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Critically ill patients with sepsis often require packed cell transfusions (PCT). However, PCT may affect white blood cell (WBC) counts. We conducted a population-based retrospective cohort study to trace changes in WBC count following PCT in critically ill patients with sepsis. We included 962 patients who received one unit of PCT while hospitalized in a general intensive care unit, and 994 matched patients who did not receive PCT. We calculated the mean values of WBC count for the 24 h before and 24 h after PCT. Multivariable analyses using a mixed linear regression model were performed. The mean WBC count decreased in both groups, but more in the non-PCT group (from 13.9 × 109/L to 12.2 × 109/L versus 13.9 × 109/L to 12.8 × 109/L). A linear regression model showed a mean decrease of 0.45 × 109/L in WBC count over the 24 h following the start of PCT. Every 1.0 × 109/L increase in the WBC count prior to PCT administration showed a corresponding decrease of 0.19 × 109/L in the final WBC count. In conclusion, among critically ill patients with sepsis, PCT causes only mild and clinically non-prominent changes in WBC count.

ObjectiveThe effectiveness of COVID-19 vaccinations wanes due to immune evasion by the B.1.1.529 (Omicron) variant and diminished antibody titres over time. We aimed to evaluate the benefit of a fourth vaccination dose in patients with autoimmune rheumatic diseases (ARDs).MethodsThis retrospective analysis included ARD patients aged 18 years or older and members of Clalit Health Services in Israel (which at the time of the study insured 52% of the entire population), and covered the period from 16 January 2022 to 31 March 2022, when the predominant SARS-CoV-2 variant was Omicron. We compared patients without previous COVID-19 infection who had received three doses of the BNT162b2 vaccine (the control group) with those who had received the fourth dose. The primary outcome was COVID-19 infection, which was analysed using multivariate Cox regression in the entire cohort and within ARD subgroups. Secondary outcomes were COVID-19–related hospitalizations and COVID-19–related death.ResultsWe included 43 748 ARD patients, of whom 27 766 and 15 982 were in the control and fourth vaccination groups, respectively. COVID-19 infection occurred in 6942 (25.0%) of the control group and 1754 (11.0%) of the fourth dose group (P ConclusionA fourth BNT162b2 vaccination of ARD patients was associated with favourable outcomes compared with three doses among patients with no history of COVID-19 infection.

Objective: We aimed to investigate the association between glucose coefficient of variation (CV) and mortality and disease severity in hospitalized patients with coronavirus disease-19 (COVID-19). Subjects and methods: Retrospective cohort study in a tertiary center of patients with COVID-19 admitted to designated departments between March 11th, 2020, and November 2nd, 2020. We divided patients based on quartiles of glucose CV after stratification to those with and without diabetes mellitus (DM). Main outcomes were length of stay and in-hospital mortality. Results: The cohort included 565 patients with a mean age of 67.71 ± 15.45 years, and 62.3% were male. Of the entire cohort, 44.4% had DM. The median glucose CV was 32.8% and 20.5% in patients with and without DM, respectively. In patients with DM, higher glucose CV was associated with a longer hospitalization in the unadjusted model (OR = 2.7, 95% CI [1.3,5.6] for Q4), and when adjusted for age, sex, comorbidities, and laboratory markers, this association was no longer statistically significant (OR = 1.3, 95% CI [0.4,4.5] for Q4). In patients with and without DM, higher glucose CV was associated with higher rates of in-hospital mortality in the unadjusted model, but adjustment for comorbidities and laboratory markers eliminated the association (OR = 0.5, 95% CI [0.1,3.4] for Q4 in patients with DM). Conclusion: Higher glucose CV was associated with increased in-hospital mortality and length of stay, but this association disappeared when the adjustment included laboratory result data. Glucose CV can serve as a simple and cheap marker for mortality and severity of disease in patients with COVID-19.

Medical cannabis use is increasing rapidly in the past several years, with older adults being the fastest growing group. Nevertheless, the evidence for cardiovascular safety of cannabis use is scarce. The aim of this study was to assess the effect of cannabis on blood pressure, heart rate, and metabolic parameters in older adults with hypertension.We conducted a prospective study of patients aged 60 years or more with hypertension and a new prescription of cannabis. We have performed the following assessments: 24-hours ambulatory blood pressure monitoring, ECG, blood tests, and anthropometric measurements prior to the initiation of cannabis therapy and 3 months afterward. The primary outcome was change in mean 24-h blood pressure at 3 months.Twenty-six patients with a mean age of 70.42 ± 5.37 years, 53.8% females completed the study. At 3 months follow-up, the mean 24-hours systolic and diastolic blood pressures were reduced by 5.0 mmHg and 4.5 mmHg, respectively (p0.001 for both). The nadir for the blood pressure and heart rate was achieved at 3 hours post-administration. The proportion of normal dippers changed from 27.3% before treatment to 45.5% afterward. No significant changes were seen in the different metabolic parameters assessed by blood tests, anthropometric measurements, or ECG exam.amongst older adults with hypertension, cannabis treatment for 3 months was associated with a reduction in 24-hours systolic and diastolic blood pressure values with a nadir at 3 hours after cannabis administration.

BACKGROUND Gun violence in the United States is a significant public health concern. The high rate of weapons carriage by Americans places medical providers at risk for exposure to firearms in the workplace and provides an opportunity for patient safety counseling. Few curricular interventions have been published on teaching firearms safety principles to medical providers. Given the risk of encountering firearms in the workplace and the opportunity to engage patients in firearms safety counseling, providers may benefit from dedicated training on safely handling firearms. METHODS This was a prospective cohort pilot study of a simulation-based educational intervention for third- and fourth-year medical students enrolled in an emergency medicine subinternship and emergency medicine bootcamp elective. Before undergoing the educational intervention, students completed a preintervention simulation case during which they discovered a model firearm in the patient's belongings and were asked to remove it. Students then received the intervention that included a discussion and demonstration on how to safely remove a firearm in the clinical setting. Two weeks later, the students were presented with a model firearm in a different simulation case, which they needed to remove. During the preintervention and postintervention simulations, students were evaluated on their performance of the critical actions in firearm removal using an 8-item checklist. Students' scores on this checklist were compared. RESULTS Fifty-three students participated in the study, 25 of whom completed the postintervention assessment. The median number of correctly performed critical actions preintervention was 5 (interquartile range = 4-6) and postintervention was 7 (interquartile range = 6-8, P < 0.001). Students showed particular improvement in 4 steps: holding the firearm by the grip only, pointing the firearm in a safe direction at all times, removing the firearm from the immediate patient care area and placing it in a safe area, and ensuring that the firearm is monitored and untouched until police or security personnel arrive to secure it. CONCLUSIONS This educational intervention is the first to formally teach students about the safe handling of firearms found in the clinical care space. This low-cost pilot project is easily transferrable to other training centers for teaching principles of safe firearms handling.

IntroductionEmerging evidence supports the immunogenic response to mRNA COVID-19 vaccine in patients with autoimmune rheumatic diseases (ARD). However, large-scale data about the association between vaccination, and COVID-19 outcomes in patients with ARD is limited.MethodsWe used data from Clalit Health Services, which covers more than half of the population in Israel. Patients with ARD older than 18 were included between 20 December 2020 and 30 September 2021, when the BNT162b2 mRNA COVID-19 vaccine, and later a third booster dose, were available. The primary outcome was a documented positive SARS-CoV-2 PCR test. We used a Cox regression models with vaccination status as time-dependent covariate and calculated the HR for the study outcome.ResultsWe included 127 928 patients with ARD, of whom, by the end of the study follow-up, there were 27 350 (21.3%) unvaccinated patients, 31 407 (24.5%) vaccinated patients and 69 171 (54.1%) patients who also received a third booster-dose. We identified 8470 (6.6%) patients with a positive SARS-CoV-2 PCR test during the study period. The HR for SARS-CoV-2 infection among the vaccination group was 0.143 (0.095 to 0.214, pConclusionOur results indicate that both the BNT162b2 mRNA COVID-19 vaccine and the booster are associated with better COVID-19 outcomes in patients with ARD.

Background Emergency providers (EPs) are uniquely placed to advocate for firearm safety and have been shown to be at risk of exposure to firearms in the emergency department (ED). We sought to characterize EPs' knowledge of firearms, frequency of encountering firearms in the ED and level of confidence with safely removing firearms from patient care settings. Methods This was a survey study of EPs representing medical centers in 22 states. A 15-item questionnaire was e-mailed to all EPs at all included institutions. Questions pertained to EPs' knowledge of firearms, experience with handling firearms, and exposure to firearms while at work. We calculated response proportions with p-values and conducted association analyses among survey items. Results Of 2,192 survey recipients, 1,074 (49.0%) completed the survey. A total of 635 (59.1%) reported encountering firearms in the ED or its immediate environment at least once per year, and 582 (54.2%) were not confident in their ability to safely handle a firearm found in a patient's possession. Frequency of handling firearms was significantly higher in states in the top quartile for firearm ownership, with 21.5% of respondents reporting handling firearms daily or weekly, compared to 10.9% in bottom-quartile states. Level of firearms training also differed significantly: 42.1% of respondents in top-quartile states reported formal training compared to 33.0% in bottom-quartile states. Increased regional firearm ownership rates were associated with decreased rates of feeling unsafe at work. Conclusions The majority of surveyed EPs reported little experience with handling firearms. Firearm experience was associated with comfort with managing firearms found in patients' possession. Regional differences were found regarding personal firearm experience and perceptions of workplace safety, both of which were associated with regional variations in firearm ownership. Despite this, no regional differences were found in encountering firearms in or around the ED. EPs may benefit from training on safely handling firearms.

Glucocorticoids might have significant influence on positive fluid balance, mostly due to their mineralocorticoid effect. We assessed the association between glucocorticoid therapy and fluid balance in septic patients, in the intensive care unit (ICU). We considered two definitions of exposure: daily exposure to glucocorticoids and glucocorticoid treatment at any time. Of 945 patients, 375 were treated with glucocorticoids in the ICU. We applied four regression models. In the first, fluid balance did not differ during days with and without glucocorticoid treatment, among patients treated and not treated with glucocorticoids in the ICU. In our second model, daily fluid balance was increased in patients who were ever treated with glucocorticoids during their ICU stay compared to untreated patients. In the third model, which included only patients treated with glucocorticoids during their ICU stay, glucocorticoid treatment days were not associated with daily fluid balance. In the last model, on "steroid-free days", patients who received glucocorticoid treatment during their ICU stay had a positive fluid balance compared to those who were never treated with steroids. Despite their known mineralocorticoid activity, glucocorticoids themselves appear not to contribute substantially to fluid retention. This work highlights the importance of precise selection of variables to mitigate biases.

During the past decade we have been witnessing a rise in medical cannabis use, yet the evidence for the safety and efficacy of the various cannabinoid compounds is scarce. The State of Israel has always been at the forefront of clinical and translational research in support of Evidence Based Medicine. With respect to cannabis Israel has created a medical and regulatory environment that enables clinical studies with cannabis which may lead to improved Evidence Based use of these compounds. This opinion paper discusses selected studies into the safety and effects of cannabis derived products.

Background: Glucocorticoids (GCS) are commonly administered to critically ill patients. Due to their mineralocorticoid effect, GCS might have a substantial influence on a positive fluid balance. We assessed the association between glucocorticoids (GCS) therapy and fluid balance in critically ill patients with sepsis.Methods: This is a retrospective study of patients with sepsis hospitalized during 2006-2018 in a general intensive care unit (ICU) at a 1100-bed tertiary medical center.Results – We considered two definitions of exposure: daily exposure to GCS and GCS treatment at any time in the ICU. Of 945 patients with a diagnosis of sepsis, 375 were treated with GCS at any time and 570 were not. We applied four regression models to assess the association between GCS treatment and fluid balance; in our first model, fluid balance did not differ during days with GCS treatment, between patients who were and were not treated with GCS in the ICU (coefficient estimate 79.5 (-55.4 to 214.4), p=0.25). In our second model, daily fluid balance was increased by 139.8 ml (10.8 to 268.9; p=0.03) in patients who were ever treated with GCS during their ICU stay compared to untreated patients. In the third model, which included only patients treated with GCS during their ICU stay, GCS treatment days were not associated with daily fluid balance (coefficient estimate -190.6 (-485.1 to 103.9), p-value=0.21). In the last model, on "steroid free days", patients who received GCS treatment during their ICU stay had a positive fluid balance compared to those who were never treated with steroids (coefficient estimate 157.7 (-24.6 to 340.1), p-value=0.09).Conclusions – Despite their known mineralocorticoid activity, GCS themselves appear not to contribute substantially to fluid retention. The findings highlight the importance of a clear definition of exposure.

Acquired factor VII deficiency is a rare coagulopathy that has not been reported in transfusion-dependent patients so far. In this study, we reviewed files of 26 transfusion-dependent patients for coagulation profiles, factor V levels, factor VII levels, possible environmental factors influencing factor VII levels, and bleeding history. In 26 of 29 patients (89.6%), we found mild factor VII deficiency (

Parkinson&rsquo, s disease (PD) and fibromyalgia (FM) are two relatively common disorders that are considered distinct diagnoses. The aim of this study was to investigate the epidemiological characteristics of patients with both PD and FM, as well as their comorbidities and medication use. We performed a population-based retrospective cohort study in Israel from 2000 to 2015. We identified patients with PD according to a refined medication tracer algorithm and patients with FM according to their medical records. Using the algorithm, we identified 2606 patients diagnosed with PD, 60 of them (2.3%) were also diagnosed with FM. Most of the patients were females (88.3%) and the mean age of FM diagnosis was 63.95 &plusmn, 12.27 years. These patients had a higher prevalence of depression, anxiety, and dementia. Of the patients diagnosed with PD + FM, 46 (76.7%) were diagnosed with FM after the diagnosis of PD. Patients with PD + FM used analgesics of distinct kinds in higher rates, as well as more anti-PD medications. We suggest that patients with PD + FM represent a distinct subgroup with a fibromyalgia-like syndrome associated with Parkinson&rsquo, s disease (FLISPAD). Their PD is more treatment resistant, and they take more medications, both analgesics and anti-PD.

Objective We aimed to determine whether fecal microbiota transplant (FMT) is safe and possibly efficacious in treating constipation, motor, and non-motor symptoms in Parkinson's disease (PD) patients. Methods Patients with PD, constipation and an indication for screening colonoscopy were treated with FMT. The study was conducted from December 2017 to November 2019, and clinical outcomes assessing motor, non-motor and constipation symptoms were compared at baseline (week 0) and at 2, 4, 8, 12, 16, 20, and 24 weeks after the FMT. Results Six patients (3 men, age range 47–73, median age 52) were treated with FMT. Four weeks following the FMT, motor, non-motor and constipation scores were improved in 5 of 6 patients. At week 24, compared to before the FMT, the changes in motor scores ranged from − 13–7 points, in non-motor scores from − 2 to − 45 points, and in constipation scores from − 12–1 point. One patient had a serious adverse event requiring admission for observation only, and no adverse events were observed in all other patients. Conclusions In this preliminary uncontrolled case series of 6 PD patients, a treatment with donor FMT infused via colonoscopy, was safe and resulted in improvement of PD motor and non-motor symptoms, including constipation, at 6 months. Further research is needed to assess longer-term maintenance of efficacy and safety, including in large scale randomized controlled trials. Trial registration ClinicalTrials.gov – NCT03876327

Atrial fibrillation (AF) is highly prevalent in dialysis patients, however whether its impact differs between patients on haemodialysis (HD) vs. peritoneal dialysis (PD) is unknown. We aimed to compare the association of AF and clinical outcomes in different dialysis modalities. We performed a population based retrospective cohort study, including adult patients who initiated dialysis between the years 2002 and 2015. Clinical, echocardiographic and laboratory data were reviewed and correlated with outcomes in HD vs. PD. During the study period, 1,130 patients began dialysis. Of the 997 patients without AF before dialysis initiation, 17% developed new-onset AF after the initiation of dialysis (17.3% of HD vs. 13.7% of PD patients, p = 0.27). Using multivariate analysis, only enlarged left atrium at dialysis initiation (hazard ratio (HR) 2.82, CI95% 2.00–3.99) and age (HR 1.04, CI95% 1.03–1.06) were significantly associated with AF. Dialysis modality was not a significant predictor of AF in either univariate or multivariate analysis. In conclusion, our study demonstrated that AF is common in dialysis patients irrespective of modality. In our cohort, the risk factors associated with AF were older age and enlarged left atrium. AF was associated with increased rates of heart failure and mortality, but not stroke.

Introduction There is a substantial growth in the use of medical cannabis in recent years and with the aging of the population, medical cannabis is increasingly used by the elderly. We aimed to assess the characteristics of elderly people using medical cannabis and to evaluate the safety and efficacy of the treatment. Methods A prospective study that included all patients above 65 years of age who received medical cannabis from January 2015 to October 2017 in a specialized medical cannabis clinic and were willing to answer the initial questionnaire. Outcomes were pain intensity, quality of life and adverse events at six months. Results During the study period, 2736 patients above 65 years of age began cannabis treatment and answered the initial questionnaire. The mean age was 74.5 ± 7.5 years. The most common indications for cannabis treatment were pain (66.6%) and cancer (60.8%). After six months of treatment, 93.7% of the respondents reported improvement in their condition and the reported pain level was reduced from a median of 8 on a scale of 0–10 to a median of 4. Most common adverse events were: dizziness (9.7%) and dry mouth (7.1%). After six months, 18.1% stopped using opioid analgesics or reduced their dose. Conclusion Our study finds that the therapeutic use of cannabis is safe and efficacious in the elderly population. Cannabis use may decrease the use of other prescription medicines, including opioids. Gathering more evidence-based data, including data from double-blind randomized-controlled trials, in this special population is imperative.

In 1937, the United States of America criminalized the use of cannabis and as a result its use decreased rapidly. In recent decades, there is a growing interest in the wide range of medical uses of cannabis and its constituents; however, the laws and regulations are substantially different between countries. Laws differentiate between raw herbal cannabis, cannabis extracts, and cannabinoid-based medicines. Both the European Medicines Agency (EMA) and the United States Food and Drug Administration (FDA) do not approve the use of herbal cannabis or its extracts. The FDA approved several cannabinoid-based medicines, so did 23 European countries and Canada. However, only four of the reviewed countries have fully authorized the medical use of herbal cannabis - Canada, Germany, Israel and the Netherlands, together with more than 50% of the states in the United States. Most of the regulators allow the physicians to decide what specific indications they will prescribe cannabis for, but some regulators dictate only specific indications. The aim of this article is to review the current (as of November 2017) regulations of medical cannabis use in Europe and North America.

Older adults may benefit from cannabis treatment for various symptoms such as chronic pain, sleep difficulties, and others, that are not adequately controlled with evidence-based therapies. However, currently, there is a dearth of evidence about the efficacy and safety of cannabis treatment for these patients. This article aims to present a pragmatic treatment protocol for medical cannabis in older adults. We followed consecutive patients above 65 years of age prospectively who were treated with medical cannabis from April 2017 to October 2018. The outcomes included treatment adherence, global assessment of efficacy and adverse events after six months of treatment. During the study period, 184 patients began cannabis treatment, 63.6% were female, and the mean age was 81.2 &plusmn, 7.5 years (median age-82). After six months of treatment, 58.1% were still using cannabis. Of these patients, 33.6% reported adverse events, the most common of which were dizziness (12.1%) and sleepiness and fatigue (11.2%). Of the respondents, 84.8% reported some degree of improvement in their general condition. Special caution is warranted in older adults due to polypharmacy, pharmacokinetic changes, nervous system impairment, and increased cardiovascular risk. Medical cannabis should still be considered carefully and individually for each patient after a risk-benefit analysis and followed by frequent monitoring for efficacy and adverse events.