The COVID-19 pandemic dramatically reduced admissions of children with and without chronic conditions to general paediatric wards.

AIM: We examined the impact of the COVID-19 pandemic on how many children were admitted to Israel's largest tertiary paediatric hospital and why they were admitted. METHODS: Israel declared COVID-19 a national emergency on 19 March 2020. This study examined daily hospital admissions to our three general paediatric wards during the COVID-19 lockdown period from 20 March to 18 April 2020. These 258 admissions were compared with the 4217 admissions from the period immediately before this, 1 February to 19 March 2020, plus 1 February to 18 April in 2018 and 2019. We also compared why patients were admitted during the study period, and any pre-existing conditions, with 638 children hospitalised during the same period in 2019. RESULTS: The mean number of daily hospitalisations during the COVID-19 lockdown period was 8.6, which was 59% lower than the 20.9 recorded during the other three periods before COVID-19. There was a significant decrease in the number of patients admitted with infectious (74%) and non-infectious (44%) aetiologies from 2019 to 2020, and these occurred among patients with (58%), and without (55%), pre-existing medical conditions. CONCLUSION: The Israeli COVID-19 lockdown had a dramatic effect on admissions to the paediatric wards of a tertiary hospital.

Changing epidemiology and resistance patterns of pathogens causing neonatal bacteremia.

To conduct a survey of the local prevalent bacteria and antibiotic resistance in a referral tertiary neonatal intensive care unit (NICU), in order to assess the efficacy of local antibiotic policies. We reviewed all positive blood and cerebrospinal fluid cultures obtained between January 2007 and December 2017 in the NICU of Schneider Children's Medical Center of Israel. Early and late-onset bacteremia were defined as episodes occurring within or after the first 3 calendar days of life respectively. Empiric treatment included ampicillin and gentamicin or piperacillin-tazobactam and amikacin for early or late-onset bacteremia respectively. The prevalence and antibiotic resistance of the bacteria were described and compared over time. Eight hundred and twenty nine of 15,947 (5.2%) newborns had at least one episode of bacteremia; 81 had multiple episodes. The most common bacteria were Escherichia coli (32.35%) and group B Streptococcus (19.11%) or coagulase negative Staphylococcus (CoNS) (60.5%) and Klebsiella sp. (12.4%) in early or late-onset bacteremia respectively. Overall, all Gram-positive bacteria were susceptible to vancomycin and most non-CoNS to ampicillin. Nosocomial vs. vertical bacteremia had increased resistance to ampicillin and cephalosporins. Resistance of nosocomial bacteria to piperacillin-tazobactam was 22.4%, to amikacin 3.3%, and to meropenem 1.8%. Changes over time: Gram-negative bacteria had a significant increase in resistance to cotrimoxazole and piperacillin. The resistance to gentamicin doubled. Our empiric antibiotic regimen covers the most frequent isolates. Amikacin may replace gentamicin for selected sick patients in early-onset bacteremia. Piperacillin-tazobactam should be combined with amikacin until susceptibility is available.

Pediatric and Adolescent Surgical Breast Clinic: Preliminary Experience.

STUDY OBJECTIVE: The diagnostic and treatment tools used in breast centers are largely geared to adults, and there is little consideration of the unique characteristics of breast diseases in younger age groups. Herein we report on the preliminary experience of a specialized breast clinic for children and adolescents. DESIGN: Retrospective, observational. SETTING: Pediatric Surgical Breast Clinic of Schneider Children's Medical Center of Israel. PARTICIPANTS: Patients referred to the clinic during the first 18 months of its establishment. INTERVENTIONS AND MAIN OUTCOME MEASURES: Rate of breast masses, rate of malignancy, and types of evaluation and treatment. RESULTS: Forty-seven patients aged 0-19 years were referred. Breast masses were suspected in 23/47 (48.9%) and confirmed using ultrasound in 14/47 (29.7%; mean age, 16.4 years), followed by needle core biopsy in 7. Seven patients had multiple masses. Breast Imaging and Reporting Data System scores ranged from 3 to 4b. All cases were treated as fibroadenomas. Four patients underwent surgery because of a large mass (>5 cm; n = 3) or patient's preference to remove the lump rather than follow-up (n = 1). There were no malignancies. The median time from patient identification of the mass until seeking medical help was 5 months. CONCLUSION: Several findings distinct to this age group were highlighted: high rate of multiple masses, lack of malignancy, and high risk of delayed diagnosis. Care should be taken when using Breast Imaging and Reporting Data System categorization because it was formulated for adults and might be very limited in the adolescent population. Longer-term studies of larger cohorts are planned.

Cardiac anomalies and associated comorbidities in a large adolescent population.

OBJECTIVE: To determine the prevalence, secular trends and associations of heart disease in a large unscreened, otherwise basically healthy, adolescent population. SUBJECTS AND METHODS: Cross-sectional study of the cardiac status of 113,694 adolescents from the northern district of Israel, who completed the profiling process between the ages of 16 and 19, including all essential measures over a 22-year period. Results of imaging were categorized as either isolated valvar or structural abnormalities, and their clinically significant subgroups defined prospectively. The findings were correlated with the socio-demographic and anthropometric data and non-cardiac health conditions. RESULTS: Of those sent for echocardiography, 1257 (0.93% of the total population) had isolated valvar disease and 216 (0.19%) had structural abnormalities, with 20% of both groups considered significant. Females had lower prevalence of heart disease. There was peak prevalence in the second 5-year period. Tall subjects or a past history of rheumatic fever had more valvar abnormalities. Thin subjects or those with skeletal anomalies had more structural abnormalities. Significant valvar and structural anomalies were more common in subjects with learning disorders, endocrine disorders and diabetes mellitus. Fewer valvar abnormalities were diagnosed in obese subjects. Heart disease was more common in those with non-solid tumors. CONCLUSION: Appreciable numbers of potentially healthy adolescents were found to have heart disease. There appeared to be an association with body size, skeletal abnormalities and relatively common medical disorders, the cause of which remains to be determined in prospective studies that could change the way common adolescent disease should be followed.

Adolescent BMI at Northern Israel: From Trends, to Associated Variables and Comorbidities, and to Medical Signatures.

The increasing prevalence of abnormal body mass index (BMI), mainly obesity, is becoming a significant public health problem. This cross-sectional study aimed to provide a comprehensive view of secular trends of BMI, and the associated socio-demographic variables and comorbidities among adolescents with abnormal BMI. Individuals of the study population were born mainly between 1970 and 1993, and were examined at 16 to 19 years of age during the years 1987 to 2010, at 1 conscription center in the northern district of Israel.The study population included 113,694 adolescents. Univariate and multivariable logistic regression models were used to investigate the associations between BMI categories, socio-demographic variables, and medical conditions.A downward trend in the prevalence of normal BMI among both male and female adolescents was obtained, while trends of overweight and obesity (in both genders) and underweight (only among females) rose. Socio-demographic variables such as religion, education, family-related parameters, residential environment, country of birth, and origin were all associated with different risks for abnormal BMI. Obesity was associated with higher risk for hyperlipidemia, endocrine disorders (only in males), knee disorders, and hypertension type I + II (in both genders). Overweight was associated with knee disorders (only in females). Underweight, exclusively in males, was associated with increased risk for endocrine disorders, proteinuria, and cardiac disorders. Hierarchical clustering analysis revealed the intricate relations between gender, BMI, and medical signatures. It brought to light novel clusters of diseases that were abundant among populations having above-normal BMI or underweight males. Furthermore, above-normal BMI was associated with a lower rate of cardiac anomalies and scoliosis/kyphosis, whereas being underweight was associated with a lower risk for hypertension and flat foot.This study provides a reliable and in-depth view of secular trends in height, weight, and BMI of male and female adolescents. It supports previous associations between abnormal BMI and demographic variables and comorbidities, while uncovering novel associations, mainly regarding medical signatures of each gender-BMI group. This might lead to better monitoring, early detection, prevention, and treatment of various conditions associated to abnormal BMI categories and gender groups.

Coordinated computerized systems aimed at management, control, and quality assurance of medical processes and informatics.

PURPOSE: As part of the routine work of the medical committees in the Israel Defense Forces, a unique nationwide computerized control system is being implemented to assess and manage medical processes. The purpose of this paper is to report on that implementation. DESIGN/METHODOLOGY/APPROACH: The computerized system consists of three main components: a specific status indicating the processes in each file, an appointment system, and an internal computerized system that uses a magnetic card for the regulation of the local waiting lists. FINDINGS: The combined computerized system improves the control and management of the medical processes and informatics from the point-of-view of both the patients and system operators. Different parameters of quality control regarding the medical and administrative processes are assessed (such as efficiency), and solutions are sought. Computerized system-based design and re-allocation of human and medical resources were implemented according to the capacities and limitations of the medical system. A reduction in the daily number of invited recruits improved the quality of the medical encounters. Specific combined status codes were introduced for the efficient planning of the medical encounters. Implementation and automation of medical regulations and procedures within the computerized system make the latter play a key role and serve as a control tool during the decision-making process. ORIGINALITY/VALUE: The computerized system allows efficient follow-up and management of medical processes and informatics, led to a better utilization of human and medical resources, and becomes a component of the decision making by the system operators and the administrative staff. Such a system could be used with success in clinics, hospitals, and other medical facilities.

Quality-assuring intervention for technical medical staff at medical committees.

PURPOSE: This paper seeks to examine an intervention program which was developed in order to improve the performance and skills of technical medical personnel at the military recruitment medical committees. DESIGN/METHODOLOGY/APPROACH: Evaluation of the technician soldiers' performance was carried out by the usage of a specifically farmed survey, comprising a designed questionnaire, and direct observation of their work, including appraisal of their measurements and interpretation skills. FINDINGS: Prior to intervention, analysis revealed: insufficient knowledge of normal range of blood pressure and pulse values, visual acuity of color vision, urinalysis and their relation to the classification process at medical committees; and inadequate technicalities such as incorrect weight and height measurements. ORIGINALITY/VALUE: The model of the intervention program could be modified and adopted by medical committees, sports medicine examinations, periodic screening procedures, and primary care medicine in order to improve the quality of medical records and medical care.

Quality control and quality assurance of medical committee performance in the Israel Defense Forces.

PURPOSE: The paper aims to focus on a unique quality control system that was set up ten years ago to evaluate Medical Classification Committee decision-making processes at the Israel Defense Forces (IDF) conscription center. DESIGN/METHODOLOGY/APPROACH: Two main approaches were deployed by the control system to assess medical classification committees' performance. The first was direct assessment of the medical committees' clinical work and decision-making processes. The second applied data mining procedures to the computerized medical databases. The functional classification codes (FCCs)--codes for the most common medical disorders assigned to male recruits from the central computerized central IDF database, the sub-districts comprising the recruitment centers, and the chairmen assigning the FCCs to recruits--were all analyzed. FINDINGS: A total of 26 FCCs, each indicating a common medical problem and its severity, constituted approximately 90 percent of all FCCs assigned at recruitment centers between 2001 and 2006. Major contributors to medical profiling outcomes were underweight, asthma, chronic headache, mental illness, symptomatic scoliosis, hypnosis, chronic back pain, knee joint disorders, allergic rhinitis and sinusitis. Evaluating the computerized medical database revealed significant differences in: medical profile prevalence; recruitment center FCCs; different sub-districts in a given recruitment center; and profiling by medical committee chairmen. PRACTICAL IMPLICATIONS: Findings indicate disparities between recruitment centers and their chairmen in the medical profiling process owing to variations in recruitment center working methods and medical history taking, physical examinations, interpreting medical information and individual differences in the chairmen's decision-making process. Other reasons include technician and laboratory staff inaccuracies. These significant discrepancies highlighted the need for an intervention program. To minimize variations and create a uniform work platform, an orderly instruction system and training programs for the committee chairmen, technicians and laboratory staff were established. These actions resulted in improved performance in 2007 as confirmed by a decreased variability in the assignment of medical FCCs. ORIGINALITY/VALUE: The paper highlights methods that can be used to assess disability screening, sports medicine committees and primary care setting procedures.

Unmasking of carnitine palmitoyltransferase deficiency during an acute exacerbation of asthma complicated by rhabdomyolysis in a soldier.

Rhabdomyolysis is a life-threatening condition that may result from various etiologies. We report a rare case of severe rhabdomyosis in a soldier after a mild acute asthma exacerbation. Further work-up revealed an underlying deficiency of type II carnitine palmitoyltransferase. The case is discussed along with a review of the literature. It is concluded that acute asthma exacerbations may be a unique precipitating factor of rhabdomyolysis and may therefore unmask underlying metabolic myopathies. Asthma may cause rhabdomyolysis through several different mechanisms, and thus the occurrence of rhabdomyolysis in the context of asthma exacerbations should warrant a work-up for metabolic diseases, especially in the presence of high creatine kinase levels. Given the high incidence of asthma, especially among young adults, a high index of suspicion is needed in order that rhabdomyolysis be promptly diagnosed and treated.