Israel Medical Association Journal

Background: At the beginning of 2020, the coronavirus disease 2019 (COVID-19) pandemic presented a new burden on healthcare systems.

Objectives: To evaluate the impact of the COVID-19 pandemic on the outcome of non-COVID patients in Israel.

Methods: We conducted a retrospective observational cohort study at a tertiary medical center in Israel. From December 2018 until June 2022, 6796 patients were hospitalized in the internal medicine wards. Patients were grouped based on their admission date: admitted during COVID waves (waves group), admitted between waves (interim group), and admitted during the same months in the previous year (former-year group).

Results: Mortality during hospitalization and 30-day mortality were higher in the waves group compared to the interim and former-year groups (41.4% vs. 30.5% and 24%, 19.4% vs. 17.9% and 12.9%, P < 0.001). In addition, 1-year mortality was higher in the interim group than in the waves and former-year group (39.1 % vs. 32.5% and 33.4%, P = 0.002). There were significant differences in the readmissions, both at 1 year and total number. The waves group had higher rates of mechanical ventilation and noradrenaline administration during hospitalization. Moreover, the waves group exhibited higher troponin levels, lower hemoglobin levels, and more abnormalities in liver and kidney function.

Conclusions: Hospitalized non-COVID patients experienced worse outcomes during the peaks of the pandemic compared to the nadirs and the preceding year, perhaps due to the limited availability of resources. These results underscore the importance of preparing for large-scale threats and implementing effective resource allocation policies.

In the position statement on the definition and diagnosis of acute myocarditis on page XXX of this issue of the Israel Medical Association Journal (IMAJ), we discussed contemporary criteria for definition of acute myocarditis and inflammatory cardiomyopathy [1-6]. We also addressed current diagnostic methods including indications for endomyocardial biopsy (EMB) [7-21]. In this position statement, we discuss the management approaches during hospitalization and following hospital discharge, including specific forms of myocarditis and recommendations for returning to physical activity after myocarditis [21-36].

Background: While several studies have noted smell impairment in schizophrenia, it is unclear whether this impairment extends to acute psychosis and whether it is associated with more severe illness as expressed in extended hospitalization.

Objectives: To evaluate the olfactory function of patients in an acute psychotic state and correlate it with clinical symptomatology and length of hospitalization.

Methods: Olfactory function was assessed in 20 patients with schizophrenia in their first week of hospital admission for acute psychosis compared with matched controls. Olfaction was evaluated via three stages: threshold, discrimination, and identification of different odors utilizing the Sniffin' Sticks test battery.

Results: Schizophrenia patients scored significantly lower on total smell score, discrimination, and identification abilities. A significant association was observed between hospitalization duration and total smell score and smell discrimination. No significant associations between smell and clinical symptomatology were observed.

Conclusions: Study observations confirm impaired sense of smell in schizophrenia patients and suggest that smell impairment may be a potential marker of more serious illness as expressed in longer hospital stay.

Background: Infants younger than 6 months of age are not eligible for coronavirus disease 2019 (COVID-19) vaccinations. Maternal variables during pregnancy and the postnatal period may affect the clinical and laboratory course of COVID-19 positive infants.

Objective: To assess the clinical manifestation and laboratory differences in infants with three maternal variables: breastfeeding, vaccinated, and co-illness.

Methods: We conducted a single-center retrospective cohort study of positive COVID-19 infants with three subgroups of maternal variables. The population included infants under 6 months of age hospitalized due to COVID-19. Data about clinical features, laboratory tests, and maternal information including vaccination status, breastfeeding status and maternal positive COVID-19 infection was gathered. All variables were compared among the three subgroups.

Results: Breastfed infants had shorter hospitalization period (mean 2.61 ± 1.378 days) compared to non-breastfed infants (mean 3.8 ± 1.549) (P = 0.051). COVID-19 infants of positive COVID-19 mothers had a higher absolute neutrophil count (mean 4.4 ± 3.8) compared to infants of COVID-19 negative mothers (mean 2.7 ± 2.4) (P = 0.042).

Conclusion: Breastfeeding was associated with shorter periods of hospitalization in COVID-19 positive infants. In addition, positive COVID-19 infants of mothers who were positive for COVID-19 are likely to have a higher absolute neutrophils count.

Background: The evaluation of syncope in emergency departments (EDs) and during hospitalization can be ineffective. The European Society of Cardiology (ESC) guidelines were established to perform the evaluation based on risk stratification.

Objectives: To investigate whether the initial screening of syncope adheres to the recent ESC guidelines.

Methods: Patients with syncope who were evaluated in our ED were included in the study and retrospectively classified based on whether they were treated according to ESC guidelines. Patients were divided into two groups according to the ESC guideline risk profile: high risk or low risk.

Results: The study included 114 patients (age 50.6 ± 21.9 years, 43% females); 74 (64.9%) had neurally mediated syncope, 11 (9.65%) had cardiac syncope, and 29 (25.45%) had an unknown cause. The low-risk group included 70 patients (61.4%), and the high-risk group included 44 (38.6%). Only 48 patients (42.1%) were evaluated according to the ESC guidelines. In fact, 22 (36.7%) of 60 hospitalizations and 41 (53.2%) of 77 head computed tomography (CT) scans were not mandatory according to guidelines. The rate of unnecessary CT scans (67.3% vs. 28.6%, respectively, P = 0.001) and unnecessary hospitalization (66.7% vs. 6.7%, respectively, P < 0.02) were higher among low-risk patients than high-risk patients. Overall, a higher percentage of high-risk patients were treated according to guidelines compared to low-risk patients (68.2% vs. 25.7% respectively, P < 0.0001).

Conclusions: Most syncope patients, particularly those with a low-risk profile, were not evaluated in accordance with the ESC guidelines.

Background: Children with forearm fractures who present to the emergency department (ED) often need a closed reduction. In our institution, until 2017, pediatric trauma patients presented to the general trauma ED (GTED) where no sedation services for pediatric patients were available. From 2017, patients presented to the pediatric emergency department (PED) where closed reductions were performed under sedation when appropriate.

Objectives: To compare GTED and PED with regard to length of stay (LOS) and hospitalization rates of pediatric patients with forearm fractures who needed a closed reduction.

Methods: Our retrospective observational study was conducted at a regional hospital. The study population consisted of all patients younger than 18 years of age who presented to the ED with a forearm fracture that needed a closed reduction. The primary outcome measure was the hospitalization rate. The secondary outcome measure was LOS in the ED.

Results: The study comprised 165 patients with forearm fractures who needed a closed reduction; 79 presented to the GTED, and 96 presented to the PED. Hospitalization rates were lower for patients undergoing closed reduction under sedation in the PED compared to the GTED (6.3% and 21.5%, respectively; P = 0.003). Median ED LOS was longer among patients undergoing sedation in the PED compared to the GTED (237 vs. 168 minutes respectively, P < 0.0001).

Conclusions: Sedation for forearm fracture reduction in a hospital’s PED was associated with a decrease of more than three times in hospitalization rate. Despite the need for more resources, PED LOS was only mildly increased.

Background: The global refugee crises have raised concerns among medical communities worldwide; nonetheless, access to healthcare has rarely been studied even though refugees are a medically high-risk group.

Objectives: To compare pediatric department admission rates from the pediatric emergency department (PED) of refugees and Israelis.

Methods: We compared data from refugee and Israeli children admitted to the pediatric department at Wolfson Medical Center in Israel between 2013–2017.

Results: A total of 104,244 patients (aged 0–18 years) came to the PED. Admission rate to the pediatric department for refugees was 695/2541 (27%) compared to 11,858/101,703 (11.7%) Israeli patients (P < 0.001). Hospital stay for patients 0–2-years of age was 3.22 ± 4.80 days for refugees vs. 2.78 ± 3.17 for Israelis (P < 0.03). Re-admission rate within 7 days was 1.3% for refugees and 2.6% for Israelis (P < 0.05). Dermatological diseases (e.g., impetigo and cellulitis) were more frequent in refugees (23.30% vs. 13.15%, P < 0.01); however, acute gastroenteritis and respiratory diagnoses were more common in Israelis (18.52% vs. 11.72%, P < 0.05 and 14.84% vs. 6.26%, P < 0.01, respectively). Neurological diseases (e.g., febrile convulsions) were also more frequent in Israelis (7.7% vs. 3%, P < 0.05). Very significantly, 23% of refugees had no healthcare coverage, while only 0.2% of the Israelis had none (P < 0.001).

Conclusions: We found significant morbidity in refugees compared to the local Israeli pediatric population, highlighting the need for different approaches for each population.

Background: During coronavirus disease 2019 (COVID-19) pandemic, less isolation of common winter viruses was reported in the southern hemisphere.

Objectives: To evaluate annual trends in respiratory disease-related admissions in a large Israeli hospital during and before the pandemic.

Methods: A retrospective analysis of medical records from November 2020 to January 2021 (winter season) was conducted and compared to the same period in two previous years. Data included number of admissions, epidemiological and clinical presentation, and isolation of respiratory pathogens.

Results: There were 1488 respiratory hospitalizations (58% males): 632 in 2018–2019, 701 in 2019–2020, and 155 in 2020–2021. Daily admissions decreased significantly from a median value of 6 (interquartile range [IQR] 4–9) and 7 per day (IQR 6–10) for 2018–2019 and 2019–2020, respectively, to only 1 per day (IQR 1–3) in 2020–2021 (P-value < 0.001). The incidence of all respiratory viruses decreased significantly during the COVID-19 pandemic, with no hospitalizations due to influenza and only one with respiratory syncytial virus. There was also a significant decline in respiratory viral and bacterial co-infections during the pandemic (P-value < 0.001).

Conclusions: There was a significant decline in pediatric respiratory admission rates during the COVID-19 pandemic. Possible etiologies include epidemiological factors such as mask wearing and social distancing, in addition to biological factors such as viral interference. A herd protection effect of adults and older children wearing masks may also have had an impact.

Background: The coronavirus disease 2019 (COVID-19) pandemic has severe consequences in terms of mortality and morbidity. Knowledge of factors that impact COVID-19 may be useful in the search for treatments.

Objectives: To determine the effect of glucose-6-phosphate dehydrogenase (G6PD) deficiency on morbidly and mortality associated with COVID-19.

Methods: All patients admitted to Hadassah Hebrew University Medical Center between 01 March 2020 and 03 May 2021 with a diagnosis of COVID-19 were included. We retrospectively retrieved demographic, clinical, and laboratory data from the hospital’s electronic medical records. The main outcomes were mortality, intensive care unit (ICU) admission, and severity of COVID-19.

Results: The presence of G6PD deficiency emerged as an independent protective predictor for ICU admission (odds ratio [OR] 0.258, 95% confidence interval [95%CI] 0.077–0.619, P = 0.003) and the development of critical illness (OR 0.121, 95%CI 0.005–0.545, P = 0.006). Moreover, patients with G6PD deficiency had a trend toward lower mortality rates that did not reach statistical significance (OR 0.541, 95%CI 0.225–1.088, P = 0.10).

Conclusions: Patients with G6PD deficiency were less likely to have a severe disease, had lower rates of ICU admission, and trended toward lower mortality rates.

Background: Statins have anti-inflammatory effects that are independent of their lipid-lowering activity.

Objectives: To examine whether prior statins therapy affects the clinical course of the first episode of acute idiopathic pericarditis (AIP) as the 1-year recurrence and length of hospitalization (LOH).

Methods: This retrospective study included 148 subjects with first episode AIP admitted between the years 2015 and 2019. Data were collected from two hospitals in Northern Israel. We divided the patients in into two groups: 117 those without statins use and 31 those with prior statins use. We compared age, sex, co-morbidities, drugs, laboratory data, 1-year recurrence, and LOH.

Results: The mean age of participants was 43.1 ± 19.4 years. Comparisons between subjects without statins and with prior statins use were made according to age (37.5 ± 16.7 years vs. 64.4 ± 12.7 years, P < 0.01), C-reactive protein (50 ± 40 vs. 48 ± 35 mg/dl, P = 0.9), LOH (5.4 ± 2.85 vs. 8.03 ± 4.92 days, P < 0.01), 1-year recurrence of pericarditis (23 vs. 6 cases, P = 0.95), respectively. Multivariate logistic regression analysis revealed that 1-year recurrence (odds ratio [OR] 0.8, 95% confidence interval [95%CI 0 0.6–1.1, P = 0.41), was not associated with prior statin use, while LOH (OR 2.56, 95%CI 2.08–2.75, P = 0.01) was prolonged with prior statins use in patients with first episode of AID.

Conclusions: Prior statins use in patients with the first episode of AIP did not reduce the 1-year recurrence of pericarditis and prolong the LOH.

Background: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. Previous studies showed that rhythm and rate control strategies are associated with similar rates of mortality and serious morbidity. Beta blockers (BB) and calcium channel blockers (CCB) are commonly used and the selection between these two medications depends on personal preference.

Objectives: To compare real-time capability of BB and CCB for the treatment of rapid AF and to estimate their efficacy in reducing hospitalization duration.

Methods: We conducted a retrospective cohort study of 306 patients hospitalized at Soroka Hospital during a 5-year period with new onset AF who were treated by a rate control strategy.

Results: A significant difference between the two groups regarding the time (in hours) until reaching a target heart rate below 100 beats/min was observed. BB were found to decrease the heart rate after 5 hours (range 4–14) vs. 8 hours (range 4–18) for CCB (P = 0.009). Patients diagnosed with new-onset AF exhibited shorter duration of hospitalization after therapy with BB compared to CCB (median 72 vs. 96 hours, P = 0.012) in the subgroup of patients discharged with persistent AF. There was no significant difference between CCB and BB regarding the duration of hospitalization (P = 0.4) in the total patient population.

Conclusions: BB therapy is more potent for rapid reduction of the heart rate compared to CCB and demonstrated better efficiency in shortening the duration of hospitalization in a subgroup of patients. This finding should be reevaluated in subsequent research.

Background: Advanced heart failure (HF) carries a high rate of recurrent HF hospitalizations and a very high mortality rate. Mechanical devices and heart transplantation are limited to a select few. Dialysis may be a good alternative for advanced HF patients with volume overload despite maximal pharmacological therapy.

Objectives: To assess the net clinical outcome of peritoneal dialysis or hemodialysis in patients with advanced HF.

Methods: We analyzed all advanced HF patients who were referred for dialysis due to volume overload in our institution. Patients were followed for complications, HF hospitalizations, and survival.

Results: We assessed 35 patients; 10 (29%) underwent peritoneal dialysis and 25 (71%) underwent hemodialysis; 71% were male; median (interquartile range) age was 74 (67–78) years. Estimated glomerular filtration rate was 20 (13–32) ml/min per 1.73 m². New York Heart Association functional capacity was III. Median follow-up time was 719 days (interquartile range 658–780). One-year mortality rate was 8/35 (23%) and overall mortality rate was 16/35 (46%). Three patients (9%) died during the first year due to line or peritoneal dialysis related sepsis, and 6 (17%) died during the entire follow-up. The median number of HF hospitalizations was significantly reduced during the year on dialysis compared to the year prior to dialysis (0.0 [0.0–1.0] vs. 2.0 [0.0–3.0], P < 0.001).

Conclusions: Dialysis is reasonably safe and significantly reduced HF hospitalization in advanced HF patients. Dialysis could be a good alternative for advanced HF patients with intractable volume overload.

Hospitalization of ulcerative colitis patients is needed in severe exacerbation of the disease or for managing complications. In this systematic review and meta-analysis the prevalence of hospitalization in ulcerative colitis and possible predictive factors are discussed. A systematic literature search of English language publications that were published before 31 December 2019 was conducted. Retrospective cohort studies describing hospitalizations of UC patients were included. Meta-analysis was performed by using comprehensive meta-analysis software. Pooled odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated for the number of patients hospitalized. Seven studies and 15 datasets were found that fulfilled the inclusion criteria. In total, the studies included 2067 patients from six countries. The event rates for the number of patients hospitalized in a follow-up duration of 42,320 patient-years and for the number of patients underwent operation in a follow-up of 24,650 patient-years were 0.065 (95%CI 0.063–0.068) and 0.019 (95%CI 0.017–0.021), respectively. More studies during the era of biologics need to be performed to identify the factors predictive of hospitalization and surgery with UC. Prevention of inflammation and UC complications may prevent hospitalization and the need for surgical treatment

Background: Patients with severe chronic obstructive pulmonary disease (COPD) experience frequent exacerbations and need to be hospitalized, resulting in an economic and social burden. Although data exist regarding reasons of frequent hospitalizations, there is no data available about the impact on the length of stay (LOS).

Objectives: To characterize the causes of prolonged hospitalizations in COPD patients.

Methods: A retrospective study was conducted of patients who were diagnosed and treated in the pulmonary department for severe COPD exacerbations. All patient demographic data and medical history were collected. Data regarding the disease severity were also collected (including Global Initiative for Obstructive Lung Disease [GOLD] criteria, pulmonologist follow-up, prior hospitalizations, and LOS).

Results: The study comprised 200 patients, average age 69.5 ± 10.8 years, 61% males. Of these patients, 89 (45%) were hospitalized for up to 4 days, 111 (55%) for 5 days or more, and 34 (17%) for more than 7 days. Single patients had longer LOS compared with married patients (48% vs. 34%, P = 0.044). Multivariate analysis showed that the number of prior hospital admissions in the last year was a predictor of LOS (P = 0.038, odds ratio [OR] = 0.807, 95% confidence interval [95%CI] = 0.659–0.988), as well as the use of non-invasive respiratory support by bilevel positive airway pressure (BiPAP) during the hospitalization (P = 0.024, OR = 4.662, 95%CI = 1.229–17.681).

Conclusions: Fewer previous hospitalizations due to COPD exacerbations and the need for non-invasive respiratory support by BiPAP were found as predictors of longer LOS.

Despite advances in therapeutic modalities, especially with biologic treatments, the number of hospitalizations due to complications for Crohn's disease did not decrease. We examined the prevalence and possible predictive factors of hospitalizations in Crohn's disease. A systematic literature search was conducted until 31 October 2018. Relevant studies were screened according to established protocol. Retrospective cohort studies describing hospitalizations of Crohn's disease patients were included. Meta-analysis was performed by using comprehensive meta-analysis software. Pooled odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated for the number of patients hospitalized. Twelve studies published before 31 March 2018 fulfilled the inclusion criteria and were comprised of 23 data-sets and included 4421 patients from six countries. A funnel plot demonstrates a moderate publication bias. We reported the event rates for the number of patients hospitalized, in a follow-up survey of 20,987 patient-years, and for the patients who underwent surgery in a follow-up of 5061 patient-years, with ORs of 0.233 with 95%CI 0.227–0.239, and 0.124 with 95%CI 0.114–0.135 (P < 0.001), respectively. Thus, when collecting the data from 12 cohort studies we found that hospitalization takes place in 23.3% of the patients, and operation in 12.4% along their disease duration. Patients with Crohn's disease may be hospitalized due to exacerbation of their inflammatory disease, because of non-inflammatory disease (such as fistula or stricture), or due to medical complications. The goal of therapy should be to keep the Crohn's disease patients in their natural environment and out of the hospital and to prevent surgery as much as possible.