranibizumab. The median central subfield retinal thickness (±interquartile range) by spectral-domain optical coherence tomography decreased from 436 ± 162 µm at baseline to 319 ± 113 µm at month 12 (p < 0.001). Median logMAR visual acuity (±interquartile range) improved from 0.40 ± 0.48 at baseline to 0.38 ± 0.40 at month 12 (p = 0.001). Linear regression suggested that higher number of intravitreal ranibizumab injections and higher pre-switch central subfield retinal thickness were associated with favorable visual outcome. Higher number of intravitreal bevacizumab injections and the presence of intraretinal fluid before the switch lessened the odds of favorable outcome., Conclusion:: Switching from bevacizumab to ranibizumab in persistent diabetic macular edema was associated with anatomical improvement in the majority of eyes and ⩾2 lines of vision improvement in 22% of eyes.

Aim: We surveyed whether clinicians used the WhatsApp messaging application to view neonatal chest radiographs and asked a sub-sample to compare them with computer screen viewings., Methods: The study was conducted at three university-affiliated medical centres in Israel from June-December 2016. Questionnaires on using smartphones for professional purposes were completed by 68/71 paediatric residents and 20/28 neonatologists. In addition, 11 neonatologists viewed 20 chest radiographs on a computer screen followed by a smartphone and 10 viewed the same radiographs in the opposite order, separated by a washout period of 2 months. After another 2 months, five from each group viewed the same radiographs on a computer screen. Different interpretations between viewing modes were assessed., Results: Most respondents used WhatsApp to send chest radiographs for consultation: 82% of the paediatric residents and 80% of the neonatologists. The mean number of inconsistencies in diagnosis was 3.7/20 between two computer views and 2.9/20 between computer and smartphone views (p = 0.88) and the disease severity means were 3.7/20 and 2.85/20, respectively (p = 0.94). Neonatologists using WhatsApp only determined umbilical line placement in 80% of cases., Conclusion: WhatsApp was reliable for preliminary interpretation of neonatal chest radiographs, but caution was needed when assessing umbilical lines., (©2018 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Objective: To evaluate tidal breathing (TB) flow-volume and flow-time curves for identification of expiratory airway obstruction in infants., Methods: Pulmonary function tests were analyzed retrospectively in 156 infants aged 3-24 months with persistent or recurrent respiratory complaints. Parameters derived from TB curves were compared to maximal expiratory flow at functional residual capacity ( V ˙ maxFRC) measured by rapid thoracoabdominal compression technique. Analyzed parameters were: inspiratory time (t I ), expiratory time (t E ), tidal volume, peak tidal expiratory flow (PTEF), time to peak tidal expiratory flow (t PTEF ), expiratory flow when 50% and 25% of tidal volume remains in the lungs (FEF 50 , FEF 25 , respectively), and the ratios t PTEF /t E , t I /t E , FEF 50 /PTEF, and FEF 25 /PTEF. Statistical comparisons between flow indices and TB parameters were performed using mean squared error and Pearson's sample correlation coefficient. The study population was also divided into two groups based on severity of expiratory obstruction (above or below z-score for V ˙ maxFRC of -2) to generate receiver operating characteristic (ROC) curves and calculate discriminatory values between the groups., Results: TB parameters that were best correlated to V ˙ maxFRC were: t PTEF /t E , FEF 50 /PTEF, and FEF 25 /PTEF, with r = 0.61, 0.67, 0.65, respectively (p < 0.0001 for all). ROC curves for FEF 50 /PTEF, FEF 25 /PTEF and t PTEF /t E showed areas under the curve of 0.813, 0.797, and 0.796, respectively. Cutoff value z-scores of -0.35, -0.34, and -0.43 for these three parameters, respectively, showed an 86% negative predictive value for severe airway obstructions., Conclusion: TB curves can assist in ruling out severe expiratory airway obstruction in infants.

In many countries sows are kept in individual stalls from insemination up to just few days prior to farrowing. The overall objective of this study was to examine group housing management system for sows during gestation as an alternative for individual confinement stalls, and the possible effects on their welfare, production and reproduction performances. Accordingly, the study included three specific objectives: (1) to compare parameters of production, reproduction, and welfare of sows housed in groups (either 30 or 7 sows/group; Large Group: LG, Small Group: SG, respectively) during gestation as compared to individual confinement stalls (IS); (2) to compare saliva cortisol of pregnant sows throughout gestation, when housed in groups of three different sizes (either 7, 15 or 30 sows per pen group); and (3) to compare sows' production and reproduction performances at the herd level, before, during and after practically transforming from a management of individual confinement stalls to a group housing system, in a large commercial swine farm over a six-year period. Mean cycle length (weaning-to-weaning) was shorter in group housing management as compared to individual stalls (P = 0.0110), but gestation length did not differ among the three groups. Overall farrowing rate (sows farrowed out of those inseminated) was higher (P ≤ 0.0134) for sows housed in groups (either SG or LG). Furthermore, there was a tendency towards a higher number of total born (P = 0.1033), and born alive piglets (P = 0.0862), in group housing system as compared to individual housing management; however, it did not differ between the LG and SG groups. Injuries and lameness index (ILI) of sows improved significantly over the gestation period in group housing management. Group saliva cortisol during gestation did not differ significantly among groups of 7, 15, or 30 sows, except on the first saliva sampling, just after sows were mixed into groups, where cortisol level was significantly higher in sows housed in a pen of 30 sows. Production and reproduction performances at the herd level, over a 6-years period- before, during and after transforming to a group housing system, improved significantly: shortened cycle length, increased farrowing rate, and increased number of total born and born alive piglets. In conclusion, group housing management during gestation was associated with better reproduction, productivity and welfare of sows, as compared to individual stalls. A welfare friendly housing system can be beneficial and effective for both the farmers and the animals., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Investigation of the optimal setting for body image prevention programmes is important to maximize the outcomes of such programmes., Objectives: We examined the preferred setting for a school-based wellness programme called "In Favour of Myself"., Methods: A total of 259 girls (mean 13.82±0.64 years) were divided into a girls-only intervention group, a mixed-gender intervention and a waiting list control group. The participants completed self-report questionnaires at baseline, post-intervention (2 months) and at follow-up (3 months) examining changes in self-esteem, media literacy, body image and risk factors for eating disorders. The intervention group participants also completed a satisfaction questionnaire., Results: Both intervention groups demonstrated statistically significant improvements in identifying advertising strategies (p<0.01) compared with the controls, with the girls-only arm (p<0.001) showing better results. Compared with the girls-only arm and the control group, the mixed-gender group demonstrated statistically significantly greater improvements in the internalization of pressure for thinness (p<0.004), the body-esteem appearance subscale (p<0.025) and body-esteem body-weight subscale (p<0.012) as well as reductions in their perceived current body silhouettes and in the gap between their current and ideal body image (p<0.003). Body dissatisfaction was increased following the programme, although not in a statistically significant manner, with the worst negative effect observed in the girls-only arm. All other differences among the study arms did not show statistically significant differences. Mediation models revealed that body-esteem was directly mediated by group, with statistically significant mediation only in the mixed group. Current body image was mediated indirectly by group through media literacy (i.e., recognizing advertisement strategies and internalization of pressure for thinness), with statistical significance only in the mixed-gender arm compared with the girls-only arm. Higher programme satisfaction was reported in the mixed-gender group (91%) vs. the girls-only groups (79%)., Conclusions: These outcomes provide preliminary evidence indicating the superiority of a mixed-gender setting compared with a girls-only setting for delivering prevention programmes to 13- to 14-year-old adolescents to enhance their media literacy, positive self-esteem and body image., Trial Registration: NCT02653586., Competing Interests: We have the following interests: The program was initiated and is sponsored by “The Dove Self Esteem Fund” and “Unilever Israel”. There are no patents, products in development or marketed products to declare. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.

Aim: The use of anaerobic blood cultures in infants suspected of bacteraemia is controversial. Our children's hospital uses both aerobic and anaerobic media, regardless of the risk of anaerobic infection, and the aim of this study was to re-evaluate the use of anaerobic cultures in infants., Methods: We collected retrospective data from 2002 to 2016 on all blood cultures taken from infants younger than 90 days in the Hadassah-Hebrew University Medical Centre, Jerusalem, Israel. The incidence and characteristics of infants with positive anaerobic blood cultures were assessed., Results: During the study period, 51 035 blood cultures were drawn from 44 304 infants. Of these, 1496 (2.9%) were clinically significant positive cultures. Pathogenic obligatory anaerobic bacteraemia was extremely rare, with only 37 positive cultures (0.07%) from all of the cultures drawn. No specific risk factors for obligatory anaerobic bacteraemia could be defined, but as many as 174 (11.6%) clinically significant isolates were only detected in the anaerobic culture bottle., Conclusion: True anaerobic bacteraemia was extremely rare in neonates. Nevertheless, using anaerobic culture media may increase the overall yield of bacterial culture growth by isolating anaerobic-facultative bacteria. This should be weighed up against increasing the volume of blood used for the aerobic culture., (©2018 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background: Anaerobic bacteremia is rare in children and current recommendations advocate against the routine use of anaerobic cultures in children. However, the incidence of anaerobic bacteremia and the utility of anaerobic blood cultures in children have not been assessed in recent years. Our pediatric emergency department (PED) policy still supports the use of both aerobic and anaerobic blood cultures in all cases of suspected bacteremia. This allowed us to re-evaluate the yield of anaerobic cultures in PED settings., Methods: Retrospective data of all blood cultures taken in the PED in a single tertiary center from 2002 to 2016 were collected. The incidence and characteristics of children with positive anaerobic blood cultures were assessed. Risk factors for anaerobic bacteremia were defined., Results: Of the 68,304 blood culture sets taken during the study period, 971 (1.42%) clinically significant positive cultures were found. Pathogenic obligatory anaerobic bacteria were isolated in 33 (0.05%) cultures. The leading risk factors for anaerobic bacteremia were head and neck abscess and intra-abdominal infection. Of all the true positive cultures, 187 (22%) were only detected in the anaerobic culture and would have otherwise been missed., Conclusions: True anaerobic bacteremia is extremely rare in children admitted to the PED. Nevertheless, using anaerobic cultures may increase the overall yield of blood cultures.

Background: The developing fetus is susceptible to environmental insults. Studying the effects of environmental exposures on fetal growth is essential for understanding the causal pathway between prenatal exposures and pregnancy outcomes. Here we describe the Haifa Pregnancy Cohort Study (HPCS) and discuss challenges and opportunities in applying "big data" paradigm., Methods: Maccabi Healthcare Services (MHS), is the second largest Israeli health maintenance organization (HMO) providing care services to two million beneficiaries. The HPCS cohort potentially includes ~750,000 newborns born between 1998 and 2017. We will estimate daily exposures to air pollutants, temperature and greenness, using satellite-based data and models. We hypothesize that residents of Haifa have higher exposures to environmental pollutants and that in pregnant women this higher exposure is associated with poorer fetal growth. We will evaluate outcomes such as birth-weight, head-circumference and gestational age at birth. We will adjust for pregnancy complications such as pre-eclampsia and gestational diabetes and parental variables, such as maternal weight, age and smoking habits as potential confounders. In addition, we will conduct a multi-tiered field study, nested within this population, among 150 pregnant women residing in two geographical regions-one in the polluted Haifa area, and one in a relatively unpolluted area in central Israel. Blood and urinary samples will be collected, as well as personal and indoor exposure to air pollution., Discussion: Evaluating environmental exposures of pregnant women and assessing in utero growth over the course of the pregnancy during different exposure windows, is of great scientific and public health interest. Recent advances in data collection and analysis pose great promise to provide insights into contribution of environment to the health of the developing fetus, but also pose major challenges and pitfalls, such as data management, proper statistical framework and integration of data in the population-based study and selectiveness in the nested field study. Yet the continuing follow-up of the study cohort, integrating data from different services, health-promotion, and eventually, application later in real life of our main promises. Our study aims to meet these challenges and to provide evidence of the environmental exposures associated with fetal growth.

Urban-dwelling Palestinians have been shown to have higher cardiovascular morbidity and mortality and prevalence of diabetes than urban Israelis. Inflammation is implicated in the etiology of these conditions. We hypothesized that increased inflammatory activation, manifested as increased GlycA, a novel biomarker of global inflammation, would be evident in Palestinians. We compared GlycA concentrations between Palestinians and Israelis and assessed the associations of GlycA with anthropometric, health behavioral and clinical variables in a sample of 1674 Palestinians and Israelis aged 25-74, residing in Jerusalem. The main outcome measure was GlycA concentration. GlycA was higher in Palestinians than Israelis (p<0.001). This finding persisted in young Palestinians with normal glucose tolerance. GlycA, total white blood cell count, the triglyceride to HDL-cholesterol ratio and small LDL-cholesterol particles were all significantly higher in Palestinians compared to Israelis across obesity and glucose tolerance categories. Palestinian women had greater GlycA compared to Israeli women and men of both ethnicities. GlycA as well as adverse cardiovascular biomarkers are all higher in Palestinian Arabs than Israeli Jews, even in young healthy adults. This propensity to inflammation may be a driver of the higher risk of cardiovascular disease, insulin resistance and diabetes observed in this population., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: We aimed to describe the online search trends of Zika and examine their association with Zika incidence, assess the content of Zika-related press releases issued by leading health authorities and examine the association between online trends and press release timing., Design: Using Google Trends, the 1 May 2015 to 30 May 2016 online trends of Zika and associated search terms were studied globally and in the five countries with the highest numbers of suspected cases. Correlations were then examined between online trends and Zika incidence in these countries. All Zika-related press releases issued by WHO/Pan America Health Organization (PAHO) and Centers for Disease Control and Prevention (CDC) during the study period were assessed for transparency, uncertainty and audience segmentation. Witte's Extended Parallel Process Model was applied to assess self-efficacy, response efficacy, susceptibility and severity. AutoRegressive Integrated Moving Average with an eXogenous predictor variable (ARIMAX) (p,d,q) regression modelling was used to quantify the association between online trends and the timing of press releases., Results: Globally, Zika online search trends were low until the beginning of 2016, when interest rose steeply. Strong correlations (r=0.748-0.922; p<0.001) were observed between online trends and the number of suspected Zika cases in four of the five countries studied. Compared with press releases issued by WHO/PAHO, CDC press releases were significantly more likely to provide contact details and links to other resources, include figures/graphs, be risk-advisory in nature and be more readable and briefer. ARIMAX modelling results indicate that online trends preceded by 1 week press releases by WHO (stationary-R 2 =0.345; p<0.001) and CDC (stationary-R 2 =0.318; p=0.014)., Conclusions: These results suggest that online trends can aid in pandemic surveillance. Identification of shortcomings in the content and timing of Zika press releases can help guide health communication efforts in the current pandemic and future public health emergencies., Competing Interests: Competing interests: This research was conducted in the framework of Gbenga Adebayo's International MPH thesis at the Hebrew University-Hadassah Braun School of Public Health and Community Medicine, under the guidance of Dr Hagai Levine and Professor Yehuda Neumark. His studies were supported by a Pears Foundation scholarship.