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To perform a systematic review of prospective clinical trials to determine whether improving vitamin D status improves asthma control.In cross sectional studies suboptimal viramin D status is often associated with poor asthma control. However, decreased 25-hydroxycholecalciferol (25 (OH) D) concentrations might not be causally associated with asthma control. We performed a systematic review until December 15, 2021 according to PRISMA guideline, searching MEDLINE, MEDLINE In-Process, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. Two searches were performed, the first using "vitamin D" and the second using "Vitamin D" or "ergocalciferol" or "cholecalciferol" and "Asthma". From 419 retrieved papers, after removal of duplicate and after using exclusion criteria, 28 full-text articles were eligible, of which 6 remained for quantitative analysis and 11 (9 studies) for qualitative analysis. From both analyses, prospective studies do not support that improving the vitamin D status of asthmatic children improves asthma control.

Background and aim Since 2014, the annual number of patients entering our emergency department (ED) has increased significantly. These were primarily Internal Medicine (IM) patients, and of these, 25–30% were admitted. The present governmental policy presents a deterrent to adding IM beds for these patients, and Emergency and IM departments cope with ever-increasing number of IM patients. We describe a quality improvement intervention to increase outflow of IM patients from the ED to the IM departments. Methods We conducted a quality improvement intervention at the Shaare Zedek Medical Center from 2014 to 2018. The first stage consisted of an effort to increase morning discharges from the IM departments. The second stage consisted of establishing a process to increase the number of admissions to the IM departments from the ED. Results Implementation of the first stage led to an increased morning discharge rate from a baseline of 2–4 to 18%. The second stage led to an immediate mean (± SD) morning transfer of 35 ± 7 patients to the medical departments (8–12 per department), providing significant relief for the ED. However, the additional workload for the IM departments’ medical and nursing staff led to a rapid decrease in morning discharges, returning to pre-intervention rates. Throughout the period of the new throughput intervention, morning admissions increased from 30 to > 70%, and were sustained. The number of patients in each department increased from 36 to 38 to a new steady state of 42–44, included constant hallway housing, and often midday peaks of 48–50 patients. Mean length of stay did not change. IM physician and nurse dissatisfaction led to increased number of patients being admitted during the evening and night hours and fewer during the morning. Conclusion We describe a quality improvement intervention to improve outflow of medical patients from the ED in the morning hours. The new ED practices had mixed effects. They led to less ED crowding in the morning hours but increased dissatisfaction among the IM department medical and nursing staff due to an increased number of admissions in a limited number of hours. The present governmental reimbursement policy needs to address hospital overcrowding as it relates to limited community healthcare beds and an aging population.

BACKGROUND: The transport of the inpatients to and from locations inside the hospital can vary in complexity depending on the patient location, status, and logistical needs. Most transport systems have not developed at the same speed as other medically related technologies. We conducted a pilot study of a new automated transport system for patients within the hospital. METHODS: Our innovative system was introduced in January 2020. We present a retrospective case review of all in-patient transport request during April 15, 2020 through May 30, 2020 at the Shaare Zedek Medical Center, Jerusalem, Israel. The system is fully automated and works via smartphone and electronic medical record integration. Transfer requests are processed on the basis of priority, proximity, and availably. RESULTS: During the study period there were 15, 581 transfer requests. Mean times to hospital destinations ranged from 9:25 to 28:02 minutes. Overall, mean times were quicker for emergency and surgical services. Trip times by priority code were likely influence by unmeasured confounders. There were no reported patient identification adverse events. Peak requests occurred during 0900-1500, and at the beginning of the week. CONCLUSION: Our automated in-patient transfer system appears to be efficient, safe, well received, and capable of servicing our large tertiary care medical center. Future controlled studies are needed to assess efficacy, adverse events, and clinical outcomes.

Purpose of review Systematic review looking for new evidence for recommendations for vitamin D supplementation in healthy infants based upon the most recent (4 years) available literature. Recent findings Randomized controlled trials published since 1 January 2017 that related to vitamin D doses in infancy were reviewed. They do not provide any additional evidence that larger, more generous amounts of daily vitamin D beyond the customary recommended 400 international units (IU) daily dose, affect any significant outcome. Larger amounts may lead to serum 25-hydroxyvitamin D [25(OH)D] concentrations that have been reported to be potentially associated with adverse effects, and a daily dose of 1200 IU may even harm in terms of increasing the risks of allergic sensitization. Summary There are still many unanswered questions left, in particular, whether or not more 'generous' amounts of vitamin D in infancy may improve long-term health outcomes such as prevention of adult osteoporosis, allergies, or cancer.

Background Reimbursement for cardiac surgical procedures in Israel is uniform and does not account for diversity in costs of various procedures or for diversity in patient mix. In an era of new and costly technology coupled with higher risk patients needing more complex surgery, these tariffs may not adequately reflect the true financial burden on the caregivers. In the present study we attempt to determine whether case mix and complexity of procedures significantly affect cost to justify differential tariffs. Methods We included all patients undergoing cardiac surgery at Shaare Zedek Medical Center between the years 1993–2016. Patients were stratified according to (1) type of surgery and (2) clinical profile as reflected by the predicted operative risk according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE). Approximate cost of each group of patients was estimated by the average number of days in the Intensive Care Unit and days in the postoperative ward multiplied by the respective daily costs as determined by the Ministry of Health. We then added the fixed cost of the components used in the operating room (manpower and disposables). The final estimated cost (the outcome variable) was then evaluated as it relates to type of surgery and clinical profile. ANOVA was used to analyze cost variability between groups, and backward regression analysis to determine the respective effect of the abovementioned variables on cost. Because of non-normal distribution, both costs and lengths of stay were Log-transformed. Results Altogether there were 5496 patients: 3863, 836, 685 and 112 in the isolated CABG, CABG + valve, 1 valve and 2 valves replacement groups. By ANOVA, the costs in all EuroSCORE subgroups were significantly different from each other, increasing with increased EuroSCORE subgroup. Cost was also significantly different among procedure groups, increasing from simple CABG to single valve surgery to CABG + valve surgery to 2-valve surgery. In backward stepwise multiple regression analysis, both type of procedure and EuroSCORE group significantly impacted cost. ICU stay and Ward stay were significantly but weakly related while EuroSCORE subgroup was highly predictive of both ICU stay and ward stay. Conclusions The cost of performing heart surgery today is directly influenced by both patient profile as well as type of surgery, both of which can be quantified. Modern day technology is costly yet has become mandatory. Thus reimbursement for heart surgery should be based on differential criteria, namely clinical risk profile as well as type of surgery. Our results suggest an urgent need for design and implementation of a differential tariff model in the Israeli reimbursement system. We suggest that a model using a fixed, average price according to the type of procedure costs, in addition to a variable hospitalization cost (ICU + ward) determined by the patient EuroSCORE or EuroSCORE subgroup should enable an equitable reimbursement to hospitals, based on their case mix.

BACKGROUND Quality assessment in health care is a process of planned activities whose ultimate goal is to achieve a continuous improvement of medical care through the evaluation of structure, process, and outcome measures. Physicians and health care specialists involved with quality issues are faced with an enormous and nearly always increasing amount of literature to read and integrate OBJECTIVE To test the hypothesis that the number of publications in the field of health care quality increases over time, and particularly the number of high-evidence journal articles such as randomized control trials, systematic reviews, and ultimately, practice guidelines. METHODS We used MEDLINE database to retrieve relevant articles published between during the 29 year-period between 1/1/1989 and 12/31/2018. The search was conducted in March 2021. Publications from 2019 and 2020 were excluded because of incomplete data. We used the keywords "quality care", "quality management", "quality indicators" and "quality improvement” and limited the search fields to title and abstract. RESULTS During the 29-year evaluation period there was a significant cubic increase in the number of publications both in total number of publications and in the variety of publication types studied The rate of increase varied for different types of publications, with the largest increase in reviews, and the smallest increase in case reports. There was a systematic stagnation or even decrease in the number of publications starting in 2015 regardless of publication type. CONCLUSIONS Over the past 29 years the field of quality in health care has seen a significant yearly increase of published original studies with a relative stagnation since 2015. We suggest that contributors to this dynamic field of research should focus on producing more evidence based publications and guidelines

Objectives The current study aims to assess different high-frequency (HF) band power calculations based on different frequency bandwidth values, and compare them with the time domain the root mean square of successive RR differences (RMSSD) value in preterm infants. Methods At week 32, electrocardiogram (ECG) and breathing rate (BR) were recorded for 24 h on 30 preterm infants born between 28 and 32 weeks. The recording held in the neonatal intensive care unit without any interruption of routine. Results The median 24 h BR was 40–78 breaths per minute. The RMSSD was highly and positively correlated with frequency bands that were based on each preterms BR range, or on a constant frequency with band limits of 0.4–2 Hz. Conclusions At week 32, HF band Hz limits should be calculated based on each child’s breathing rate, generally between 0.4 and 2 Hz.

Background The first case of COVID‐19 in Israel was reported on February 21, 2020. Shaare Zedek (SZ), a 1000‐bed tertiary care medical centre in Jerusalem, Israel, cared for a significant number of these patients. While attention focused on COVID‐19 patients, uninfected patients were admitted to decreasing numbers of available internal medicine (IM) beds as IM departments were converted to COVID‐19 isolation wards. As a result of the increase in COVID‐19 patients, closure of IM wards, re‐assignment of staff and dynamic changes in available community placement options, we investigated the impact of the outbreak on IM patient not admitted for COVID‐19. Methods We reviewed IM admissions during March 15‐April 30, 2020 for patients without COVID‐19. Characteristics assessed included number of admissions, age, length of stay, mortality rate, number of discharges, number discharged home and functional status of the patients. Data were compared with the previous 3 years (2017‐2019) during the same time period. Results During March 15‐April 30, 2020 there were 409 patients admitted to IM compared with a mean of 557 over the previous 3 years. Fewer patients were admitted to the ED and the IM wards during the outbreak. There was no significant difference between the two groups with regards to gender, in‐hospital mortality rate, number discharged, number discharged home and patient functional level. Patients admitted during the outbreak to IM were younger (74.85 vs 76.86 years) and had a mean shorter hospital length of stay (5.12 vs 7.63 days) compared with the previous 3 years. Conclusion While the characteristics of patients admitted to IM during the outbreak were similar, hospital length of stay was significantly shorter. Internal management processes, as well as patient preferences may have contributed to this observation. An infectious disease outbreak may have a significant effect on uninfected admitted patients.

Little is known about the perinatal aspects of COVID-19. To summarize available evidence and provide perinatologists/neonatologists with tools for managing their patients. Analysis of available literature on COVID-19 using Medline and Google scholar. From scant data: vertical transmission from maternal infection during the third trimester probably does not occur or likely it occurs very rarely. Consequences of COVID-19 infection among women during early pregnancy remain unknown. We cannot conclude if pregnancy is a risk factor for more severe disease in women with COVID-19. Little is known about disease severity in neonates, and from very few samples, the presence of SARS-CoV-2 has not been documented in human milk. Links to websites of organizations with updated COVID-19 information are provided. Infographics summarize an approach to the pregnant woman or neonate with suspected or confirmed COVID-19. As the pandemic continues, more data will be available that could lead to changes in current knowledge and recommendations.

Immigration studies can shed light on diabetes pathogenesis and risk factors. To this end, we investigated the association between age at immigration and diabetes occurrence at adolescence among immigrants to Israel. We analysed cross-sectional data on 2,721,767 Jewish adolescents assessed for mandatory military service at approximately 17 years of age between 1967 and 2014. The study population comprised 430,176 immigrants with origins in Ethiopia, former USSR, Middle East and North Africa (ME/NA) and western countries. ORs for diabetes were calculated for men and women, grouped according to age at immigration, with Israel-born participants as controls. Unadjusted and fully adjusted models were made to account for possible confounders. Additionally, the study population was stratified by origin and each immigrant group was referenced to Israel-born participants of the same origin. There was a graded decrease in OR for diabetes across the study groups in the fully adjusted model. Immigrants arriving at age 0–5 years had comparable OR for diabetes to the Israeli-born reference group; those arriving at age 6–11 years had an OR of 0.82 (95% CI 0.70, 0.97; p = 0.017) and recent immigrants, arriving at age 12–19 years, had the lowest OR of 0.65 (95% CI 0.54, 0.77; p

Medical clowns have an important role in helping patients cope with their pain and distress. This is especially true in the pediatric population. However, their activity in a disaster area is unheard of. Following the Nepal earthquake in 2015, the Israeli field hospital set up in Kathmandu, Nepal was joined by five volunteer medical clowns. They were active in all parts of the field hospital. Following the hospital's activity, an online questionnaire was sent to the field hospital members to assess the impact of medical clowning on the hospital in general and its members' individual performance. Physicians and nurses found that medical clowning had a positive impact both generally and personally. (65.4 and 78.3% respectively on general impact.) Personnel that were not previously exposed to medical clowning also found them to have a positive impact; however, they were less likely to view it as impacting their personal performance.Medical teams in disaster areas may benefit from the presence of medical clowns. What is known about this topic: • Medical clowns are used for alleviation and distraction in painful and distressful medical procedures and treatments. Its positive effect on patients, and their families are well established.• This is the first description of medical clowning in a disaster area. In addition, the impact of medical clowning on the medical staff working in a disaster area is evaluated. No previous studies have explored the impact of medical clowns on the medical staff.

A case of neonatal pyloric stenosis, presenting very early in life, accompanied by massive aspiration is described. We speculate that early intrauterine exposure to maternal azithromycin therapy was linked to the disease.

Rationale, aims and objectives Israel's healthcare system has been facing increasing hospital bed shortage over the last few decades. Community-based services and shortening length of stay have helped to ease this problem, but hospitals continue to suffer from serious overload and saturation. The objective of this study is to present hospitalization trends in Israel's internal medicine departments. Methods The data is based on the National Hospital Discharges database (NHDR) in the Israeli Health Ministry, pertaining to hospitalizations in all internal medicine departments nationwide between 2000 and 2012. Results Total yearly hospitalization days, representing healthcare burden, had increased by 4.2% during the study period, driven mainly by the most advanced age groups. The rate of total hospitalization days per 100,000 people for all the age groups has decreased by 17.6%, but the oldest patient group had a modest reduction in comparison (7.5%). The parameter of age correlated with length of stay and readmission rates, and neither decreased during the surveyed years. Conclusions These results demonstrated that the healthcare burden on acute internal medicine services has been reduced mostly for middle-aged populations but only modestly for elderly populations. The length of hospital stay and the readmission rates have reached and maintained a plateau in recent years, regardless of age. The findings of this study call for planning specific to elderly populations in light of changing demographics. Possible directions may include renewed emphasis on internal medicine and geriatric medicine, and efforts to shorten hospitalization time by extended utilization of multidisciplinary primary care.

Rare diseases are chronic, progressive genetic disorders, which affect around 6-8% of the general population, mainly children. Therefore, in Israel approximately 500,000 people are probably affected by a rare disease. In this article, we review some of the issues pertaining to rare diseases, such as the need for accurate diagnosis which is necessary not only for specific care and treatment but also for informed family planning. In addition, we review the impact of the activities of patients' organizations on the awareness of rare diseases and their involvement in the creation of the Orphan Drug Act, which was the leading point on the way to drug development worldwide. During the last few years networks for reaching leading specialists' opinions on the way to proper diagnosis were created. Thereafter, the next generation genetic technologies, such as exome sequencing, have been a revolution in terms of options and hope for patients with rare undiagnosed diseases. Patients with rare diseases and their families are a challenge to the health care system, not only in terms of diagnosis and therapy, but also in terms of special needs. In addition, deciphering molecular pathways of rare diseases might be the key for understanding molecular events involved in common disorders. We emphasize the duty to ensure appropriate capacity and equal access to follow-up and clinical management of patients with rare diseases in Israel.

The treatment of newborns in a disaster zone can be extremely challenging. The effects of the disaster combine with local health care disparity to give these neonates little chance of survival in the event of even minor complications. Rescue teams arriving at such locations must be prepared to handle and to aid these difficult situations using improvisation and ingenuity to overcome many of the unexpected hurdles. A discussion of the difficulties faced in the Philippines following a typhoon and recommendations for future teams are presented.MendlovicJ,AlbukrekD,DaganD,MerinO,WeiserG.Improvised neonatal care‒realizing the gaps in a disaster zone.Prehosp Disaster Med.2016;31(1):111–113.

In November 2013, super-typhoon Haiyan made several landfalls in the Philippines archipelago. It was one of the strongest cyclones ever recorded, with gusting winds and giant waves that left enormous damage in its wake: more than 6000 people were killed, almost 28 000 were injured and over four million lost their homes. Most basic infrastructure ceased to function, including electricity and water supplies, transportation and communication. Ten million Filipinos were affected overall. Following a formal aid request from the Filipino government, the Israeli Defense Forces (IDF) mobilised a medical response team to the island of Cebu, some 10 000 kms away. Because of the immense destruction, there were many casualties and only a few injured patients alive at the scene, making trauma care less a priority than ambulatory medical services for acute and chronic diseases. Of the 148 IDF mission participants, 56 were medical personnel. Others included logistics, support and rescue personnel from the IDF Home Front Command. Among 24 physicians, there were four paediatricians (including an emergency medicine specialist) and three paediatric nurses. Portable facilities included an imaging unit (portable digital X-ray and ultrasound machines), clinical laboratory (chemistry and haematology analyses, bacterial cultures and virology studies) and a fully supplied pharmacy. In coordination with the Filipino authorities, we reached our destination of Bogo city, in the northern part of the island of Cebu. We were the first medical task force and the only paediatric multidisciplinary team operating in the area, where most primary clinics were destroyed or closed. Unlike other paediatric field hospitals in disaster areas,1 ,2 we decided to create an integrated paediatric emergency unit (PEU), together with the staff of Bogo district hospital. This 80-bed urban hospital, staffed by four physicians (including one paediatrician) and 15 nurses, had already admitted more than 100 patients by the time of our arrival, despite having …

Procedural sedation and analgesia (PSA) should be a priority in the emergency care of injured children. This humanistic approach is particularly important in paediatric victims of disaster, because these patients are prone to psychological distress secondary to the traumatic event. Following the Nepal earthquake, an Israeli field hospital (IFH) was deployed in Kathmandu. We report our experience with PSA in the emergency room (ER) of the IFH. 22 children underwent surgery in the operating room and 10 underwent PSA in the ER by paediatric emergency physicians: 6 had wound debridement, 2 had fracture reduction and 2 had laceration repair. All the procedures were successfully completed in the ER and no patient required intubation or admission to the intensive care unit due to an adverse event. The present study is the first report of the practice of paediatric PSA by non-anaesthesiologists in a field hospital.

Background. Despite a gradual reduction in the workload during residency, 24-hour calls are still an integral part of most training programs. While sleep deprivation increases the risk propensity, the impact on medical risk taking has not been studied. Objective. This study aimed to assess the clinical decision making and psychomotor performance of pediatric residents following a limited nap time during a 24-hour call. Methods. A neurocognitive battery (IntegNeuro) and a medical decision questionnaire were completed by 44 pediatric residents at 2 time points: after a 24-hour call and following 3 nights with no calls (sleep ≥5 hours). To monitor sleep, residents wore actigraphs and completed sleep logs. Results. Nap time during the shift was

We present a case of a child with a suspected brain abscess treated by a military field hospital in post-typhoon Philippines. We review our intervention and decision process both at the field hospital and following his transfer to a referral center. These interventions were critical for his successful outcome.

Medical variations between geographical areas in Israel have been widely discussed in the last years, especially regarding accessibility to medical services in the periphery of the country. However, this is the first report that focusses on a selected set of hospital interventions and procedures. The interventions with the lowest variation across districts were hospital medical admissions, PTCA and surgery after hip fracture, while the highest variation was for knee arthroscopy, with a 4.5-fold variation between the districts with the lowest and the highest rate. Regarding cardiac revascularisation procedures, the trend over time in PTCA rates varied across districts, with PTCA rates increasing in some districts (the Northern and Southern districts) while decreasing in others. This trend is attributed to a vast investment in manpower and infrastructures in the periphery. More generally, one of the main findings of this report is that the Israeli periphery (the Northern district in particular) tends to have higher rates of hospital medical admissions and surgical activities for many of the procedures reviewed in this report. This phenomenon is not attributed to a specific policy and needs to be further investigated.

To describe and compare heart rate (HR) and heart rate variability (HRV) at rest, during active movements and passive standing among children with cerebral palsy (CP), with Gross Motor Function Classification System (GMFCS) levels IV and V, and to describe the association between daily physical activity and HRV.Thirty children with CP were included aged 6-12 years. HR and HRV parameters were recorded during rest, during Gross Motor Functional Measure (GMFM) assessment, during two minutes of repeated performance of the highest activity achieved in the GMFM, and during passive standing. Parents were asked to inform about any habitual physical activities their child participates outside school in the previous 4 months.Children with GMFCS IV increased their HR and reduced HRV values during the GMFM assessment, the repeated task and during passive standing, while no such effect was noted among children with GMFCS V. Children participated in a limited range of activities with a median frequency of three times a week (range 1-6 times), with insignificant differences between GMFCS levels. No significant differences were noted in HR or HRV parameters based on activity level.Only children with GMFCS IV responded to passive and active manipulation of the cardiac autonomic system. This may imply that the HR autonomic regulation system has an opportunity to be influenced by training in this group of children.

Background Major natural disasters adversely affect local medical services and resources. We sought to characterize pediatric patients presenting with otolaryngology-head and neck surgery (OTO-HNS)-related diseases/injuries to a field hospital over 11 days of operation, which was deployed to assist the healthcare facilities in Bogo, the Philippines, in the aftermath of typhoon Haiyan (Yolanda). Methods We reviewed charts of pediatric patients aged 0–18 years visiting our field hospital, who presented with OTO-HNS-related diseases/injuries. We also describe the structure of the field hospital, equipment, facilities and capabilities of our service, discuss medical and ethical concerns, and propose several recommendations for future similar missions. Results Of the 863 pediatric visits, 91 (11%) presented with OTO-HNS-related diseases/injuries, 3 of them were of recurring patients. Of the 88 included individual patients, 47 (53%) were boys, with an average age of 6.9 ± 4.9 years. Ear-related diseases, mostly acute otitis media (AOM), and neck-related diseases were the most common pathologies (49% and 16% of the patients, respectively). Antibiotic therapy was administered to 36 (41%) patients, mostly to children with AOM. Despite limited resources, we were able to perform surgical interventions on 8 (9%) patients, which included laceration suturing, abscess drainage and neck surgery. Conclusions Otolaryngologists have an important role in the treatment of children affected in a disaster area, at a time of an increased demand for healthcare. Unlike ‘acute phase’ missions, where traumatic injuries are the focus for treatment, ‘subacute’ phase missions provide more routine medical and surgical care.