Search

Background: Red blood cell transfusion (RBCT) is a therapeutic procedure with important and undesirable secondary effects. Inappropriate overuse of RBCT is significant, and a significant percentage of physicians prescribe RBCT unnecessarily. Patient involvement in treatment decision-making is poor worldwide. Shared (with the patient) transfusion decision-making (TrDM) can temper a “quick finger on the trigger” of blood transfusion (BT). The objective of this study was to determine patients’ preferences surrounding their involvement in the TrDM process as well as physicians’ willingness to involve the patient in TrDM. The study also determined the role of patient age, gender, ethnicity, and schooling years in the TrDM process. Methods: This cross-sectional study was conducted in a variety of departments, with 123 patients over 18 years old, who received a BT for the first time. The patients completed an anonymous questionnaire which included demographic characteristics (age, gender, ethnicity, and schooling years) and 2 questions linked to potential willingness to participate in the decision to transfuse. Results: The questionnaire response rate was 100%. The data showed that 60% of patients (especially younger patients), independent of ethnicity, preferred a passive role in TrDM and 40% preferred to share the decision. Conclusions: The majority of patients, especially younger patients, prefer a passive role in TrDM, possibly due to insufficient information about the need for BT and its significance. We feel that active involvement on the part of the patient can provoke a more judicious thought process about the real need of BT on the part of the physician and have a positive influence on patient blood management.

A significant percentage of red blood cell transfusions (RBCTs) are the result of overuse. The implementation of patient blood management (PBM) is challenging. We examined whether blood-linked myths and ethnic-cultural background factors are impediments to PBM education and implementation. Data about the influence of blood myths and diverse ethnic-cultural communities were collected from physicians in our medical center via an anonymous questionnaire which contained questions about myths as well as knowledge of blood transfusion. No statistical differences were found between ethnic and cultural groups regarding blood myths and cultural background influence, although the Jewish participants were less influenced by myths than their Arab colleagues. The influence of blood myths concerning the decision to transfuse exists in both studied ethnic groups. With regard to the association between knowledge and myths influence, we found that the greater the knowledge of the participant, the lower was the myths influence. In a significant proportion of our physician cohort, blood myths and cultural-ethnic status influenced their approach toward RBCT and can be considered an impediment in PBM education. A high knowledge level is associated with less myths influence. The myths and cultural-ethnic background may play a role in PBM education.

Venous thromboembolism (VTE) is a serious disease, which demands a fast accurate diagnosis to begin suitable treatment. It presents a major problem in the emergency department (ED), and its confirmation requires adequate evaluation.To evaluate a potential role of mean platelet volume (MPV) in differentiating VTE from other potential diagnosis in patients with suspected VTE.We conducted a retrospective case-controlled study of 440 consecutive patients who presented to the ED of our hospital with clinical VTE, but only 316 with proven VTE. A control group was composed of patients (124) who presented with clinical VTE but without proven VTE. We checked the MPV value in all 440 patients and the correlation with VTE occurrence in the study group vs. control group.Statistical analysis of the acquired results indicated that MPV value could not aid in determining the difference of real VTE vs. patients with VTE-like clinical picture presenting to the ED. We found an inverse correlation between MPV value and proven VTE, in contrast to most researchers who have studied the same issue.Although MPV can be a useful diagnostic marker in many diseases, we found no definite association between low MPV and VTE.

Objective Studies have demonstrated a potential correlation between low vitamin D status and both an increased risk of infection with SARS-CoV-2 and poorer clinical outcomes. This retrospective study examines if, and to what degree, a relationship exists between pre-infection serum 25-hydroxyvitamin D (25(OH)D) level and disease severity and mortality due to SARS-CoV-2. Participants The records of individuals admitted between April 7th, 2020 and February 4th, 2021 to the Galilee Medical Center (GMC) in Nahariya, Israel, with positive polymerase chain reaction (PCR) tests for SARS-CoV-2 (COVID-19) were searched for historical 25(OH)D levels measured 14 to 730 days prior to the positive PCR test. Design Patients admitted to GMC with COVID-19 were categorized according to disease severity and level of 25(OH)D. An association between pre-infection 25(OH)D levels, divided between four categories (deficient, insufficient, adequate, and high-normal), and COVID-19 severity was ascertained utilizing a multivariable regression analysis. To isolate the possible influence of the sinusoidal pattern of seasonal 25(OH)D changes throughout the year, a cosinor model was used. Results Of 1176 patients admitted, 253 had records of a 25(OH)D level prior to COVID-19 infection. A lower vitamin D status was more common in patients with the severe or critical disease (p < 0.001). Patients with vitamin D deficiency (p < 0.001). Conclusions Among hospitalized COVID-19 patients, pre-infection deficiency of vitamin D was associated with increased disease severity and mortality.

Vaccine hesitancy is a global health threat which may hinder the widespread acceptance of several COVID-19 vaccines. Following the collection of 2470 responses from an anonymous questionnaire distributed between October and November 2020 across Israel, we analyzed the responses of physicians, life science graduates (biology, virology, chemistry, etc.), and the general public to whether they would obtain a COVID-19 vaccine with particular vaccine characteristics such as vaccine country of origin, technology, side effect profile, efficacy, and other attributes. Physicians and life science graduates were least likely to accept a vaccine based on mRNA technology (30%) while the general population seemed to adopt any vaccine technology if the declared efficacy is above 90% and the country of manufacturing is the USA/UK rather than China or Russia. However, current inoculation rates in Israel far outpace our predicted rate. Our results highlight the importance of tailored vaccine educational campaigns based on population demographic details and specific vaccine concerns.

To assess the usefulness of proton MR-spectroscopy (1H-MRS) and diffusion-weighted MRI (DW-MRI) sequences in the follow-up of CLL-patients with chemotherapy treatment.

Background: Northern Israel is characterized by a multi-ethnic population. We looked for differences in the risk factors for hyperglycemia in Jews, Muslims and Druze without diabetes. Methods: Adult visitors to our Medical Center without known diabetes were included in the study. A point-of-care (POC) capillary blood glucose level with institutional glucometer and a seated blood pressure were measured and additional data were collected from an interview. We excluded people with hypoglycemic drug usage, acute disease, glucocorticoid usage, pregnancy and capillary blood glucose in the diabetes range. The blood glucose levels were divided according to last caloric intake to postprandial (4 hours or less) or pre-prandial (more than 4 hours). Hyperglycemia was defined as pre-prandial blood glucose level ≥100 mg/dl or postprandial glucose level ≥140 mg/dl. High systolic blood pressure was defined as ≥140 mm Hg. Backward stepwise logistic regression was used to identify the factors independently associated with hyperglycemia. Results: A total of 1062 Jews, 419 Muslims and 341 Druze were included in the analysis. 57% of Muslims, 44% of Jews and 34% of Druze reported that they are religious. Compare to Jews, Muslims had increased risk for hyperglycemia (OR 1.73, 95% CI 1.22-2.43, p=0.002) and Druze had no significant difference. After adjusting for sex, high systolic blood pressure and fewer than 12 years of education, age was a significant risk factor for hyperglycemia in all three religions and obesity was an independent risk factor for Druze (OR 2.45, 95% CI 1.28-4.69, p=0.07) and Muslims (OR 2.25, 95% CI 1.31-3.86). Only religious Muslims had an independently lower risk for hyperglycemia than non-religious Muslims (OR 0.5, 95% CI 0.29-0.86, p=0.012). Conclusion: Religion and religiosity are independently associated with hyperglycemia in people without diabetes. Muslims in north Israel have increased risk for hyperglycemia compared to Jews but this risk is lower in religious people. Disclosure A. Bashkin: None. M. Shehadeh: None. R. Yaacovy: None. M. Nodelman: None. A. Zur: None. M. Barhoum: None.

MicroRNAs play functional roles in the etiology of type 2 diabetes mellitus (T2DM) and complications, and extracellular microRNAs have attracted interest as potential biomarkers of these conditions. We aimed to identify a set of plasma microRNAs, which could serve as biomarkers of T2DM and complications in a mixed Israeli Arab/Jewish patient sample. Subjects included 30 healthy volunteers, 29 early-stage T2DM patients, and 29 late-stage T2DM patients with renal and/or vascular complications. RNA was isolated from plasma, and the levels of 12 candidate microRNAs were measured by quantitative reverse transcription and polymerase chain reaction (qRT-PCR). MicroRNA levels were compared between the groups and correlated to clinical measurements, followed by stepwise regression analysis and discriminant analysis. Plasma miR-486-3p and miR-423 were respectively up- and down-regulated in T2DM patients compared to healthy controls. MiR-28-3p and miR-423 were up-regulated in patients with complicated T2DM compared to early T2DM, while miR-486-3p was down-regulated. Combined, four microRNAs (miR-146a-5p, miR-16-2-3p, miR-126-5p, and miR-30d) could distinguish early from complicated T2DM with 77% accuracy and 79% sensitivity. In male patients only, the same microRNAs, with the addition of miR-423, could distinguish early from complicated T2DM with 83.3% accuracy. Furthermore, plasma microRNA levels showed significant correlations with clinical measurements, and these differed between men and women. Additionally, miR-183-5p levels differed significantly between the ethnic groups. Our study identified a panel of specific plasma microRNAs which can serve as biomarkers of T2DM and its complications and emphasizes the importance of sex differences in their clinical application.

The immunotherapy treatments offered for Chronic lymphocytic leukemia (CLL) activate various cellular and biochemical mechanisms, including the complement system. Recently it was shown that the classical complement pathway (CP) in CLL patients is persistently activated at a low level through (Michelis et al. PlosOne, 2019), and that the mechanism of chronic CP activation involves the formation of IgG-hexamers (Michelis et al. PlosOne, 2020). According to recent studies, formation of ordered IgG-hexamers occurs on cell surfaces via specific interactions between Fc regions of the IgG monomers, which occur only after antigen binding. The study investigated the formation of IgG-hexamers in CLL patients and normal controls (NC), their ability to activate complement, their incidence as cell-free and cell-bound forms and the identity of the antigen causing their formation. Sera from 30 patients and NC were used for separation of IgG-hexamers. The obtained IgG-hexamers were measure and used for assessment of CP activity. For evaluation of the presence of IgG-hexamers on blood cells, whole blood samples were stained and assessed by flow cytometry. Serum levels of IgG-hexamers were higher in patients compared to NC. Also, they activated the complement system to a higher extent in patients than in NC. Alpha 2 macroglobulin (A2M) was recognized as the antigen causing the hexamerization of IgG, and was found to be part of the hexamer structure by mass spectrometry, Western blot and flow cytometry analysis. The presence of A2M-IgG-hexamers on B-cells suggests that it may be formed on B cells surface and then be detached to become cell-free. Alternatively, it may form in the plasma and then attach to the surface of the cells. The exact course of A2M-IgG-hexamers formation in CLL should be further studied. The results in this study may be useful for improvement of current immunotherapy regimens. Disclosures Tadmor: Neopharm: Consultancy, Speakers Bureau; AbbVie: Consultancy, Speakers Bureau; Janssen: Consultancy, Speakers Bureau; Takeda: Consultancy, Speakers Bureau; Sanofi: Consultancy, Speakers Bureau; Medison: Consultancy, Speakers Bureau; 6. Novartis Israel Ltd., a company wholly owned by Novartis Pharma AG: Consultancy, Speakers Bureau. Aviv:Abbvie: Honoraria.

Chronic lymphocytic leukemia (CLL) is the most common adult leukemia in the Western world. The therapeutic approach to CLL includes chemotherapeutic regimens and immunotherapy. Complement-mediated cytotoxicity, which is one of the mechanisms activated by the therapeutic monoclonal antibodies, depends on the availability and activity of the complement (C) system. The aim was to study the structure of circulating C components and evaluate the importance of C5 structural integrity for C activity in CLL patients. Blood samples were collected from 40 naïve CLL patients and 15 normal controls (NC). The Western blot analysis showed abnormal C5 pattern in some CLL patients, while patterns of C3 and C4 were similar in all subjects. Levels of the C activation markers sC5b-9 and C5a were quantified before and after activation via the classical (CP) and alternative (AP) pathways. In patients with abnormal C5, basal levels of sC5b-9 and C5a were increased while activities of the CP and of the CP C5-convertase, the immediate C5-upstream complex, were decreased compared to NC and to patients with normal C5. The data indicate a link between CP activation and apparent C5 alterations in CLL. This provides a potential prognostic tool that may personalize therapy by identifying a sub-group of CLL patients who display an abnormal C5 pattern, high basal levels of sC5b-9 and C5a, and impaired CP activity, and are likely to be less responsive to immunotherapy due to compromised CP activity.

As an expected consequence of the civil war in Syria, emergent neurosurgical care for battlefield trauma has been provided for severely head-injured Syrians transferred to Northern Israel.Sixty-six patients suffering from brain injury were brought to the border and then referred to the institution after initial resuscitation. Both the time and type of injury were recorded based on paramedic testimony, forensic material or on details provided by patients. A retrospective analysis of all medical charts and imaging material was performed.Most injuries were combat-related, either caused by blast (13.6%), shrapnel (24.2%), assault (28.8%) or gunshot wound (15.2%). Only a minority of patients (18.2%) suffered from injuries that were not directly caused by weapon. A total of 55 surgical procedures were performed in 46 out of 66 patients, including craniotomies in 40 patients, burr hole alone for placement of intraparenchymal intracranial pressure (ICP) sensor in nine instances and ventricle peritoneal shunt in two patients. Decompressive craniectomy was used only for the treatment of gunshot wound and was performed in eight out of 10 patients. The most common complication consisted in cerebrospinal fluid fistulas (16.7%). Post-operative infections occurred in seven patients (10.6%). Short-term outcomes were favourable in 60.7%, with a mortality rate of 4.5%.The present findings suggest that aggressive surgery and neuro-intensive care measures may lead to good functional results, even in the presence of seemingly devastating injuries in some selected patients.

It was clear to the anguished parents that any hope to save the life of their son would be in the West, beyond the border. Thus, a 12-year-old boy appeared one morning in September 2014, draped over a donkey’s back and accompanied by his adolescent brother, who deposited him in the care of Israeli soldiers and returned to Syria. The boy lost his eyesight and suffered multiple fractures when his home in Damascus was bombed. The local surgeons had no option but to amputate his right arm below the elbow and were considering amputation of the lower limbs as well. Desperate, the family smuggled him to Israel, having heard rumors of the prospects for limb salvage there. The media tend to describe the huge numbers of casualties and refugees as masses of hundreds of thousands. Yet, individual stories such as this one vividly embody the immeasurable tragedy.1 The Syrian civil war started during the Arab Spring in 2011. After initial high hopes for a change of regimen and for democracy, the country rapidly deteriorated into a bloody conflict. Targeting civilians has emerged as a brutal form of warfare, with the intentional and systemic destruction of infrastructure for health care and education. Emergency services as well as routine medical … Address correspondence to Anath A. Flugelman, MD, MPH, Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, 7 Michal St, Haifa, Israel 34642. E-mail: cmdanath{at}clalit.org.il

Blood transfusion questionnaire. (DOCX 14 kb)

During the last two decades the importance of molecular biology in transfusion medicine has been growing. Reference centers for immunohematology commonly use molecular methods to clarify problems, discrepancies or unusual results in patient serology. Nowadays there are immunohematology reference laboratories that recommend using molecular genotyping for patient blood management. Our blood bank laboratory is not a reference center, but we routinely use molecular genotyping to solve serologic problems. Due to the proximity to the Syrian border, since the beginning of the Syrian civil war, our medical center has received hundreds of injured patients, some of them with unique features concerning the blood type testing. From our previous experience of such a case in Dec 2015, we realized that due to extreme war conditions and lack of medical amenities, severely injured patients are likely to receive unmatched blood transfusions in Syria, sometimes ABO-incompatible blood transfusions. The patients arriving to our medical center are usually in critical condition and without medical records. Serologic tests show double population (DP) blood type. Molecular genotype of blood samples is not helpful, because it can detect the blood type of the unmatched/incompatible donor. In these cases, we use molecular genotyping from a tissue specimen, usually skin. Until we receive the results, which take about 5 hours in our molecular lab, we give only type O blood and AB plasma. Since Dec 2015, 11 injured patients with DP on serologic typing were admitted to our medical center. Tissue genotyping was performed on 8 of these. We determined that seven of the eleven patients previously received ABO-incompatible blood in Syria. With one exception, all patients were transfused in Israel (detailed data not shown), three with incompatible blood upon admission, based on initial serotype (patients 1,3,4 in the table). Tissue genotyping allowed us to transfuse compatible ABO-matched blood components afterward. All patients survived and were released in good condition. Tissue molecular genotyping helps improve patient blood management in the population of injured causalities from Syria. Table. Table. Disclosures No relevant conflicts of interest to declare.

Introduction Hospitals worldwide are preparing for mass casualty incidents (MCIs). The Major Incident Hospital in the Netherlands was constructed 25 years ago as a dedicated hospital for situations wherein a sudden increase in medical surge capacity is mandated to handle an MCI. Over the years, more initiatives of dedicated MCIs have arisen. Herein, we compared the MCI facilities from three countries considering the reasons for construction and the functionality. Methods Three dedicated mass casualty hospitals and one hospital with a largely fortified structure were compared. The centres were located in the Netherlands, Italy, and Israel. Between August 2015 and January 2016, structured interviews were conducted with representatives of the hospitals’ medical operations. The interviews focussed on general information regarding the need for MCI preparedness and scenarios that require preparation, reasons for construction, hospital missions, and the experiences gained including training. Results All dedicated MCI hospitals had a common policy wherein they sought to create normal work circumstances for the medical staff by using similar equipment and resources as in normal hospitals. The MCI hospitals’ designs differed substantially, as determined by the threats faced by the country. In Europe, these hospitals are designed as a solution to surge capacity and function as buffer hospitals offering readily available, short term, additional medical capacity to the local health care system. Israel faces constant threat from long-term conflicts; during the 2006 war, several hospitals suffered direct missile impacts. Therefore, Israeli MCI hospitals are designed to be fortified structures offering shelter against both conventional and non-conventional warfare and intended as a long-term solution during siege situations. Conclusion Several dedicated MCI hospitals are presently being constructed. During construction, the local circumstances should be taken into account to determine the functionality for both short-term solutions for surge capacity and as fortified structures to withstand under-siege situations.

Quality improvement in health care organizations requires structural reorganization and system reform and the development of an appropriate organizational "culture." In 2007, the Division of Quality and Excellence in Civil Service in Israel developed a concept to improve quality management in governmental institutions throughout the country. To put this strategy into practice, Western Galilee Hospital, a governmental hospital, in northern Israel, developed a plan to advance the quality management system where each department and unit is autonomously responsible for its own quality and excellence. Since the hospital has been certificated by ISO 9001 for more than 10 years (the only hospital in Israel to have this certificate), the main challenge now is to improve the quality and excellence system in every department. The aim of this article is to describe the implementation of a comprehensive program designed to raise the ability of managers and workers in Western Galilee Hospital in addressing all of the government's requirements for quality and excellence in service in Israel.