The Nuremberg Racial Laws: The End of Jewish Medical Teaching in Germany. Who Were the Last Jewish Medical Professors in Berlin?

BACKGROUND: On 7 April 1933, the Nazi Law for the Restoration of the Professional Civil Service was enacted. The law triggered the dismissal of most Jewish medical staff from German universities. A few Jewish professors in Berlin were permitted to continue their academic activity with restrictions. Those professors were gradually dismissed as laws and restrictions were enforced. OBJECTIVES: To identify the last Jewish medical professors who, despite severe restrictions, continued their academic duties and prepared students for their examinations in Berlin after the summer of 1933. METHODS: We reviewed dissertations written by the medical faculty of Berlin from 1933 to 1937 and identified Jewish professors who mentored students during those years. RESULTS: Thirteen Jewish tutors instructed dissertations for the medical examinations after the Nazi regime seized power. They were employees of different university hospitals, including the Jewish hospitals. We did not identify Aryan students instructed by Jewish professors. The professors were active in different medical disciplines. Half of the reviewed dissertations were in the disciplines of surgery and gynecology. The last Jewish tutors were dismissed in October 1935. However, some of their studies were submitted for examination after that date. CONCLUSIONS: After the Nazi regime seized power, academic activities and medical research by Jewish professors declined but did not stop. However, these professors worked with only Jewish students on their theses. Most dissertations were approved and examined after the Jewish academics were dismissed by the university, in some cases even after they left Germany.

Pediatric Hospitalizations After School Reopening During the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Alpha (B.1.1.7) Variant Spread: A Multicenter Cross-sectional Study in Israel.

This multicenter, cross-sectional study provides evidence on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated emergency department visits and hospitalizations in pediatric wards and intensive care units after school reopening during the SARS-CoV-2 Alpha (B.1.1.7) variant spread in Israel. Study findings suggest that school reopening was not followed by an increase in SARS-CoV-2-related pediatric morbidity.

Presence of SARS-CoV-2 RNA on playground surfaces and water fountains.

The possibility of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission by fomites or environmental surfaces has been suggested. It is unclear if SARS-CoV-2 can be detected in outdoor public areas. The objective of the current study was to assess the presence of SARS-CoV-2 in environmental samples collected at public playgrounds and water fountains, in a country with high disease prevalence. Environmental samples were collected from six cities in central Israel. Samples were collected from drinking fountains and high-touch recreational equipment at playgrounds. Sterile pre-moistened swabs were used to collect the samples, put in viral transfer media and transferred to the laboratory. Viral detection was achieved by real-time reverse transcriptase-polymerase chain reaction, targeting four genes. Forty-three samples were collected from playground equipment and 25 samples from water fountains. Two of the 43 (4.6%) samples from playground equipment and one (4%) sample from a drinking fountain tested positive. It is unclear whether the recovery of viral RNA on outdoor surfaces also indicates the possibility of acquiring the virus. Adherence to environmental and personal hygiene in urban settings seems prudent.

Fever response to ibuprofen in viral and bacterial childhood infections.

OBJECTIVE: to compare the antipyretic effects of ibuprofen in febrile children with serious bacterial infections (SBI), and children with a presumed viral infection. METHODS: A prospective cross- sectional study was conducted in a pediatric Emergency department between October 2018 and March 2020 for children aged 3 months to 4 years with a rectal temperature ≥ 38.5 °C. Patients received 10 mg/kg of ibuprofen oral suspension. Rectal temperature was measured 60 and 120 min after administration. Laboratory and imaging evaluations were performed for each study participant in order to identify serious bacterial infection. RESULTS: Ninety patients were included, of which 18 were diagnosed with serious bacterial infections. There was no significant difference in age, fever at presentation and duration of fever between the groups. No significant difference was noted in body temperature reduction at 60 and 120 min after ibuprofen administration (1.09 ± 0.75 °C vs 0.89 ± 0.58 °C, mean difference -0.12 °C, 95% CI -0.54-0.15 °C; 1.85 ± 0.53 °C vs 1.78 ± 0.83 °C, mean difference - 0.07 °C, 95% CI -0.49-0.36 °C, in the SBI and non-SBI groups respectively). CONCLUSION: Fever response to Ibuprofen administration is not indicative of serious bacterial infections in children under 4 years of age. Larger prospective studies are required to define whether the lack of response to Ibuprofen has any impact on the management of febrile children.

Children discharged from an emergency department with bacteraemia had lower C-reactive protein and better outcomes than admissions.

AIM: To investigate whether there are common clinical findings in bacteraemic children that were discharged from the emergency department (ED) and to follow their clinical outcome. METHODS: A retrospective chart review of children above one-month-old with positive blood cultures obtained in Shamir Medical Center's ED between January 2011 and December 2019 was conducted. RESULTS: A total of 250 cases were analysed, of which 68 discharged after first evaluation. Streptococcus pneumonia was the most commonly isolated pathogen. Compared to children that were admitted when first evaluated in the ED, discharged children had lower C-reactive protein (mean 50.5 ± 62.8 vs 121.7 ± 113.2 mg/L, p < 0.001). Dyspnoea and being ill-looking were less prevalent among the latter (6.7% versus 35.1%, p = <0.001, 3.0% versus 22.2% p < 0.001, respectively), as were presence of Kingella kingae and other Gram-negative bacteria. Of the children hospitalised in our institution, the duration of hospitalisation was significantly lower than in those admitted during the first visit (6.3 ± 4.3 vs 9.0 ± 7.4 days, p = .002). None of the discharged children were admitted to paediatric intensive care unit. CONCLUSION: Children with bacteraemia who were discharged home before knowing their positive blood cultures results had lower C-reactive protein and better outcome compared to those admitted on first evaluation in emergency department.

The Kristallnacht Pogrom. The End of Jewish Medical Study in Germany: Who were the Last Jewish Medical Students in Berlin?

BACKGROUND: In April 1937 it was forbidden for German Jewish students to sit for examinations. However, a few Jewish medical students were able to continue studying at Berlin University. The order to expel all Jewish students from German Universities was published on the morning after Kristallnacht (November 1938) and was strictly imposed. OBJECTIVES: To identity the last Jewish medical students who managed, in spite of the severe restrictions, to continue their study and apply for the examinations in Berlin from summer 1937 through 1938. METHODS: Reviews of the dissertations written in the medical faculty of Berlin during 1937-1938 identified the Jewish students. We presented their demographic and academic characteristics. RESULTS: Sixteen Jewish students were identified: six Germans, six Americans, and four Eastern Europeans. Their average age was 18.7 ± 1.0 years, 22.5 ± 2.0 years, and 20.8 ± 2.5 years, respectively. The last Jewish student took the exams in July 1938 and submitted a thesis one month later. One German student was half Jewish. Five gained the rights to take the examinations as foreign students by renouncing their German citizenship. They were the main group affected by the government's restrictions. The American and the Eastern European students were more protected by law. CONCLUSIONS: Each of those groups had different academic careers. The Americans were the last Jewish students allowed to study in Germany. It seems that they were less aware of the national socialist atmosphere in the medical faculty in Berlin during 1937-1938.

Correction to: Hyperpyrexia and high fever as a predictor for serious bacterial infection (SBI) in children-a systematic review.

It has been identified that the data listed within the above article was incorrectly presented. This is now presented correctly in this article.

The Clinical Value of Routine Acetaminophen Level Screening in Pediatric Patients Presenting to the Emergency Department.

BACKGROUND: Acetaminophen is the most common drug involved in pediatric poisonings, both intentionally and accidentally, and is the leading cause of acute liver failure among all age groups. OBJECTIVES: To define the characteristics of patients admitted to a pediatric emergency department (ED) where serum acetaminophen concentrations were measured, and to determine which variables are associated with significant risk of acetaminophen toxicity. METHODS: Acetaminophen serum concentrations were measured, in a retrospective case series, of patients younger than 18 years who had been admitted to the ED at Shamir Medical Center between 1 January 2008 and 31 December 2015. RESULTS: During the study period 180,174 children were admitted to the ED. Acetaminophen serum concentrations were measured in 209 (0.12%) patients. Mean age was 12.4 ± 5.9 years. Elevated liver enzymes were found in 12 patients, 5 of whom had documented acute liver injury. All five were older than 11years.Two cases of acute liver injury were attributable to acetaminophen ingestion. In both cases the cause was intentional overdose. Univariate analysis showed a significant (P < 0.05) correlation between detectable acetaminophen blood level and a positive history of drug or acetaminophen ingestion, and suicide attempt. Not all children with non-severe acetaminophen poisoning had been diagnosed during the study period. A positive history of acetaminophen ingestion was associated with a 28-fold higher risk for detectable acetaminophen blood level. CONCLUSIONS: In the absence of a positive history of acetaminophen ingestion and in young children with accidental intoxication, the risk of hepatotoxicity is relatively low.

Hyperpyrexia and high fever as a predictor for serious bacterial infection (SBI) in children-a systematic review.

It is not clear if children with high fever are at increased risk for serious bacterial infection (SBI). Our aim was to systematically review if children suffering from high fever are at high risk for SBI. Our data sources were Embase, Medline, and Pubmed; from their inception until the last week of March 2017. The study selection were of cohort and case control studies comparing the incidence of SBI in children with hyperpyrexia with children with fever of 41 °C or less, and children with a temperature higher than 40 °C, with children with fever of 40 °C or less. Two reviewers independently pooled studies for detailed review using a structured data-collection form. We calculated the odds ratio and 95% confidence intervals (CI) for SBI, assuming a random-effects model. A sub-group analysis was conducted. In our results, 11 studies met the inclusion criteria. Two studies showed that children with hyperpyrexia are at higher risk for SBI (OR 1.96 95% CI 1.3-1.97). An increased risk for SBI in children with high fever (OR 3.21 95% CI 1.67; 6.22). SBI in infants with temperature over 40 °C was higher compared to infants with lower degree of fever (OR 6.3 95% CI 4.44; 8.95). On older children, the risk for SBI was only slightly higher in children with fever above 40 °C. The limitation of the study is the small amount of studies and that the heterogeneity of the studies was very high. CONCLUSION: Young infants with temperature higher than 400 °C are at increased risk for SBI. Risk of SBI in older children with temperature > 400C is minimal. What is known: • An association between high fever and increased risk for SBI was reported in young infants. • Based on only two studies from the 1970s and 1980s, hyperpyrexia is associated with increased risk for SBI. What is new: • Infants under the age of 3 months with fever > 40 °C were found to have increased risk for SBI. • Risk of SBI in older children with temperature > 40 °C is minimal.

[REFERRAL LETTERS TO THE PEDIATRIC EMERGENCY UNIT - COMMUNITY PHYSICIANS' INTENTIONS VERSUS EMERGENCY DEPARTMENT PHYSICIANS' AND PARENTS' COMPREHENSION].

BACKGROUND: Referral notes are the main communication method between primary physicians and hospital physicians. Therefore, the written referral, has great importance in explaining the patient's condition or complaint, and the additional steps or actions that may be required for their complete evaluation and diagnosis. In this research we evaluated the main reasons for child referral to the hospital and, whether both the hospital physician and the child's parents understood those reasons correctly. METHODS: All the children referred to the ED during four weeks in July 2013 were included. For all cases with referral notes three questionnaires were presented: One to the hospital physician, one to the child's parents and a third, (via phone conversation), to the referring physician. RESULTS: At least two questionnaires were completed for each of the 261 cases. When primary physicians' original goals were compared with the hospital physicians' interpretation, only 33.7% of cases were fully matched, in 24.8% of cases there was a partial match and in 41.6% there was no match at all. When primary physicians' original goals were compared with the parents' understanding only 35.5% showed that they were fully matched, 30.3% showed partial match and 34.2% show no match at all. When evaluating primary physicians' intention with hospital physicians' interpretation, we found that during on-call hours the probability for a match was lower. Matching was higher for more experienced primary physicians. CONCLUSIONS: This research reinforces the impression of many hospital physicians of misunderstanding referral goals. Over 65% of referrals were partially or totally misunderstood. These findings are of importance when evaluating a sick child, since the community doctor usually has a greater acquaintance with the patient's condition gathered over the years or during an acute illness.

Shivering in Febrile Children: Frequency and Usefulness in Predicting Serious Bacterial Infections - A Prospective Case-Control Study.

A prospective case-control study was conducted in a pediatric emergency department to describe the proportion of febrile children experiencing shivering and its clinical significance. Shivering was reported in 186 of 645 febrile children (28.8%). The rate of serious bacterial infection was similar in 86 children with shivering and 86 matched controls.

Association of Acetaminophen and Ibuprofen Use With Wheezing in Children With Acute Febrile Illness.

BACKGROUND: Many infants and children receive acetaminophen and/or ibuprofen during febrile illness. Previously, some studies have linked acetaminophen and ibuprofen use to wheezing and exacerbation of asthma symptoms in infants and children. OBJECTIVE: To assess whether acetaminophen or ibuprofen use are associated with wheezing in children presenting to the emergency department (ED) with febrile illness. METHODS: This was a cross-sectional study of children who presented with fever to the pediatric ED between 2009 and 2013. The data were collected from questionnaires and from the children's medical files. Patients with wheezing in the ED were compared with nonwheezing patients. Associations between medication use and wheezing were assessed using univariate and multivariate analyses. The multivariate analysis adjusted for potential confounding variables (ie, age, atopic dermatitis, allergies, smoking, antibiotics use, etc) via propensity scores. RESULTS: During the study period, 534 children admitted to the ED met our inclusion criteria, of whom 347 (65%) were included in the study. The use of acetaminophen was similar in children diagnosed with wheezing compared with those without wheezing (n = 39, 81.3%, vs n = 229, 82.7%, respectively). Ibuprofen use was significantly lower in children diagnosed with wheezing (n = 22, 52.4%, vs n = 168, 69.4%, respectively). In multivariate analysis, acetaminophen was not associated with a higher rate of wheezing during acute febrile illness (adjusted odds ratio [OR] = 0.76, 95% CI = 0.24- 2.39), whereas ibuprofen was associated with a lower risk of wheezing (adjusted OR = 0.36, 95% CI = 0.13-0.96). CONCLUSIONS: Our study suggests that acetaminophen and ibuprofen are not associated with increased risk for wheezing during acute febrile illness.

Hyperbaric oxygen treatment and nephrotoxicity induced by gentamicin in rats.

BACKGROUND: Nephrotoxicity is a significant adverse side effect of gentamicin. Previous preclinical studies showed that hyperbaric oxygen treatment (HBOT) may have beneficial effects by attenuating renal damage in rats subjected to renal injury. We evaluated the effect of HBOT on acute renal failure caused by gentamicin. METHODS: Thirty-six rats were divided into four groups. Gentamicin (150 mg/kg for 5 consecutive days) was administered in 30 rats, 10 rats received only gentamicin, 10 rats received 100% oxygen therapy on days 1-5 of the experiment, 10 received daily HBOT on days 1-5 of the experiment, and the remaining six served as a control group. On day 6, renal function tests and renal pathological examinations were performed. RESULTS: Body weight and biochemical parameters were similar in all groups except for higher plasma levels of calcium in the 100% oxygen group (P = 0.03). All the rats in the experimental group showed biochemical parameters compatible with renal failure (high serum levels of urea and creatinine). All the rats in the control group had normal renal function tests. Two rats from the HBOT group died on the fifth day of the experiment. All rats in the control group demonstrated normal renal morphology. All 28 intoxicated rats showed moderate to severe histopathological changes without significant differences between the groups. CONCLUSIONS: Treatment of gentamicin-induced nephrotoxicity with either HBOT or 100% oxygen for 5 days had no beneficial renal effect. Mortality was observed only in the HBOT group.

The proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation.

OBJECTIVE: To evaluate the rate of medication related errors in the pediatric ward and pediatric emergency department (PED), before and after implementing intervention strategies according to the Joint Commission International (JCI) accreditation program. DESIGN: A retrospective cross-sectional study that included chart review. SETTING: A university affiliated pediatric ward and PED. PARTICIPANTS: Children 0-18 years old admitted on February 2013 (before the JCI program) and February 2014 (during implementation of the JCI program). INTERVENTION(S): A training program designed to meet the JCI official standards on medication prescribing. MAIN OUTCOME MEASURE(S): The number of prescribing and medication administration errors in the 2 years. RESULTS: We collected 937 valid prescription orders and 924 administration orders (1861 medical orders) from February 2013, and 961 valid prescription orders and 958 administration orders (1919 medical orders) from February 2014. There was a significant reduction in prescribing errors from 6.5 to 4.2% between years 2013 and 2014 (P = 0.03). There was no significant difference in administration error rates between the two periods (104 (11.3%) in the first period and 114 (11.9%) in the second; P = 0.61). CONCLUSIONS: The errors rate we found was within the range described in the literature. Quality assurance interventions can significantly reduce medication prescribing errors.

Success rate of pneumatic reduction of intussusception with and without sedation.

BACKGROUND: Pneumatic reduction of ileocolic intussusception is often performed without sedation. The aim of this study was to evaluate the success rate of pneumatic reduction of intussusception with and without sedation. METHODS: We conducted a retrospective cohort study in Israel in two tertiary care centers using a similar protocol for pneumatic reduction of intussusception. In one center, patients had pneumatic reduction of intussusception under propofol-based sedation, while in the other, patients had pneumatic reduction of intussusception without any sedation. Children aged 3 months to 8 years who were diagnosed with ileocolic intussusception between January 1, 2008 and July 31, 2015 were included in the study. Multivariable regression was used to adjust for the possible confounders of age, gender, number of cases of intussusception prior to the study period, time period from the beginning of symptoms to emergency department admission (<12 h, >12 h), and time period from emergency department admission to the beginning of pneumatic reduction of intussusception. Secondary outcomes of the study included the proportion of bowel perforations during the procedure, and the proportion of early (within 48 h) recurrence of intussusception. RESULTS: The sedation and nonsedation cohorts included 124 and 90 patients, respectively. The cohorts were comparable with regard to demographic characteristics, hemodynamic vital signs on admission to the emergency department, blood gases tests during emergency department stay, and time variables prior to reduction of intussusception. Multivariable regression revealed reduction of intussusception success rates of 89.5% and 83.3% for the sedation group and nonsedation group, respectively, with an adjusted odds ratio of 1.2, 95% CI 1.1-5.3. Three sedated patients and 0 nonsedated patients developed bowel perforations during the procedure. Rates of early recurrence of intussusception of sedated patients and nonsedated patients were 5.1% (6/117) and 1.3% (1/79), respectively (P = 0.15, RR = 3.9, 95% CI: 0.47 to 31.81). CONCLUSION: The findings suggest that the pneumatic reduction of intussusception under propofol-based sedation had a slightly higher success rate than the pneumatic reduction of intussusception without sedation; however, the safety of this practice is yet to be determined.

Abdominal injuries following bicycle-related blunt abdominal trauma in children.

BACKGROUND: The aim of this study was to confirm our clinical impression that intra-abdominal handlebar injuries are progressively increasing in number and severity in the latest years. METHODS: A retrospective analysis of data concerning 132 patients admitted to our department of pediatric surgery during a 10-year period (between 2003 and 2012), following bicycle-related blunt abdominal trauma, was performed. Patients were divided into two groups: those who fall from their bicycle (N.=43) and those who sustained direct impact from the handlebars (N.=89) and compared. RESULTS: Number of admitted patients due to bike related injury was increased during a 10-year period. The bikes used by 91.6% of the participants were the high quality BMX, with rigid and strong handlebars. The average age for both groups was 10.3 years (4-16 years). Boys were injured more than girls. Thirty patients from both groups sustained severe abdominal visceral injuries, 25 from the handlebar group and 6 from the fall group (P=0.018). The overall average length of hospital stay was 3.04 days, with 36 cases (27.36%) requiring pediatric intensive care unit (PICU) admission (N.=26 of the handlebar group and N.=10 of the fall group, P=0.024). Eight children sustaining handlebar injuries required abdominal surgery compared to only one case for the fall group (P=0.018), when excluding extra-abdominal procedures. CONCLUSIONS: Number of pediatric patients admitted due to bike related injury has been gradually increasing. Children who suffer from direct impact of the handlebars are more likely to require abdominal operative intervention and PICU admission than those who fall. Preventive measures are urgently needed in order to defeat this trend.

The Risk of Serious Bacterial Infection in Neutropenic Immunocompetent Febrile Children.

Only few reports have looked into the risk of invasive bacterial infection in children with neutropenia that is not malignancy related. The objective of the current study was to determine the clinical significance of neutropenia as a predictor of serious bacterial infection (SBI) in immunocompetent children. We conducted a retrospective case-control study including children 3 months to 18 years of age with fever ≥ 38°C hospitalized or presenting to the emergency department. Patients who had neutropenia ≤ 1000 ANC/µL and had a blood culture taken were matched for age with the consecutive febrile patients for whom a blood culture was taken. The main outcome was the rate of SBI. SBIs were more prevalent among the control group than in the group of children with neutropenia, 19/71 and 6/71, respectively (P = 0.0005). More children were treated with antibiotics among the control group than in the group of children with neutropenia, 39/71 and 20/71, respectively (P < 0.0001). Acute-phase reactants including CRP and platelets were higher in the control group. We concluded that immunocompetent patients with fever and moderate neutropenia do not carry a higher risk for SBIs compared with patients with fever who do not have neutropenia.

Toxicity from repeated doses of acetaminophen in children: assessment of causality and dose in reported cases.

Liver injury has been reported in children treated with repeated doses of acetaminophen. The objective of this study was to identify and validate reports of liver injury or death in children younger than 6 years who were administered repeated therapeutic doses of acetaminophen. We reviewed US Poison Center data, peer-reviewed literature, US Food and Drug Administration Adverse Event Reports, and US Manufacturer Safety Reports describing adverse effects after acetaminophen administration. Reports that described hepatic abnormalities (description of liver injury or abnormal laboratory testing) or death after acetaminophen administration to children younger than 6 years were included. The identified reports were double abstracted and then reviewed by an expert panel to determine if the hepatic injury was related to acetaminophen and whether the dose of acetaminophen was therapeutic (≤75 mg/kg) or supratherapeutic. Our search yielded 2531 reports of adverse events associated with acetaminophen use. From these cases, we identified 76 cases of hepatic injury and 26 deaths associated with repeated acetaminophen administration. There were 6 cases of hepatic abnormalities and no deaths associated with what our panel determined to be therapeutic doses. A large proportion of cases could not be fully evaluated due to incomplete case reporting. Although we identified numerous examples of liver injury and death after repeated doses of acetaminophen, all the deaths and all but 6 cases of hepatic abnormalities involved doses more than 75 mg/kg per day. This study suggests that the doses of less than 75 mg/kg per day of acetaminophen are safe for children younger than 6 years.

Computed tomography is not justified in every pediatric blunt trauma patient with a suspicious mechanism of injury.

OBJECTIVE: Computed tomography (CT) has become an important tool for the diagnosis of intra-abdominal and chest injuries in patients with blunt trauma. The role of CT in conscious asymptomatic patients with a suspicious mechanism of injury remains controversial. This controversy intensifies in the management of pediatric blunt trauma patients, who are much more susceptible to radiation exposure. The objective of this study was to evaluate the role of abdominal and chest CT imaging in asymptomatic pediatric patients with a suspicious mechanism of injury. METHODS: Forty-two pediatric patients up to 15 years old were prospectively enrolled. All patients presented with a suspicious mechanism of blunt trauma and multisystem injury. They were neurologically intact and had no signs of injury to the abdomen or chest. Patients underwent CT imaging of the chest and abdomen as part of the initial evaluation. RESULTS: Thirty-one patients (74%) had a normal CT scan. Two patients of 11 with an abnormal CT scan required a change in management and were referred for observation in the Intensive Care Unit. None of the patients required surgical intervention. CONCLUSION: The routine use of CT in asymptomatic pediatric patients with a suspicious mechanism of blunt trauma injury is not justified.