High degree atrio-ventricular block following COVID-19 vaccination.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has resulted in more than four million deaths globally. In addition to the lower respiratory system, a wide range of major organ injuries have been reported among patients infected with COVID-19. These injuries include cardiac involvement. The spectrum of cardiac manifestations includes cardiac injury, heart failure, cardiogenic shock, acute coronary syndrome, myocarditis, tachyarrhythmias, and bradyarrhythmia [1]. Different degrees of atrioventricular blocks have been reported [2]. The pathogenesis of these complications is not fully understood. Different mechanisms are proposed, including direct myocyte injury, interstitial inflammation and fibrosis, cytokine storm, plaque destabilization, and and/or hypoxia [3]. Many countries have worked toward mass vaccination using the Pfizer BioNTech (BNT162b2) COVID-19 vaccine, including Israel. We report a case of high degree atrioventricular block (AVB) following vaccination with the COVID-19 BNT162b2 vaccine.

Characteristics and Outcomes of Patients Infected with SARS-CoV-2 in Israel: Correlation between Laboratory Findings on Admission to Emergency Department and Subsequent Respiratory Failure.

BACKGROUND: There is limited clinical information on coronavirus disease-19 (COVID-19) patients in Israel. OBJECTIVES: To describe the characteristics, outcomes, and potential associations of hospitalized COVID-19 patients in Israel. METHODS: We conducted a single-center, retrospective study of 58 consecutive laboratory-confirmed COVID-19 patients admitted to Laniado Hospital, Israel, between 14 March 2020 and 14 May 2020. Demographic, clinical, and laboratory data on admission were collected and analyzed, and the association to subsequent respiratory failure was assessed. RESULTS: Mean age of patients was 70.7 ± 16.9 years (53% males, 47% females.); 74% had at least one co-morbidity. Most patients were of Jewish Ashkenazi descent. During hospitalization 15 patients (mean age 78.18 ± 10.35 years); 80% male, 73% Sephardi descent developed respiratory failure rates of 60% occurring on average 10.6 days following intubation. Laboratory tests at admission displayed a significant increase in C-reactive protein (CRP) and creatine kinase (CK) and a decrease in absolute lymphocyte count (ALC) in patients who eventually developed respiratory failure (163.97 mg/L, 340.87 IU/L, 0.886 K/µl vs. 50.01 mg/L and 123.56 IU/L, 1.28 K/µl, respectively). Multivariate logistic analysis revealed an integrated parameter of CRP, CK, and ALC highly correlated with respiratory failure. Receiver operating characteristic curve revealed the area under the curve of CRP, CK, and ALC and the integrated parameter to be 0.910, 0.784, and 0.754, respectively. CRP was the strongest predictor to correlate with respiratory failure. CONCLUSIONS: CRP, CK, and ALC levels on admission could possibly be used to detect high-risk patients prone to develop respiratory failure.

[COVID-19 - A RECENT REVIEW].

INTRODUCTION: Corona disease sprang into our lives towards the end of 2019. In November/December 2019, in Wuhan, Hubei province in China, a SARS-like viral disease with a high adhesive capacity and the potential to endanger the life of the patient was reported. It soon became clear that the disease was very contagious and new hospitals were being built on the site and a General closure was underway. Many doctors from all over China were recruited and sent to the isolated area. Local medical reports were acute respiratory distress syndrome (ARDS)-like, and patients needed respiratory support for oxygenation and some needed ventilation on respiratory devices with significant mortality rates. The disease has since spread to many parts of the world, mainly towards Europe. Hospitals have received hundreds of patients, to the point of partially collapsing the glorious Italian healthcare system. Italy and Spain reported a lung disease that causes severe oxidative disruption but no disruption in ventilation unlike ARDS. Initial post-mortem shows that the main cause of death is thromboembolic. Heart involvement with myocarditis and even heart attacks are beginning to be reported. Various drugs are involved in the treatment plan and are often known to fail. Even promising remedies such as Remdesavir, which is an antiviral drug, are beginning to receive reports from controlled trials, which are not as successful as originally expected. All in all, we continue to wander in the dark, both about the disease and certainly, regarding the treatment. The primary treatment involves maximum efforts for respiratory, hematologic, nephrologic and cardiologic support. In this review, I will try to describe the disease and the enigma concerning suggested treatments.

[CHARACTERISTICS OF MEDICAL CANNABIS USAGE AMONG PATIENTS WITH FIBROMYALGIA].

INTRODUCTION: Medical cannabis (MC) is becoming more and more popular among patients with chronic pain syndromes. In this study we evaluated the characteristics of MC use among patients with fibromyalgia. METHODS: All patients with fibromyalgia who were followed up at Laniado Hospital in Netanya and at the Nazareth Hospital in Nazareth, in addition to all patients followed at the different health service organizations by the first author were located and contacted regarding a large number of parameters. The data included demographic information, duration of fibromyalgia symptoms and diagnosis, duration of MC use, monthly consumption of MC, frequency of daily use, number of species of MC currently used, number of species previously used, types and features of MC supplied, methods of MC consumption, delay in MC supply, symptoms of cannabis withdrawal during delay in supply or shortage of MC, familiarity with the content of (-)- trans-Δ9-tetrahydrocannabinol (THC) and Cannabidiol (CBD) of the current species used. Furthermore, information was retrieved on current medications for fibromyalgia and medications for fibromyalgia stopped after starting MC consumption, discontinuation of MC treatment, companies growing and supplying the currently consumed MC, names of current MC species, dominance of Sativa or Indica of the current MC species, and the impact of MC on clinical parameters such as pain, sleep, anxiety, depression, memory, concentration and weight. In addition, questions were presented regarding work, outdoor leisure time, driving, sharing their own MC with other people, opinion on the reform of MC in Israel and adverse effects of MC. RESULTS: One-hundred and one patients completed the study; 73% of the participants were female with a mean age of 45±11.8 years. The mean duration of fibromyalgia symptoms and diagnosis were 8.39±6 and 4.69±3.9 years, respectively. The mean duration of MC consumption was 15.3±12.6 months and the mean monthly consumption amount was 28.6±10.2 g. 54% smoked pure cannabis, 18% used vaporized cannabis only and 3 participants only used MC oil. The rest used a variety of combinations. The mean minimal daily frequency of MC consumption was 4.11±2.9 times and the mean maximal daily frequency was 7.9±5.6 times. The mean number of current daily MC species was 2.11±1 and the mean number of tried species was 6.7±5.2 for each participant; 47% of all the participants stopped any other treatment for fibromyalgia and 51% reduced the dose or the number of other medications for fibromyalgia. One patient only stopped MC treatment. Tikun Olam was the manufacturing company with the largest number of clients and its most popular species for daytime was "Alaska" and "Erez" for night-time. Mean improvement in sleep and pain was slightly more than 77% with less improvement in other parameters; 36% of the patients reported weight gain, while 16% reported weight loss; 51% reported having more leisure time outdoors. Nearly all patients refused sharing any amount of their MC with friends or family members, and all patients recommended MC treatment for their loved ones once they develop severe fibromyalgia; 61% of the participants were against the reform of MC and 11% were in favor of it. Nearly one quarter of the patients reported mild adverse effects and one patient developed a psychotic attack (was consuming 70 gram of MC monthly). CONCLUSIONS: MC is an effective treatment for fibromyalgia, with nearly zero % withdrawal from this treatment. The mean daily amount consumed was relatively low, less than 1 gram, and the main method of consumption was smoking with a huge variety in the frequency of smoking during the day and night among the participants. MC treatment enabled nearly half of the patients to discontinue any treatment for fibromyalgia and all participants recommended MC treatment for their loved ones in case they develop severe fibromyalgia. Most participants were against the reform of MC in Israel. Mild adverse effects were reported in nearly a quarter of the patients but did not result in discontinuing its consumption.

[THE IMPACT OF ADMISSION TO THE MEDICAL WARD ON HEMOGLOBIN A1C LEVELS AMONG PATIENTS WITH TYPE-2 DIABETES].

INTRODUCTION: Blood glucose monitoring is a routine medical practice in the medical ward regardless of the cause of hospitalization of patients with diabetes. In this study we prospectively evaluated the impact of hospitalization on hemoglobin A1c (HbA1c) among patients with type-2 diabetes admitted to the medical ward, for reasons unrelated directly to their diabetes. METHODS: Patients with type-2 diabetes who were admitted to the medical ward for reasons not directly related to diabetes were asked to participate in our study. After consent , demographic, clinical and laboratory parameters were documented on admission, including age, sex, social status, years of study, duration of diabetes, type of anti-diabetic treatment, background medical problems and treatment, diagnosis on admission, temperature, blood glucose levels on admission to the medical ward, complete blood count and serum creatinine. In addition, HbA1c levels on admission, first 24-hour blood glucose levels at the medical ward, change of therapeutic treatment of their diabetes, diagnosis at discharge and recommended medication at discharge, were also documented. Three months following admission, the HbA1c study was repeated again. Paired t-test and Wilcoxon's rank sign test were used to compare between HbA1c levels at baseline and 3 months later among all the patients and among the subgroups. Multivariate regression analysis was used also to predict change in HbA1c levels among these patients. Physicians taking care of the patients on the medical ward were not aware of the study. RESULTS: Forty-four patients were recruited and 40 patients completed the study. There were 24 men (60%), with a mean age of 69.625±11.53 years for all the patients. The most common diagnosis on admission was infection followed by congestive heart failure. Mean 24-hour blood glucose level following admission was 209 mg% ±95. Among 12 patients there was an augmentation in diabetes treatment and in 3 there was dis-augmentation/discontinuation. Mean hemoglobin A1c levels on admission and 3 months later was 7.29% and 6.80% respectively (p=0.095). However, sub-analysis of patients with HbA1c levels >7.5% on admission, showed a significant decrease in the repeated HbA1c levels (p=0.003). CONCLUSIONS: Medical ward admission was associated with reduced HbA1C levels, yet not significant, among patients with type-2 diabetes who were admitted for reasons not directly related to diabetes.

[FORCING TREATMENT AND PREVENTING PATIENT INFORMATION].

INTRODUCTION: An ethics committee is a quasi-judicial committee whose basis is its law. The Ethics Committee's actions in the area of coercive treatment and prevention of information from the patient have been clarified, but creative solutions can sometimes be used without compromising the spirit of the law, causing patients to receive treatment or non-treatment with a minimum of harm to their values and wishes. An experienced ethics committee, with members capable of breaking out of the box, combined with innovative professionals, will also solve complex ethical dilemmas to reach solutions agreed upon by all concerned.

Decreasing urine culture rates in hospitalized internal medicine patients.

BACKGROUND: There are no previous studies on decreasing urine cultures in hospitalized internal medicine patients by a combination of physician education and reflex cancellation of urine cultures in those with a negative dipstick urinalysis. METHODS: We compared urine culture rates in all hospitalized internal medicine patients 18 years or older before intervening (2016), during medical education efforts (2017), and after reflex cancellation of urine cultures in patients with a negative dipstick (negative leukocyte esterase and nitrites) (2018, 2019). RESULTS: Compared to the preintervention period (2016), urine cultures decreased from a baseline of 32.7% (95% confidence intervals [95%CI]-31.7-33.6) to 26.6% (95%CI-25.8%-27.4%) after medical education efforts, and to 18.2% (95%CI-17.4%-19.0%) and to 15.2 (95%CI-14.5%-15.9%) during the 2 years after reflex cancellation of the urine cultures. There were no physician complaints and there were no urine cultures orders after reflex cancellation. CONCLUSIONS: We conclude that physician education and cancellation of urine cultures in those with negative dipsticks resulted in a persistent decrease in urine cultures of around 50%. Extrapolation to other settings requires caution since the results are dependent on patient selection, physician behavior, and methods of urine testing.

Medical Cannabis in Treatment of Resistant Familial Mediterranean Fever.

BACKGROUND Colchicine-resistant familial Mediterranean fever can be treated by anti-IL-1 biologic therapy; however, such treatment needs approval by the health insurance company, and many patients are denied such treatment or do not respond to it. CASE REPORT Two familial Mediterranean fever (FMF) patients, both homozygous for M694V mutation and resistant to colchicine treatment, were treated with medical cannabis. Prior to that, 1 patient was denied biologic treatment and the other had no significant response to anakinra. Under medical cannabis treatment, both patients had remarkable improvement in the severity of the attacks and also a decrease in the frequency of the attacks, from once every 2 weeks to 1 attack every month in 1 patient; this patient had also a remarkable reduction in the C-reactive protein level during the attacks. CONCLUSIONS Cannabis is a therapeutic option for treating the most complex patients with FMF.

Optimization of Endotracheal Tube Cuff Pressure by Monitoring CO2 Levels in the Subglottic Space in Mechanically Ventilated Patients: A Randomized Controlled Trial.

BACKGROUND: Many of the complications of mechanical ventilation are related to inappropriate endotracheal tube (ETT) cuff pressure. The aim of the current study was to evaluate the effectiveness of automatic cuff pressure closed-loop control in patients under prolonged intubation, where presence of carbon dioxide (CO2) in the subglottic space is used as an indicator for leaks. The primary outcome of the study is leakage around the cuff quantified using the area under the curve (AUC) of CO2 leakage over time. METHODS: This was a multicenter, prospective, randomized controlled, noninferiority trial including intensive care unit patients. All patients were intubated with the AnapnoGuard ETT, which has an extra lumen used to monitor CO2 levels in the subglottic space.The study group was connected to the AnapnoGuard system operating with cuff control adjusted automatically based on subglottic CO2 (automatic group). The control group was connected to the AnapnoGuard system, while cuff pressure was managed manually using a manometer 3 times/d (manual group). The system recorded around cuff CO2 leakage in both groups. RESULTS: Seventy-two patients were recruited and 64 included in the final analysis. The mean hourly around cuff CO2 leak (mm Hg AUC/h) was 0.22 ± 0.32 in the manual group and 0.09 ± 0.04 in the automatic group (P = .01) where the lower bound of the 1-sided 95% confidence interval was 0.05, demonstrating noninferiority (>-0.033). Additionally, the 2-sided 95% confidence interval was 0.010 to 0.196, showing superiority (>0.0) as well. Significant CO2 leakage (CO2 >2 mm Hg) was 0.027 ± 0.057 (mm Hg AUC/h) in the automatic group versus 0.296 ± 0.784 (mm Hg AUC/h) in the manual group (P = .025). In addition, cuff pressures were in the predefined safety range 97.6% of the time in the automatic group compared to 48.2% in the automatic group (P < .001). CONCLUSIONS: This study shows that the automatic cuff pressure group is not only noninferior but also superior compared to the manual cuff pressure group. Thus, the use of automatic cuff pressure control based on subglottic measurements of CO2 levels is an effective method for ETT cuff pressure optimization. The method is safe and can be easily utilized with any intubated patient.

The Ethics Committee at the Patient's Bedside (ECatPB): a retrospective view on the past two years.

The Ethics Committee at the Patient's Bedside (ECatPB) was established at Beilinson Hospital and began its activity a few years ago. A retrospective viewpoint will enable us to reflect on moral dilemmas and ethical conflicts as sources of professionals' moral distress. The activities of the ECatPB will be reviewed through sample cases and in the light of the promotion of optimal treatment. Five dominant contributions of the ECatPB will be discussed: prevention of moral distress; positioning the committee as an integral and inseparable component of the medical institution's daily life; cultivating the advisory, rather than punitive, character of the committee; maintaining constant ethics dialogues with patients, caregivers and professionals; and communications with guardians in light of informed consent or informed refusal. The summary ofthis paper will include conclusions, recommendations and personal notes.

Obesity-associated infertility - the earliest known description.

Polycystic ovarian syndrome is a leading cause of anovulatory infertility. It was originally described as a syndrome by Stein and Leventhal in 1935. Its frequent association with obesity and the beneficial effects of weight loss are well established. In 1328, the French Rabbi Levi ben Gershom (1288-1344 AD), in a detailed commentary on the Bible, states that: '...it is recognized that excess fat and obesity are reasons for infertility'. He explains that Sarah and Rachel allowed Abraham and Jacob respectively to have children with their maids, expecting this to reduce their own appetite, lead to weight loss and consequent conception. Even if one doubts the historical accuracy of this explanation of the ancestors' situation, one cannot doubt that Rabbi Levi ben Gershom is describing a situation familiar to him, to explain the seemingly paradoxical behaviour of the two mothers.

Induction of spermatogenesis in azoospermic men after internal spermatic vein embolization for the treatment of varicocele.

BACKGROUND: To evaluate the improvement in semen quality and pregnancy rate after internal spermatic vein (ISV) embolization in men with nonobstructive azoospermia virtual azoospermia, or extremely severe oligoteratoasthenoazoospermia (OTA). METHODS: A prospective cohort of 101 azoospermic or severe oligoteratoasthenospermic men of mean (+/-SD) age 34.1+/-7.7 years who underwent ISV between September 1998 and June 2003 were evaluated for semen characteristics, endocrinology profile, and conception rate. RESULTS: Significant improvement was noted in mean sperm concentration, motility, and morphology in 83 men (82%). Mean sperm concentration increased from 0.22+/-0.30 x 10(6)/ml total sperm in the ejaculate to 9.28+/-1.2 x 10(6)/ml after embolization (P < 0.001); mean sperm motility rose from 8.78+/-1.59 to 29.56+/-2.0% (P < 0.001), and mean sperm morphology rose from 3.79+/-0.74 to 13.72+/-1.37% (P < 0.005). Pregnancy was achieved in 34 cases (34%), 20 (20%) unassisted and 14 (14%) assisted. CONCLUSIONS: Based on our findings, the following statements can be made: (i) Varicocele may cause any variation of severity in OTA, including azoospermia. (ii) Since male fertility is preserved with only one testis, OTA, azoospermia or virtual azoospermia represent bilateral testicular dysfunction. (iii) Treatment of bilateral varicocele may reverse testicular dysfunction and improve spermatognesis and testosterone production in men with extremely severe OTA and induce sperm production in men with azoospermia and virtual azoospermia. (iv) If azoospermia is not too long-standing, the treatment of varicocele may significantly improve spermatogenesis and renew sperm production. (v) Adequate treatment may spare in > 50% of azoospermic patients the need for testicular sperm extraction as preparation for ICSI. (vi) Since achievement of pregnancy in IVF units is higher when spermatogenesis is better, the treatment of varicocele (bilateral) is an effective medical adjunct for the IVF units prior to the treatment. We recommend that infertile men with azoospermia or virtual azoospermia or extremely severe OTA be evaluated for varicocele, with special attention to its bilateral nature.