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Noa Kvatinsky,1 Rivka Carmiel,2 Ronit Leiba,3 Itai Shavit1 1Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel; 2Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; 3Quality of Care Unit, Rambam Health Care Campus, Haifa, IsraelCorrespondence: Itai Shavit POB 274, Kibutz Maayan Tzvi, Haifa 3080500, IsraelTel +972-50-2063239Fax +972-4-777-4012Email itai@pem-database.orgBackground: Cast immobilization is the primary treatment for children with forearm fractures. After emergency department (ED) discharge, some patients develop cast-related pain (CstRP) around the distal part of the upper extremity. We examined variables associated with ED revisits due to CstRP in children with forearm fractures.Methods: A retrospective cohort study of all children who were treated with cast immobilization for forearm fracture over a 7-year period was conducted. Patient demographics, fracture location, casting method (below elbow/above elbow), first visit pain scores, treatment with fracture reduction, and revisit data were collected. Multivariate regression was used to identify predictors of revisits due to CstRP within 72 hrs post-discharge.Results: A total of 2307 children were treated with cast immobilization; 95 (4.2%) revisited the ED due to CstRP (median pain score 7, interquartile range 5–9). No patient had neurovascular compromise or required surgery or re-reduction. Fifty-eight (61.1%) patients were treated with cast splitting, 10 (10.5%) with trimming, and 27 (28.4%) with cast replacement. Variables on first visit that were associated with increased odds for ED revisit included treatment with fracture reduction (odds ratio [OR] 2.31; 95% confidence interval [CI] 1.58–3.36) and a median pain score of 6 or more upon ED presentation (OR 1.57; 95% CI 1.32–2.13).Discussion: A small number of children with forearm fractures revisited the ED due to CstRP. Study findings suggest that being treated with closed reduction and having a pain score ≥ 6 on the first visit were associated with ED revisit due to CstRP.Keywords: child, fracture, casting, pain

Gal Neuman,1,* Rana Swed Tobia,2,* Liron Koren,3 Ronit Leiba,4 Itai Shavit5 1Clinical Pharmacology and Toxicology Unit, 2Department of Pediatrics, Ruth Children’s Hospital, Rambam Health Care Campus, 3Rappaport Faculty of Medicine, Technion – Institute of Technology, 4Quality of Care Unit, 5Emergency Department, Ruth Children’s Hospital, Rambam Health Care Campus, Haifa, Israel *These authors contributed equally to this work Background: In the pediatric emergency department, patients are commonly treated with a single dose of oral midazolam for minor procedures. We sought to evaluate the effect of this treatment on procedure completion rates.Methods: We conducted a single-center retrospective cohort study of all patients who were treated with pre-procedure oral midazolam between January 2011 and June 2016. The primary outcome was the procedure completion rate.Results: During the study period, 1,504 patients were treated with oral midazolam as per department protocol; 1,467 received midazolam and 37 declined midazolam. Oral midazolam was used in 14 different types of emergency department procedures. The procedure completion rates in the treatment and non-treatment groups were 1,402/1,467 (95.6%) and 24/37 (64.8%), respectively (difference 30.7%; 95% confidence interval [CI] 17.3%–46.8%); p

Abstract Background A surgical site infection (SSI) is a postoperative infection that occurs at or near the surgical incision. SSIs significantly increase morbidity, mortality, length of hospital stay, and healthcare costs. The World Health Organization (WHO) has established hospital hygiene precaution guidelines for the prevention of SSIs, which were enhanced during the COVID-19 pandemic. The current study aims to explore the effect of the COVID-19 pandemic on SSI incidence among initially uninfected postoperative patients. We hypothesize that these enhanced precautions would reduce the incidence of SSIs. Materials and methods A retrospective study comparing surgical outcomes before and during the pandemic. Patients who had abdominal surgery between June and December 2019 (Non-COVID-19) or between February and June 2020 (COVID-19) were included. The two groups were matched in a 1:1 ratio based on age, Sex, acuity (elective or emergent), surgical approach, and comorbidities. Electronic medical records were reviewed to identify SSIs and hospital readmissions within 30 days after surgery. Pearson's chi-square test and Fisher's exact test were used. Results Data was collected and analyzed from 976 patients who had surgery before the COVID-19 pandemic (non-COVID group) and 377 patients who had surgery during the pandemic (COVID group). After matching, there were 377 patients in each group. In our study, we found 23 surgical site infections (SSIs) in both laparoscopic and open surgeries. The incidence of SSIs was significantly higher in the non-COVID period compared to the COVID period [17 cases (4.5%) vs. 6 cases (1.6%), respectively, p = 0.032], especially in non-COVID open surgeries. The incidence of SSIs in laparoscopic surgeries was also higher during the non-COVID period, but not statistically significant. Conclusions Enhanced hygiene precautions during the COVID -19 pandemic may have reduced SSIs rates following abdominal surgery.

We study the continuity of an abstract generalization of the maximum-entropy inference--a maximizer. It is defined as a right-inverse of a linear map restricted to a convex body which uniquely maximizes on each fiber of the linear map a continuous function on the convex body. Using convex geometry we prove, amongst others, the existence of discontinuities of the maximizer at limits of extremal points not being extremal points themselves and apply the result to quantum correlations. Further, we use numerical range methods in the case of quantum inference which refers to two observables. One result is a complete characterization of points of discontinuity for 3 3 matrices. [ABSTRACT FROM AUTHOR]

Background: Easy or unrestricted access to specialists improves patient satisfaction and quality of care. However, this may create an overuse of healthcare, induce a demand for costly services and interfere with the ability of the GPs to give comprehensive care. Objectives We evaluated these controversial aspects of easy accessibility to specialists: health services use, cost (money and time), and the attitude of GPs. Methods: On 1 March 2001, a specialist outreach clinic was established in a homefront military primary care clinic. Patients were referred by primary physicians to nearby specialists, but no further referral was required for continued specialty care. We followed this clinic prospectively for six months. We measured the use of general and specialty services, average monthly costs and loss of workdays by soldiers attending the clinics, and compared values before and after the introduction of the specialist outreach clinic. The same analysis was applied to a similar clinic which employs only GPs and refers soldiers to military specialist centres or to hospital outpatient clinics. Results: The incorporation of specialists did not result in a significant increase in the overall consumption of medical services (P > 0.05). It reduced the number of referrals out of the clinic to regional specialist centres (from 1449 to 421 referrals a month; P < 0.05), to outpatient hospital clinics (from 574 to 419 referrals a month; P < 0.05) and to emergency departments (from 302 to 205 referrals a month; P < 0.05). In the control clinic, referrals to distant specialist centres and to outpatient clinics showed a slight and non-significant increase. Loss of workdays was reduced from 2891 working days per month to 1938 days per month (P < 0.001). The total cost of all medical interactions and referrals did not significantly change after the introduction of the outreach specialist clinic (P > 0.05). Primary physicians graded their satisfaction with the newly established clinic as 4.5 (out of 5). Conclusion: Improving access to specialists by patients geographically and by removing the need for a referral for each specialist visit did not increase total healthcare use and cost. It significantly decreased loss of working days and received approval of the clinic's GPs. [ABSTRACT FROM AUTHOR]

COVID-19-related mortality among hematopoietic stem cell transplantation (HSCT) recipients in the pre-vaccine era ranged between 22 and 33%. The Pfizer/BioNTech BNT162b2 vaccine demonstrated significant immunogenicity and efficacy in the healthy population; however, its long-term effects on allogeneic HSCT recipients remained unclear. Our study longitudinally evaluated humoral and cellular responses to the BNT162b2 vaccine in adult allogeneic HSCT patients. A positive response was defined as antibody titers ≥ 150 AU/mL post-second vaccination. Among 77 included patients, 51 (66.2%) responded to vaccination. Response-associated factors were female gender, recent anti-CD20 therapy, and a longer interval between transplant and vaccination. Response rates reached 83.7% in patients vaccinated >12 months post-transplant. At 6 months post-second vaccination, antibody titers dropped, but were significantly increased with the booster dose. Moreover, 43% (6/14) of non-responders to the second vaccination acquired sufficient antibody titers after booster administration, resulting in an overall response rate of 79.5% for the entire cohort. The BNT162b2 vaccine was effective in allogeneic transplant recipients. Although antibody titers decreased with time, the third vaccination led to their significant elevation, with 93% of third-dose responders maintaining titers above 150 AU/mL at 3 months post-administration.

Introduction: The fourth SARS-CoV-2 vaccine dose was found to protect against infection and more importantly against severe disease and death. It was also shown that the risk of symptomatic or severe disease was related to the antibody levels after vaccination or infection, with lower protection against the BA.4 BA.5 Omicron variants. The aim of our study was to assess the impact of the fourth dose on infection and perception of illness seriousness among healthcare workers (HCWs) at a tertiary health care campus in Haifa, Israel, and to investigate the possible protective effect of antibody levels against infection., Methods: We conducted a prospective cohort study among fully vaccinated HCWs and retired employees at Rambam Healthcare Campus (RHCC), a tertiary hospital in northern Israel. Participants underwent serial serological tests at 1, 3, 6, 9, 12 and 18 months following the second BNT162b2 vaccine dose. Only a part of the participants chose to receive the fourth vaccine. A multivariable logistic regression was conducted to test the adjusted association between vaccination, and the risk of infection with SARS-CoV-2. Kaplan-Meier SARS-CoV-2 free "survival" analysis was conducted to compare the waning effect of the first and second, third and fourth vaccines. Receiver Operating Characteristic (ROC) curve was plotted for different values of the sixth serology to identify workers at risk for disease., Results: Disease occurrence was more frequent among females, people age 40-50 years old and those with background chronic lung disease. The fourth vaccine was found to have better protection against infection, compared to the third vaccine; however, it also had a faster waning immunity compared to the third vaccine dose. Antibody titer of 955 AU/mL was found as a cutoff protecting from infection., Conclusions: We found that the fourth vaccine dose had a protective effect, but shorter than the third vaccine dose. Cutoff point of 955 AU/mL was recognized for protection from illness. The decision to vaccinate the population with a booster dose should consider other factors, including the spread of disease at the point, chronic comorbidities and age, especially during shortage of vaccine supply.

Objectives: This study sought to correlate the SARS-CoV-2 IgG antibody response level to the BNT162b2 (Pfizer BioNTech) mRNA vaccine after the first and second doses with the reported adverse events., Methods: This cohort study examined the adverse events profiles of people vaccinated with BNT162b2 in our institute between late 2020 and May 2021. Adverse events, age, and sex were reported using an electronic questionnaire, and their SARS-CoV-2 IgG antibody levels were retrieved from the hospital database., Results: Between 20 December 2020 and 31 May 2021, the adverse events questionnaire was completed by 9700 individuals who received the first vaccine dose and 8321 who received the second dose. After the first and second doses, the average antibody levels were 62.34 AU/mL (mean 4-373) and 188.19 AU/mL (mean 20-392), respectively. All of the adverse events, except local pain, were more common after the second vaccine dose. Multivariate analysis showed that after the first vaccine dose, female sex and younger age (but not IgG titres) were associated with a higher probability of adverse events (OR 2.377, 95% CI, 1.607-3.515, p = 0.000; OR 0.959, 95% CI, 0.944-0.977, p £0.000; OR 1.002, 95% CI, 0.995-1.008, p £0.601; respectively); however, all three parameters were associated with the incidence of adverse events after the second dose (OR 2.332, 95% CI, 1.636-3.322, p = 0.000; OR 0.984, 95% CI, 0.970-0.999, p £0.039; OR 1.004, 95% CI, 1.001-1.007, p £0.022; respectively)., Discussion: Adverse events are significantly more common after the second BNT162b2 vaccine dose than after the first dose. We found an association between sex, age, and SARS-CoV-2 IgG antibody titre with the incidence of adverse events., (Copyright © 2022 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

This study assessed humoral response to the third BNT162b2 dose among healthcare workers (HCW). This prospective cohort study of HCW tested for anti-spike antibodies (LIAISON SARS-CoV-2 S1/S2 IgG assay) at 1, 3, 6, 9, and 12 months after receiving the second BNT162b2 vaccine dose (tests 1, 2, 3, 4, and 5, respectively). A third (booster) vaccination dose was introduced before test 4. Linear regression model was used to determine the humoral response following vaccine doses. For each serology test, changes in log-transformed antibody concentrations over time, adjusted for age, sex, underlying diseases, steroid treatment, and smoking were described using the general linear mix model. Serology tests were performed at 3, 6, 9, and 12 months after the second vaccine dose in 1113, 1058, 986, and 939 participants, respectively. The third dose was received by 964 participants before the 9-month tests, 797 of whom participated in the 9- and 12-month serology tests. A significant inverse correlation was noted between time from third dose and antibody concentrations (Spearman correlation −0.395; p < 0.001). Age (p < 0.0001; CI 95% −0.005−−0.004), heart disease (p < 0.0001; CI 95% −0.177−−0.052), immunodeficiency (p < 0.0001; CI 95% 0.251−−0.106), and smoking (p < 0.0001; CI 95% −0.122−−0.040) were significantly associated with decreased antibody concentrations. Female sex (p = 0.03; CI 95% 0.013−0.066) was associated with increased antibody concentrations. The third booster dose had a better effect on immunogenicity, with higher antibody concentrations among tested HCW. Heart disease, smoking, and other known risk factors were associated with decreased antibody concentrations.

Remission assessment in acute myeloid leukemia has evolved over the recent years with the advent of molecular and flow-based minimal residual disease determination. Nonetheless, early time point such as day 5 and day 14 (D14), still have prognostic and therapeutic implications. D14 refractory disease is regarded as a poor prognostic factor, however the therapeutic intervention is still under debate, with evidence suggesting a successful re-induction might offer similar long-term outcome as D14 aplasia. Others advocate the use of more intensive salvage protocols as a mean to overcome the negative prognostic effect. In the current study, we compare outcome of D14 refractory AML patients treated with either re-induction or salvage protocol. More importantly, we identify response characteristics that might suggest which patients will benefit from re-induction approach. Accurate identification of chemotherapy refractory patients might allow the early incorporation of non-chemotherapy based protocols in the future., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: The effectiveness and safety of colonoscopy are directly dependent on the quality of bowel preparation. Multiple risk factors for inadequate bowel preparation (IBP) have been identified; however, IBP is still reported in 20-30% of cases in most studies. We aimed to identify modifiable predictors of the adequacy of bowel preparation using sodium picosulfate, and to recommend easily modifiable parameters to increase the success rate of colonoscopies., Methods: This was a single-center observational study of adult outpatients referred for an elective colonoscopy. Patients were interviewed prior to colonoscopy; volume of liquids consumed was calculated as number of 200-mL cups showed to the patient. Additional information, including medical history, diagnoses and regular medications, was procured from patients' medical records. Univariate and multivariate regression analyses were performed to identify factors significantly associated with IBP in a subgroup analysis of high-risk patients., Results: The rate of IBP in 1172 subjects was 19.4%. This rate decreased as fluid consumption increased, with a further drop associated with shorter intervals from end of preparation to colonoscopy. Drinking < 1.4 L significantly increased the risk of IBP (odds ratio [OR] 3.62, 95% confidence interval [CI] 2.65-4.95), while drinking ≥2 L was associated with adequate preparation (OR 0.09, 95%CI 0-0.42). These associations were stronger in high-risk individuals., Conclusion: Greater fluid intake and short interval to colonoscopy are easily modifiable parameters that can substantially reduce the rate of IBP, especially among high-risk individuals., Competing Interests: Conflict of Interest: Elizabeth Half is a recipient of a research grant from Ferring Pharmaceuticals. All other authors report no financial or other conflicts of interest, (Copyright: © Hellenic Society of Gastroenterology.)

Objectives: Midostaurin, a multikinase and FLT3 inhibitor, is the first non-chemotherapy agent approved and widely adopted for the treatment of FLT3-ITD acute myeloid leukemia (AML). Yet, its role in improving survival of patients referred to allogeneic stem cell transplantation (allo-SCT) in first complete remission (CR1) needs to be defined., Methods: This multicenter study retrospectively evaluated the outcome of 119 FLT3-ITD AML patients [59 (49.6%) males and 60 females] intensively treated between 2015 and 2019 at five Israeli centers. In our cohort, allo-SCT in CR1 was widely implemented (47%) and patient stratification was based on the current allelic ratio (AR) cutoff of 0.5., Results: Ninety-eight patients (82.3%) achieved CR1/CR with incomplete count recovery (CRi). Death during induction was reported in 7 (5.9%) patients. In multivariate analysis, midostaurin use and allo-SCT in CR1 were the most significant factors affecting overall survival (OS). Midostaurin incorporation in chemotherapy regimens significantly improved CR + CRi rates (P = .002), reduced relapse rates (P = .02), and was remarkably advantageous for high-AR patients (2-year OS 82%). In low-AR patients, the midostaurin effect was much less prominent., Conclusions: Our results demonstrate benefits of midostaurin incorporation in intensive chemotherapy regimens, particularly for high-AR AML patients to whom it should be offered along with allo-SCT in CR1., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: Triage nurse-initiated analgesia (TNIA) has been shown to be associated with decreased time to the provision of analgesia and improved patient satisfaction. We examined variables that influence the provision of analgesia in a pediatric emergency department that uses TNIA., Methods: A 4-year retrospective cohort study of all children with triage pain scores ≥1 was conducted. Data on demographics and patients' and nurses' characteristics were collected. Logistic regression analyses were used to examine the effect of multiple variables on the provision of any analgesia and opioid analgesia., Results: Overall, 28,746 children had triage pain scores ≥1; 14,443 (50.2%) patients received analgesia of any type and 1888 (6.6%) received opioid analgesia. Mean time to any analgesia was 8.0±3.7 minutes. Of the 9415 patients with severe pain, 1857 (19.7%) received opioid analgesia. Age, sex, hourly number of patients waiting to be triaged, and nurse experience were not associated with the provision of any analgesia or opioid analgesia. Severe pain had the highest odds ratios (ORs) for the provision of any analgesia and opioid analgesia (7.7; 95% confidence interval [CI]: 7.1-8.2 and 22.8; 95% CI: 18.1-28.8, respectively). Traumatic injury and time-to-triage <8 minutes were associated with the provision of opioid analgesia (OR: 4.7; 95% CI: 4.2-5.2 and OR: 1.6; 95% CI: 1.5-1.8, respectively)., Discussion: TNIA yielded a short time to analgesia, but rates of any analgesia and opioid analgesia were low. Several variables associated with the provision of any analgesia and opioid analgesia were identified. Our findings provide evidence to guide future educational programs in this area.

Introduction: Despite advances in medical knowledge, the treatment of viral bronchiolitis is mainly supportive. Antiviral therapies are being investigated in clinical trials. Identifying population-attributable risk factors for RSV hospitalization may help prioritizing targeted treatment., Aim: To utilize MDClone, a data acquisition tool, to examine factors associated with the risk of hospitalization and length of stay (LOS) in bronchiolitis., Methods: A single tertiary medical center retrospective study. Infants discharged with a diagnosis of bronchiolitis between January 2001 and March 2019 were included. Demographic, clinical, laboratory, microbiologic parameters and co-morbidities were collected. Correlations with the risk of hospitalization and LOS were examined., Results: A total of 4793 infants with bronchiolitis, 3851 (80.3%) previously healthy, were seen; 975 visited emergency room only; 3311 were hospitalized in pediatric wards and 507 required pediatric intensive care unit. O 2 saturation, age and fever correlated with the risk of hospitalization (OR = 0.703, p < 0.0001, OR = 0.4, p = 0.024 and OR = 2.388, p < 0.0001, respectively). Saturation, fever, gestational age and birth weight correlated with LOS (r = -0.283, p = 0.000; r = 0.16, p = 0.000; r = -0.12, p = 0.00; and r = -0.117, p = 0.00, respectively). Rates of hospitalization were higher (81.1% vs. 75.6%, p = 0.0008) and LOS was longer (median 2.97 vs. 2.73 days, p < 0.001) in Arabs than in Jews. In a multivariate model, saturation, fever, gestational age and age predicted LOS. Saturation and ethnicity predicted LOS for previously healthy infants. Prematurity and cardiac anomalies increased LOS (p = 0.016 and p < 0.0001, respectively)., Conclusions: Population-based data may enable predicting disease severity and LOS in bronchiolitis. Focusing on children at greatest risk may aid targeting new therapies., 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 © 2019 Elsevier Ltd. All rights reserved.)

Relative fat mass (RFM) had been recently developed. We aimed to examine RFM predictability to various cardiometabolic risk factors, compared to BMI., Methods: Observational, cohort study, among patients who visited the Rambam Periodic Examinations Institute (RPEI). We compared the correlation of BMI and RFM to hypertension, impaired fasting glucose, high LDL, low HDL and metabolic syndrome, by gender., Results: During study years, 20 167 patients visited the RPEI and included in the trial. Compared to BMI, RFM showed significantly better predictability (odds ratio [OR], [95% confidence interval (CI), P value]) of high LDL [1.618 (1.441-1.816, P < 0.001) vs. 0.732 (0.67-0.8, P < 0.001) in men; 1.572 (1.377-1.794, P < 0.001) vs. 0.938 (0.849-1.163, P = 0.94) in women], low HDL [2.944 (2.569-3.373, P < 0.001) vs. 2.177 (2-2.369, P < 0.001) in men, 2.947 (2.519-3.448, P < 0.001) vs. 1.9 (1.658-2.176, P < 0.001) in women], high triglycerides [4.019 (3.332-4.847, P < 0.001) vs. 1.994 (1.823-2.181, P < 0.001) in men, 3.93 (2.943-5.247, P < 0.001) vs. 2.24 (1.887-2.62, P < 0.001) in women] and metabolic syndrome [7.479, (4.876-11.47, P < 0.001) vs. 3.263 (2.944-3.616, P < 0.001) in men, 16.247 (8.348-31.619, P < 0.001) vs. 5.995 (5.099-7.048, P < 0.001) in women]. There was no significant difference in the predictability of BMI and RFM to hypertension and diabetes mellitus., Conclusion: RFM provides high predictability for dyslipidemias and metabolic syndrome., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

The current study evaluated the prognostic significance of the monoallelic deletion of the whole locus of the immunoglobulin heavy-chain (w&#95;del(IGH)) gene compared to translocations t(4;14) and t(14;16) among newly diagnosed multiple myeloma (MM) patients. We retrospectively analyzed clinical (age, gender, and staging) and laboratory data at diagnosis and the overall survival (OS) of 255 newly diagnosed MM patients carrying w&#95;del(IGH) or translocations t(4;14) or t(14;16). Bone marrow samples were examined by morphological and sequential interphase fluorescense in situ hybridization analyses. Among 255 patients, 117 (45.8%) had w&#95;del(IGH), 99 (38.8%) had t(4;14), and 39 (15.3%) had t(14;16). Mean age was 61.6 ± 11.6 years. Groups did not differ significantly in age, gender, or lactate dehydrogenase levels. Patients in the w&#95;del(IGH) group presented more frequently at International Staging System stage I than at stage II/III. Patients in the w&#95;del(IGH) group had significantly fewer additional chromosomal aberrations (1.58) than the other two groups (2.3 and 2.13 in the del(IGH), t(14;16) and t(4;14) groups, respectively, P < 0.0001). Furthermore, the w&#95;del(IGH) group had significantly longer estimated median OS (9.47 years) compared to those with translocations t(14;16) (3.02 years, P = 0.002) or t(4;14) (4.18 years, P = 0.001), respectively. These findings suggest a potential prognostic significance of monoallelic deletion of IGH among these patients. Additional studies are needed to better understand the nature and mechanism of this prognostic factor., (© 2019 Wiley Periodicals, Inc.)

The aim of the study was to assess whether body mass index (BMI) can be used as a simple and reliable survey test for metabolic syndrome.The study is an observational cohort study among patients who visited the Rambam Periodic Examinations Institute (RPEI). We analyzed the correlation between obesity indices and presence of metabolic syndrome. We identified the ideal value of BMI for identification of patients at risk for metabolic syndrome. We also described the correlation between different BMI values and its negative predictive value (NPV) for metabolic syndrome.During the study years, 23,993 patients visited the RPEI, and 12.5% of them fulfilled the criteria for metabolic syndrome. Women with metabolic syndrome had higher proportion of obesity, when compared with men (89.9% vs 52.6%; P < .0001). Normal BMI had very high NPV to rule out metabolic syndrome among men and women (98% and 96%, respectively). Using receiver-operating characteristic curve, we found BMI 27 to be the ideal value for identification of metabolic syndrome for the entire cohort (area under the curve [AUC] 0.767, 95% confidence interval [CI] 0.758-0.775, P < .0001), for men (AUC 0.726, 95% CI 0.715-0.738, P < .0001), and for women (AUC 0.843, 95% CI 0.831-0.855, P < .0001). BMI below 30 provided NPV of 91.1% to rule out metabolic syndrome.The BMI as single survey measurement of obesity offers high NPV for metabolic syndrome and can be used by physician and patients for this purpose.

Background: Despite enormous differences between acute and chronic pain, the numeric pain scale (NRS) is commonly used in pain research and clinical practice for assessing the intensity of both acute and chronic pain. The use of this scale has been challenged as it may fail to accurately reflect the pure intensity of chronic pain., Aim: To compare the effect of anchoring the NRS on the intensity of pain reported by patients with acute vs. chronic pain., Methods: Patients with acute postoperative or chronic pain (n = 100/group) were requested to rate their: current clinical pain intensity on an NRS from 0 to 100; the intensity of an anchoring pain event on the same scale; and subsequently to rate again their current pain intensity while making reference to the reported intensity of the pain event. The magnitude of correction was compared between the 2 groups., Results: The anchoring pain was rated identically between the groups. However, following anchoring, patients with chronic pain made a significantly larger correction of their pain intensity than did those with acute pain (mean ± standard deviation = 9 ± 9, median [interquartile range] = 10 [0 to 10] vs. 3 ± 7, 0 [0 to 5], respectively; P < 0.0001). More patients in the chronic pain group corrected their pain intensity. Logistic regression showed that chronic pain and female gender significantly increased the likelihood of making the correction (chronic pain: odds ratio 7.2, 95% confidence interval 3.5 to 15.1, P < 0.0001; female gender: odds ratio 2.8, 95% confidence interval 1.4 to 5.5, P < 0.0001)., Conclusion: The results suggest that anchoring the NRS can potentially improve the accuracy of reported chronic pain intensity., (© 2018 World Institute of Pain.)

Heart rate variability (HRV) reflects cardiac and autonomic nervous system activity. It is usually measured over a relatively prolonged period and presented using multiple parameters. Here, we studied rapid HRV changes during airway obstruction using a short (1 min) sampling window. Forty healthy volunteers underwent a trial of obstructed breathing. Heart rate was recorded during three consecutive sets comprised of 1-min control followed by 1 min of obstructed breathing, with 1 min of rest between sets. Time and frequency domain analysis were used to compare HRV during control versus obstructed breathing. Compared with control, HRV intensely increased during obstructed breathing: R-R intervals (time between consecutive R waves) standard deviation increased from 65 to 108 msec (P < 0.0001), root mean square of successive R-R interval from 61 to 82 msec (P = 0.001), number of pairs of successive R-R intervals that differ by more than 50 msec (NN50) from 16.5 to 25.3 events (P < 0.0001), and proportion of NN50 divided by total number of R-R intervals from 26.6 to 35.1% (P = 0.001). Low frequency power increased by more than fourfold (P < 0.0001), allowing 90% sensitivity and 75% specificity for identifying airway obstruction (ROC area 0.88, P < 0.0001). We observed a rapid intense increase in HRV during obstructed breathing, significant enough to detect during a short 1-min sampling window. These findings suggest that HRV may be useful for rapid detection of airway obstruction, especially in situations where end-tidal CO 2 monitoring is not optimal, such as during partial airway obstruction., (© 2019 The Authors. Physiological Reports published by Wiley Periodicals, Inc. on behalf of The Physiological Society and the American Physiological Society.)

Objective: In 2015, the Israeli Ministry of Health issued national guidelines demanding the use of a five-level triage system in pediatric emergency departments (EDs). The present study aimed to evaluate the validity of the Pediatric Canadian Triage Acuity Scale (PedCTAS) in the ED of a tertiary children's hospital in Israel., Methods: A retrospective cohort study of all patients admitted between January 2011 and December 2015 was carried out. The proportion of hospitalization was the primary outcome measure. The secondary outcomes were proportion of admissions to the ICU, proportions of patients who left without being seen (LWBS), and length of stay (LOS) in the ED., Results: A total of 83 609 patients were included in our analysis. Triage levels 1-5 included 533 (0.6%), 4428 (5.3%), 46 461 (55.6%), 28 510 (34.1%), and 3677 (4.4%) patients, respectively. Hospitalization proportions were 70, 51, 28, 15, and 12% for triage levels 1, 2, 3, 4, and 5, respectively. Admission proportions to ICU were 24.2, 3.05, 0.24, 0.05, and 0.05% for PedCTAS levels 1, 2, 3, 4, and 5, respectively. The proportions of LWBS were 0.001, 0.002, and 0.005% for triage levels 3, 4, and 5, respectively. LOS was shorter as the triage level increased from 2 to 5., Conclusion: Triage level was predictive of hospitalization, admission to the ICU, and proportions of LWBS and LOS in the ED. The findings suggest validity of the PedCTAS in this cohort. This is the first report of the performance of a triage tool in an Israeli ED.

Background: The identification of the etiology of a pleural effusion can be difficult. Measurement of serum B-type natriuretic peptide (BNP) levels is helpful in the diagnosis of congestive heart failure (CHF) as a cause of respiratory failure, but pleural fluid BNP measurement is still not part of the workup for pleural effusion., Objectives: To identify the correlation between pleural fluid BNP levels and clinical diagnosis., Methods: In this cross-sectional study, data from 107 patients admitted to the department of internal medicine between November 2009 and January 2015 were obtained from medical records. Patients underwent a diagnostic thoracocentesis as part of their evaluation. They were grouped according to final diagnosis at discharge and clinical judgment of the attending physician., Results: Serum BNP levels were significantly higher in the CHF patients compared to patients with non-cardiac causes of pleural effusion (1519.2 and 314.1 respectively, P < 0.0001). Mean pleural fluid BNP was also significantly higher in the CHF patients (1063.2 vs. 208.3, P < 0.0001). Optional cutoff points to distinguish between cardiac and non-cardiac etiology of pleural effusion were 273.4 pg/ml (sensitivity 83.3%, specificity 72.3%, accuracy 76.7%) or 400 pg/ml (sensitivity 78.6%, specificity 86.2%, accuracy 83.0%). A strong correlation was found between serum BNP and pleural fluid BNP levels., Conclusions: High levels of serum BNP in patients presenting with pleural effusion suggest CHF. In cases with doubt regarding the etiology of pleural effusion, high levels of pleural fluid BNP can support the diagnosis, but are not superior to serum BNP levels.

Objective: Emergency department (ED) visits due to concussion have increased over recent years. We aimed to identify variables associated with unscheduled adolescents return to the ED., Methods: A retrospective cohort study was conducted. All children aged 11 to 18 years who were admitted to the ED due to concussion between 2011 and 2016 were included. Multivariable logistic regression was performed to identify predictors of ED return., Results: Overall, 616 adolescents were admitted to the ED due to concussion. Within the first week from discharge, 37/616 (6%) patients returned unscheduled to the ED, 21 (3.4%) during the first 48 hours and 16 (2.6%) during the following 3-7 days. Age, gender, ethnicity, diagnosis of concussion on first visit and length-of-stay in the ED were not associated with unscheduled ED returns. Variables that were independently associated with increased odds for an unscheduled ED return included two or more symptoms of concussion [odds ratio (OR): 2.81; 95% confidence interval (CI): (1.16-6.82)], bicycle or motor vehicle accident (OR: 3.48; 95% CI: 1.29-9.4), and performance of CT scan on first visit (OR: 2.47; 95% CI: 1.12-5.48)., Conclusions: The findings suggest that certain variables on the first ED visit can predict an unscheduled return visit in adolescents., Abbreviations: Emergency department (ED); Length of stay (LOS); computerised tomography (CT).

Background: The purpose of this study was to assess ethnic differences in Emergency Department (ED) waiting times between Jewish and Arab children in a tertiary childrens' hospital in Israel., Methods: This was a retrospective cohort study of all children who were admitted to the pediatric ED of the largest hospital in northern Israel, between January 2011 and December 2015. Univariate and multivariate analyses were used to assess the strength of association between ethnicity category and waiting time. The following were tested as possible confounders: triage category, age, gender, time of arrival category. The effect of nurse-patient ethnic concordance was assessed., Results: Full data were available in 82,883 patients, 55,497 (67.0%) Jews and 27,386 (33.0%) Arabs. Jews and Arabs had a similar median waiting time of 38 min (interquartile range [IQR] 22-63 and IQR 21-61, respectively). Ethnicity was not associated with a change in waiting time (p = 0.36). Factors that most influenced shorter waiting time were triage category 1 (change in waiting time: -25.5%; 95% confidence interval [CI]: -29.3 to -21.7), or triage category 2 (change in waiting-time: -21.8%; 95% CI: -23.7 to -20.05). Factors that most influenced longer waiting time were patient arrival during the morning shift period (change in waiting time: 5.45%; 95% CI: 4.59 to 6.31), or during the evening shift period (change in waiting time: 4.46%; 95% CI: 3.62 to 5.29). Ethnic discordance between triage nurses and patients did not yield longer waiting times., Conclusion: In this large pediatric cohort, ethnic differences in ED waiting time were not found.

Objectives: Our goal was to examine factors associated with the administration of emergency department analgesia (any analgesia, opioid analgesia) in patients with acute appendicitis in a tertiary children's hospital in Israel, and to examine ethnic differences., Methods: A retrospective cohort study of children evaluated in the emergency department, who had International Classification Of Disease-Ninth Revision (ICD-9) diagnosis of acute appendicitis. Regression analysis was used to test the effect of multiple variables on the provision of analgesia. Medications were administered according to a nurse-driven pain protocol. Multivariate regression was performed to estimate the strength of association between ethnicity and provision of analgesia. The effect of patient-nurse ethnicity concordance was assessed., Results: During the 6-year study period, there were 715 children with acute appendicitis, 457 Jews and 258 Arabs. Overall, 289 (40.4%) received some form of analgesia, and 139 (19.4%) received opioid analgesia. Univariate analysis revealed that higher pain score (P<0.001) and higher triage acuity (P<0.001) were associated with administration of any type of analgesia and of opioid analgesia. When adjusted for age, weight, sex, triage category, pain score, and 24-hour time of arrival, Jewish and Arab patients had similar likelihood of receiving analgesia of any type 41.8% (95% confidence interval [CI], 40.3%-43.3%) versus 40.7% (95% CI, 38.7%-42.8%), and receiving opioid analgesia 26.1% (95% CI, 24.4%-27.8%) versus 25.3% (95% CI, 22.9%-27.7%). Similar proportions of Jewish and Arab patients received analgesia from Jewish and Arab nurses., Conclusions: Low rates of analgesia and opioid administration were found with no ethnic differences.

To determine the effectiveness of guaiac faecal occult blood tests (gFOBT) in the early detection of colorectal cancer (CRC) within a population of asymptomatic individuals who attended general periodic examinations, and to suggest the recommended age for this screening tool, the electronic database of the periodic examination institute of Rambam Healthcare Campus for the years 2004-2013 was reviewed. Individuals with positive gFOBT results were interviewed for further workup. Proportions of individuals for whom a polyp or CRC was detected were evaluated according to sex and age. 18 858 individuals were examined during the study period, mean age 48 years. The overall gFOBT uptake was 40.8%. Uptake was significantly higher among men and increased with age. Positive gFOBT was detected in 105 individuals (1.4%). The proportion of positive gFOBT was significantly lower among individuals aged 30-50 years than those older than 50 years of age (1.1 and 1.7%, respectively, P=0.005). No positive gFOBT was detected among individuals younger than 30 years of age. Positive gFOBT was higher in men than in women: 1.8 and 0.9% respectively (P=0.002). CRC was detected in six individuals, including two younger than 50 years of age. Polyps were detected in 15 individuals; of these, four were younger than 50 years of age. In the gFOBT-positive group, proportions of polyps and CRC were the same for subgroups according to age. The findings support consideration of annual gFOBT screening from the age of 40 years.

MTHFR C677T is a common gene polymorphism that has been shown to be associated with hyperhomocysteinemia. Studies on the role of MTHFR in inflammatory bowel diseases (IBD) have yielded conflicting results, perhaps due in part to genetic heterogeneity. The prevalence of the MTHFR C677T variant allele varies according to Jewish subpopulations: Ashkenazi vs non-Ashkenazi. The aim of this study was to examine the association between MTHFR C677T genotype and IBD in the different Jewish populations.DNA samples were assessed for the presence of the MTHFR C677T variant allele in 445 Jewish Israeli IBD patients: 338 with Crohn's disease [CD] (214 Ashkenazi and 124 non-Ashkenazi Jews) and 107 with ulcerative colitis [UC] (73 Ashkenazi and 34 non-Ashkenazi Jews), and in 347 healthy controls: 173 Ashkenazi and 174 Non-Ashkenazi Jews. Possible genotype-phenotype associations were investigated.We showed a significantly higher frequency of MTHFR 677T variant genotypes in non-Ashkenazi CD patients: Odds ratio of 1.86 for heterozygotes (CT) and 2.89 for homozygotes (TT) compared to non-Ashkenazi healthy controls. No significant association was found for UC in non-Ashkenazi patients or for CD or UC in Ashkenazi patients.Our findings suggest that the MTHFR 677T variant may contribute to the risk of CD in non-Ashkenazi but not Ashkenazi Jews. This may result from genetic heterogeneity and highlights the complexity of the genetic etiology of IBD., Competing Interests: The authors have no conflicts of interest to disclose.

Nephrotic syndrome (NS) after allogeneic hematopoietic stem cell transplantation (HSCT) is a rare phenomenon usually associated with graft-versus-host disease (GVHD). This systematic review of post-HSCT NS cases reported in the literature aimed to identify risk factors and unique features of the disease in this clinical setting. One hundred sixteen cases of post-HSCT NS published in the English literature between 1988 and 2015 were revealed and analyzed. The median onset of NS was 20.5 months (range, 3 to 174) post-HSCT. NS development was associated with acute or chronic GVHD in 87.2% of cases. Membranous nephropathy (MGN) was the most frequent pathology (65.5%), followed by minimal change disease (MCD) (19%). Complete remission of the NS was achieved in 63.5% of patients (59.1% of MGN cases and 81.3% of MCD cases; P = .15). Patients presenting with MCD recovered at a median of 1.75 months (range, 1 to 12) and with MGN a median of 7 months (range, 1 to 53) (P = .001). NS was treated with corticosteroids alone in 16.8% of patients and with a combination of corticosteroids and other immunosuppressive agents in 73.5% of patients. Univariate analysis failed to identify a single predictive factor of response to therapy. In conclusion, post-HSCT NS usually develops concomitant to GVHD and is associated with high rates of response to therapy. Although most patients were treated with a combination of immunosuppressive drugs, single-agent therapy with steroids may be sufficient in some cases., (Copyright © 2015 The American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.)

Evaluation of early response during induction therapy for acute myeloid leukemia (AML) is used for prognostication and re-induction strategy, yet the optimal evaluation time point is unknown. Clearance of bone marrow (BM) blasts by day 14 of therapy does not ensure remission; thus, some patients requiring re-induction are neglected. This study aimed to examine the role of earlier BM evaluation during induction for predicting remission and overall survival. Results of BM testing on the 5th and 14th day of intensive induction were prospectively compared in 127 adult patients with AML. Re-induction was given, based on Day 14 results, to 25 patients. Reduction of the BM blast count to <5% as early as by the fifth day of induction was more specifically associated with the achievement of remission compared to Day 14 (88.2% vs. 60%, respectively). Rapid responders have a better 3-year overall survival (OS). Day 5 results are a stronger predictor of OS by multivariate analysis and better segregate long-term survivors than the Day 14th BM count (66% vs. 30%, P = 0.0001 and 48% vs. 37%, respectively, P = 0.04). The Day 5 evaluation of BM carries significant clinical information. The benefit of prescribing re-induction based on such early evaluation should be prospectively studied., (© 2015 Wiley Periodicals, Inc.)

Background: Literature to date has suggested advantages of sedation with the combination of ketamine and propofol over ketamine alone or propofol alone. However, there is a paucity of data regarding sedation with the combination of ketamine and propofol in pediatric emergency medicine., Methods: A retrospective case series analysis of children who underwent sedation with the combination of ketamine and propofol in a pediatric emergency department was conducted. Study covariates were extracted from the emergency department medical records., Results: Four hundred twenty-nine patients, 297 males and 132 females, with a median age of 6.8 years (interquartile range, 3.9-10.9 years), underwent sedation by pediatric emergency physicians. Serious adverse events during sedation (SAEDS) were recorded in 52 procedures (12.1%), which included 39 hypoxic events (9.1%), 12 apneic events (2.8%), and 1 laryngospasm (0.2%). All SAEDS were managed successfully, and no child underwent intubation because of an adverse reaction or required hospitalization. Multivariate logistic regression analysis did not reveal any association between age, weight, fasting time, analgesic medication provided before sedation, length of procedure, capnography use, dosages of medications, and the presence of SAEDS., Conclusions: This is the largest reported series of sedation with the combination of ketamine and propofol in pediatric emergency medicine. Findings suggest that sedation with the combination of ketamine and propofol can be safely performed by a skilled emergency physician., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Azacitidine (AZA) dose reduction is a common practice in cytopenic patients. However, a correlation between AZA dose and infection complications has never been studied., Patients and Methods: Higher-risk patients with myelodysplastic syndrome or acute myeloid leukemia treated with AZA in 18 Israeli hospitals between the years 2008 and 2011 were included in a former national survey. To reveal the effect of AZA dosage on infection risk we limited our analysis to the infection rate after the first AZA dose alone. We excluded subsequent cycles of AZA from the analysis, because infectious events during these cycles might be related to other cofactors such as disease response to AZA therapy., Results: After the first AZA cycle, infectious events were more frequent after doses of 75 mg/m(2) for 7 days than 75 mg/m(2) for 5 days (36/106 [34%] and 10/67 [14.9%], respectively; P = .008), regardless of the patient's age. Of the 46 recorded infectious events, the causative pathogen was identified as bacterial in 25 (54.3%) and as viral or fungal in 2 (4.3%) and 2 (4.3%) cases, respectively. No pathogen was identified in 17 (37%) cases. Infections were significantly more prevalent among patients who presented with platelet counts < 20,000 (43.6% vs. 23.6%; P = .012) and poor risk cytogenetics (40.7% vs. 19.8%; P = .008)., Conclusion: Reduction of AZA dose might decrease infection rate and therefore should be considered in patients with high infection risk., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Three-drug induction regimens have become the standard of care in newly diagnosed transplant-eligible multiple myeloma patients. Two frequently used protocols are bortezomib, cyclophosphamide and dexamethasone (VCD) and bortezomib, thalidomide and dexamethasone (VTD). Comparisons between the two are lacking. The present study aimed to identify the differences in response rate and toxicity between the two regimens. Databases were searched using the terms 'VTD' or 'VCD' and 'induction regimens for newly diagnosed multiple myeloma'. Prospective trials evaluating initial response in transplant eligible patients were included. The main outcome measures were response rates and adverse events. Eight clinical trials were eligible for analysis. Overall 672 patients were treated with either VCD (n = 157) or VTD (n = 515) as induction therapy. Patients treated with VTD presented with a significantly higher complete/near complete response (34% vs. 6%, P = 0·002) as well as a higher very good partial response rate or better, following induction therapy (62% vs. 27%, P < 0·0001). Although grade 3-4 neurotoxicity was more frequent during VTD therapy (11% vs. 6%, P = 0·057), a higher incidence of overall grade 3-4 adverse events was found in the VCD-treated patients (74% vs. 51%, P < 0·001). VTD induction therapy may be superior in achieving deeper response rate following induction therapy, and is better tolerated., (© 2014 John Wiley & Sons Ltd.)