Compassionate use of convalescent plasma for treatment of moderate and severe pneumonia in COVID-19 patients and association with IgG antibody levels in donated plasma.

BACKGROUND: We assessed outcome of patients with moderate and severe COVID-19 following treatment with convalescent plasma (CP) and the association with IgG levels in transfused CP. METHODS: A prospective cohort study. Primary outcome was improvement at day 14 defined as alive, not on mechanical ventilation, and moderate, mild, or recovered from COVID-19. Antibody levels in CP units were unknown at the time of treatment. IgG against the spike protein S1 was subsequently measured by ELISA. Neutralizing antibodies titers were determined in a subset. Outcome was assessed in relation to the mean antibody level transfused to the patients (≤4.0 versus >4.0). FINDINGS: Of 49 patients, 11 (22.4%) had moderate, 38 (77.6%) had severe disease, 28 were ventilated. At day 14, 24 (49.0%) patients improved, 9 (18.4%) died, and 13 (26.5%) were ventilated. In 14/98 (14.3%) CP units IgG was < 1.1 (cutoff calibration) and in 60 (61.2%) ≤4.0. IgG level and neutralizing antibody titer were correlated (0.85 p < 0.001). In patients receiving ≤4.0 antibody levels, 11/30 improved (36.7%) versus 13/19 (68.4%) in patients receiving >4.0 odds ratio (OR) 0.267 [95% confidence interval (CI) 0.079-0.905], P = 0.030. In patients diagnosed >10 days prior to treatment, 4/14 (22.4%) improved in the ≤4.0 antibody group, versus 6/7 (85.7%) in the >4.0 antibody group, OR 0.048 (95% CI, 0.004-0.520), P = 0.007. No serious adverse events were reported. INTERPRETATION: Treatment with CP with higher levels of IgG against S1 may benefit patients with moderate and severe COVID-19. IgG against S1 level in CP predicts neutralization antibodies titers.

Financial incentives as a governmental tool to bridge the medical manpower gap between Israel's center and periphery.

One of the major health disparities between Israel's center and periphery relates to the physician to population ratio. To overcome it, the Israeli government launched a financial incentive program in 2011, in an attempt to encourage physicians to work in the periphery and in specialties experiencing major shortages. A recent IJHPR study found that residents who choose to work in a peripheral institution gave more weight to the grant in their decision-making process than did residents from central institutions. This finding lends support to the rationale behind the government program and suggests that it is an effective means of achieving the desired goal.This commentary details how the program was repeatedly adjusted during the 2011-2018 period, in light of changing needs. As financial and human resources are expected to remain scarce in the future, the program must continue to be constantly evaluated and adjusted in order to maintain its effectiveness.

The influence of flint stones on a soil microbial community in the northern Negev Desert.

In the Negev Desert ecosystems, flint-stone cover on slopes acts as a barrier against water flow. As a result, soil moisture increases and organic matter accumulates under the stone and in the immediate surroundings, both affecting the duration of soil microbial activity. On the other hand, during the dry season (characterized by approximately 210 dew nights), flint-stone cover plays an important role in the formation of dew, which eventually trickles down beneath the stone, correspondingly enhancing biological activity. The present study examined the possible role of flint stones as hotspots for soil microbial-community activity and diversity. The results were compared with those obtained from the adjacent stone-free soils in the open spaces (OS), which served as controls. Microbial activity (respiration and biomass) and functional diversity were determined by the MicroResp™ method. In addition, estimates of genetic diversity and viable counts of bacteria and fungi [colony-forming units (CFUs)] were obtained. The soil was significantly wetter and contained more organic matter beneath the flint stones (BFS). As hypothesized, biological activity was enhanced under the stones, as described by CO2 evolution, microbial-community biomass functional diversity, and fungal phylogenetic diversity. BFS environments favored a greater range of catabolic functions. Taxa generally known for their stress resilience were found in the OS habitats. The results of this study elucidate the importance of flint-stone cover to soil microbial biomass, community activity, and functional diversity in the northern Negev Desert.

Can outcome-based continuing medical education improve performance of immigrant physicians?

INTRODUCTION: Immigrant physicians are a valued resource for physician workforces in many countries. Few studies have explored the education and training needs of immigrant physicians and ways to facilitate their integration into the health care system in which they work. Using an educational program developed for immigrant civilian physicians working in military primary care clinics at the Israel Defence Force, we illustrate how an outcome-based CME program can address practicing physicians' needs for military-specific primary care education and improve patient care. METHODS: Following an extensive needs assessment, a 3-year curriculum was developed. The curriculum was delivered by a multidisciplinary educational team. Pre/post multiple-choice examinations, objective structured clinical examinations (OSCE), and end-of-program evaluations were administered for curriculum evaluation. To evaluate change in learners' performance, data from the 2003 (before-program) and 2006 (after-program) work-based assessments were retrieved retrospectively. Change in the performance of program participants was compared with that of immigrant physicians who did not participate in the program. RESULTS: Out of 28 learners, 23 (82%) completed the program. Learners did significantly better in the annual post-tests compared with the pretests (p <.01) and improved their OSCE scores (p <.001). Most program graduates (90%) rated overall satisfaction as very good or excellent. In comparison with nonparticipants, program graduates performed better on work-based assessments (Cohen's d =.63). DISCUSSION: Our intensive, outcome-based, longitudinal CME program has yielded encouraging results. Other medical educators, facing the challenge of integrating immigrant physicians to fit their health care system, may consider adapting our approach.

Effect of a tailor-made continuous medical education program for primary care physicians on self-perception of physicians' roles and quality of care.

BACKGROUND: A survey conducted among Israel Defense Force primary care physicians in 2001 revealed that they consider patients' needs more than they do organizational needs and that the education PCPs currently receive is inadequate. In 2003 the medical corps initiated a multi-format continuous medical education program aimed at improving skills in primary care medicine. OBJECTIVES: To measure and analyze the effect of the tailor-made CME program on PCPs' self-perception 3 years after its implementation and correlate it to clinical performance. METHODS: In 2006 a questionnaire was delivered to a representative sample of PCPs in the IDF. The questionnaire included items on demographic and professional background, statements on self-perception issues, and ranking of roles. We compared the follow-up survey (2006) to the results of the original study (2001) and correlated the survey results with clinical performance as measured through objective indicators. RESULTS: In the 2006 follow-up survey PCPs scored higher on questions dealing with their perception of themselves as case managers (3.8 compared to 4.0 on the 2001 survey on a 5 point scale, P = 0.046), perceived quality of care and education (3.5 vs. 3.8, P = 0.06), and on questions dealing with organizational commitment (3.5 vs. 3.8, P = 0.01). PCPs received higher scores on clinical indicators in the later study (odds ratio 2.05, P < 0.001). CONCLUSIONS: PCPs in the IDF perceived themselves more as case managers as compared to the 2001 survey. A tailor-made CME program may have contributed to the improvement in skills and quality of care.

Reorganization of secondary medical care in the Israeli Defense Forces Medical Corps: A cost-effect analysis.

OBJECTIVE: To increase accessibility and availability of secondary medical care, 10 secondary unit specialist clinics were established side-by-side with five existing regional specialist centers, thus achieving decentralization. The purpose was to analyze the impact of this reorganization on overall consumption of secondary medical care and expenditures. METHODS: Consumption of secondary medical care was analyzed by using computerized clinic and Medical Corps databases. Functional efficiency and budgetary expenditures were evaluated in four representative unit specialist clinics. RESULTS: The reorganization resulted in an 8% increase in total secondary care consumption over 2.5 years. The establishment of unit specialist clinics did not achieve increased accessibility or availability for military personnel. Functional analysis of representative unit specialist clinics showed diversity in efficiency, differences in physicians' performance, and excess expenditures. CONCLUSION: The decentralizing reorganization of secondary medical care generated an increase in medical care consumption, possibly because of supply-induced demand. The uniform inefficiency of the unit specialist clinics might have been related to incorrect planning and management. The decentralization of secondary medical care within the Israeli Defense Forces has not proved to be cost-efficient.

Serologic testing for celiac disease in young adults--a cost-effect analysis.

In recent years, there has been a marked increase in the diagnostic workups for celiac disease among military personnel, thereby significantly increasing overall laboratory testing expenditures and burden. We evaluated the serologic testing procedure in symptomatic young adults, using a "cost-effect" approach. We evaluated the serologic screening policy for celiac disease among serologically tested military personnel. The study population was divided into subgroups according to the clinical presentation prior to screening: isolated (low-risk) and combined complaints (high-risk). Sensitivity, specificity, and predictive values of serologic markers for celiac disease were evaluated. Cost analyses were based on diagnostic expenditures. Cost-effect ratio is expressed as cost per newly diagnosed patients, and cost minimization as cost per screened individuals. Five hundred thirty-eight military personnel were serologically tested for celiac disease. Eight new cases of celiac were diagnosed, all of whom belonged to the high-risk subgroup and tested positive for at least two positive serologic tests (tTG + EMA or tTG + AGA IgG + EMA). EMA Ab measured the highest sensitivity, specificity, and predictive values. Average screening expenditure was U.S. $287 per patient. The lowest cost-effect and cost minimization ratios were achieved by implementing a two-step single-marker screening protocol for high-risk subjects and one-step follow-up for low-risk subjects. Among patient population of young adults, selective diagnostic workup could result in cost-minimization without risking quality of diagnosis. From a cost-effect perspective, implemented screening procedures need to be dependent on subgroup: low-risk, clinical follow-up; and high-risk, serological testing for EMA and, only if positive, possibly a small-bowel biopsy.