Clinical and Prognostic Features of Diabetic Ketoacidosis According to the Trigger of the Syndrome.

BACKGROUND: Diabetic ketoacidosis (DKA) is an acute metabolic, life-threatening complication of diabetes mellitus with a mortality rate that now stand at less than 1%. Although mortality is coupled with the etiology of DKA, literature on the influence of DKA etiology on patient outcome is scarce. OBJECTIVES: To study different triggers for DKA and their effect on outcomes. METHODS: We conducted a retrospective study that include 385 DKA patients from 2004 to 2017. The study compared demographics, clinical presentation, and mortality rates by different precipitating factors. RESULTS: Patients with DKA due to infections had a higher risk to develop in-hospital mortality after controlling for age and sex (odds ratio 4.40, 95% confidence interval 1.35-14.30), had a higher Charlson Comorbidity Index score, a higher risk of being mechanical ventilated (14% vs. 3%, P < 0.01), and a longer duration of hospitalization (5 days vs. 3 days, P < 0.001). CONCLUSIONS: It is crucial to find the triggers that precipitate DKA and start the treatment as early as possible in addition to the metabolic aspect of the treatment especially when the trigger is an infectious disease.

Secondary organizing pneumonia after recovery of mild COVID-19 infection.

A 36-year-old male with diffuse large B-cell lymphoma on maintenance rituximab therapy presented to the emergency department with high fever and fatigue. A chest X-ray showed a lobar infiltrate, 40 days before admission the patient suffered from a mild coronavirus disease 2019 (COVID-19) infection and fully recovered. PCR nasopharyngeal swab was negative for COVID-19. Comprehensive biochemical, radiological, and pathological evaluation including 18-fluorodeoxyglucose positron emission tomography with computed tomography and transbronchial lung biopsy found no pathogen or lymphoma recurrence. Treatment for pneumonia with antibiotic and antifungal agents was nonbeneficial. A diagnosis of secondary organizing pneumonia (OP) was made after pneumonia migration and a rapid response to corticosteroids. OP secondary to a viral respiratory infection has been well described. Raising awareness for post-COVID-19 OP has therapeutic and prognostic importance because those patients benefit from steroid therapy. We believe the condition described here is underdiagnosed and undertreated by doctors worldwide. Because of the ongoing global pandemic we are now encountering a new kind of patient, patients that have recovered from COVID-19. We hope that this case may contribute to gaining more knowledge about this growing patient population.

Adapting Surgical Clerkship Curricula in Response to the COVID-19 Pandemic.

BACKGROUND: Coronavirus disease-19 (COVID-19) impacted medical education and led to the significant modification or suspension of clinical clerkships and rotations. OBJECTIVES: To describe a revised surgery clerkship curriculum, in which we divided in-person clinical teaching into smaller groups of students and adopted online-based learning to foster student and patient safety while upholding program standards. METHODS: The third-year surgery core clerkship of a 4-year international English-language program at the Medical School for International Health at Ben Gurion University of the Negev, Beer Sheva, Israel, was adapted by dividing students into smaller capsules for in-person learning and incorporating online learning tools. Specifically, students were divided evenly throughout three surgical departments, each of which followed a different clinical schedule. RESULTS: National Board of Medical Examiners clerkship scores of third-year medical students who were returning to in-person clinical clerkships after transitioning from 8 weeks of online-based learning showed no significant difference from the previous 2 years. CONCLUSIONS: To manage with the restrictions caused by COVID-19 pandemic, we designed an alternative approach to a traditional surgical clerkship that minimized the risk of exposure and used online learning tools to navigate scheduling challenges. This curriculum enabled students to complete their clinical rotation objectives and outcomes while maintaining program standards. Furthermore, this approach provided a number of benefits, which medical schools should consider adopting the model into practice even in a post-pandemic setting.

[ETHNIC DIVERSITY AND CLINICAL CHARACTERISTICS OF HOSPITALIZED PATIENTS WITH ACUTE PANCREATITIS].

BACKGROUND: Previous studies have shown a correlation between acute pancreatitis and several different risk factors that vary in different countries and ethnic groups. The aims of this study are to examine the clinical characteristics and outcomes of acute pancreatitis in patients of Jewish and Bedouin origin. METHODS: We performed a retrospective cohort study of patients hospitalized with acute pancreatitis in the Soroka University Medical Center between the years 2012 and 2016 and compared two groups of patients: patients of Jewish and Bedouin origin. The primary outcome was a composite outcome consisting of 30-days mortality, ICU admission, complications (defined as necrotizing pancreatitis or pseudocyst formation), surgery due to these complications and 30-days re-admission due to pancreatitis. RESULTS: A total of 560 patients were included, 483 patients (86.3%) of Jewish origin and 77 patients (13.7%) of Bedouin origin. The most common cause in both groups was biliary pancreatitis: 49.7% among Jewish, 61% among Bedouin. In our study alcohol consumption, the most common worldwide risk factor of pancreatitis, accounts for only a small percentage of the disease in the Jewish population (5.6%) and does not exist in the Bedouin population. We found no significant differences in outcomes between the two groups. CONCLUSIONS: Biliary pancreatitis was the most common cause in both groups of patients. The important finding of our study is that alcohol use is a minor cause of acute pancreatitis in the Negev. Moreover, it is uncommon in the Jewish population and is completely non-existent among Bedouins. No differences were found in the primary outcomes between the two groups.

High prevalence of fibromyalgia syndrome among Israeli nurses.

OBJECTIVES: Stress has extensively been shown to trigger fibromyalgia syndrome (FM). Nursing is associated with high levels of stress. Our hypothesis was that nurses suffer from an increased prevalence of FM symptoms, and that these symptoms correlate with the levels of stress to which they are exposed in the course of their occupation. METHODS: The study was conducted as a targeted survey distributed to nursing staff in Soroka University Medical Centre, Beer-Sheva, Israel. Participants were asked to answer a questionnaire evaluating symptoms of FM, based on the current diagnostic criteria, which include the widespread pain index (WPI) and the symptom severity scale (SSS). Participants were further questioned regarding stressful experiences during their work and about post-traumatic symptoms as well as regarding work performance and motivation. RESULTS: 206 participants completed the study questionnaire (84.5% females and 15.5% males). Twenty (9.7%) participants of the sample fulfilled criteria for diagnosis of FM reaching rates among females and males of 10.9% and 3.1% respectively. The prevalence of FM in our study was related to age with the highest prevalence in the older age groups (p=0.012). FM symptoms were strongly correlated with work related stress and were strongly correlated with Post Traumatic Stress Disorder (PTSD)-related symptoms. Work-performance parameters did not show a significant correlation with FM parameters. CONCLUSIONS: FM is highly prevalent among nursing staff. Our findings point towards the possibility that work-related stress and traumatic events may play a major role in the development of FM symptoms among nurses. With aging this association is more significant.

The healthcare worker at risk during the COVID-19 pandemic: a Jewish ethical perspective.

The current COVID-19 pandemic has raised many questions and dilemmas for modern day ethicists and healthcare providers. Are physicians, nurses and other healthcare workers morally obligated to put themselves in harm's way and treat patients during a pandemic, occurring a great risk to themselves, their families and potentially to other patients? The issue was relevant during the 1918 influenza epidemic and more recently severe acute respiratory syndrome epidemic in 2003. Since the risk to the healthcare workers was great, there was tension between the ethical duty and responsibility to treat and the risk to one's own life. This tension was further noted during the 2014 Ebola outbreak in West Africa that left hundreds of healthcare workers dead. The AMA Code of Ethics states that physicians are to 'provide urgent medical care during disasters…even in the face of greater than usual risk to physicians' own safety, health or life.'1 Classic Jewish sources have dealt with this question as well. There is an obligation 'to not stand by idly when your friends life is in danger'; however, the question arises as to whether there are limits to this obligation? Is one required to risk one's own life to save another's? There is a consensus that one is not required but the question open to debate is whether it is praiseworthy to do so. However, regarding healthcare workers, there is agreement for ethical, professional and societal reasons that they are required to put themselves in harm's way to care for their patients.

Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective.

The novel COVID-19 pandemic has placed medical triage decision-making in the spotlight. As life-saving ventilators become scarce, clinicians are being forced to allocate scarce resources in even the wealthiest countries. The pervasiveness of air travel and high rate of transmission has caused this pandemic to spread swiftly throughout the world. Ethical triage decisions are commonly based on the utilitarian approach of maximising total benefits and life expectancy. We present triage guidelines from Italy, USA and the UK as well as the Jewish ethical prospective on medical triage. The Jewish tradition also recognises the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making.

Remote pathology education during the COVID-19 era: Crisis converted to opportunity.

CONTEXT: The COVID-19 pandemic led to shutting of education faculties, including clinical clerkships for medical students. OBJECTIVE: To review a selective for a course in diagnostic pathology geared toward undergraduate medical students, including its design, technical implementation, instructor and student evaluations, and suggestions for options for further adjusting and optimizing the selective. DESIGN: Whole slide images (WSI) were anonymized and students were given remote access to university computers, which were prepared with two freely available WSI viewers. Each topic was taught in a four-part module: Self-assigned reading, lecture via Zoom, quiz based on digital slide sets, and a frontal review of the slides via Zoom. Fifty-nine students participated in the selective. Following the course, students completed an anonymous questionnaire. RESULTS: Of the 59 participants, 42% (n = 25) responded. None of the respondents had any previous instruction in diagnostic pathology. Overall, the course was rated very favorably: 68% (n = 17) gave at least 3 points on a 4-point scale on questions relating to course interest, improvement in understanding of the covered diseases, and how strongly they would recommend a student take this course if given an option. The most significant disadvantage of the class, as reported by 80% (n = 20) were technical challenges in accessing the slides. CONCLUSION: We believe the course was a success and can be a model for future virtual pathology electives. Great effort should be done to provide technical support to the students. The selective demonstrated value for students and provided much-needed exposure to diagnostic pathology in clinical practice.

Placebos in the era of open-label trials: An update for clinicians.

Placebos have been used extensively by vast numbers of physicians, in a majority of clinical trials. Placebo effects involve behavioural, psychological and genetic factors and have been subject to ethical controversies stemming from the use of deception in treating patients. The patient-physician encounter, endogenous pharmacological pathways, personality traits and genetic diversity have all been reported to be key players in placebo responses. In the last decade, a new methodological paradigm of placebo research has emerged, using open-label placebos to investigate their effects which showed promising results for various common medical conditions. In this review, we will summarize the current body of evidence on placebos in clinical practice, with a view to open-label placebo trials in particular. It is our view that future larger-scale randomized blinded open placebo trials will benefit physicians and improve patient outcomes.

Clinical, Epidemiological, and Etiological Changes in Erythema Nodosum.

BACKGROUND: Erythema nodosum (EN) is the most common type of panniculitis, commonly secondary to infectious diseases. OBJECTIVES: To elucidate the causative factors and the clinical presentation of patients with EN (2004-2014) and to compare their data to those reported in a previous study. METHODS: A retrospective study was conducted of all patients diagnosed with EN who were hospitalized at Soroka University Medical Center (2004-2014). The clinical, demographic, and laboratory characteristics of the patients were compared to those in a cohort of patients diagnosed with EN from 1973-1982. RESULTS: The study comprised 45 patients with a diagnosis of EN. The most common symptoms of patients hospitalized with EN were arthritis or arthralgia (27% of patients). Patients with EN, compared to those reported in 1987, has significantly lower rates of fever (18% vs. 62% P < 0.001), streptococcal infection (16% vs. 44%, P = 0.003), and joint involvement (27% vs. 66%, P < 0.001). In addition, fewer patients had idiopathic causes of EN (9% vs. 32%, P = 0.006). CONCLUSIONS: In the past decades, clinical, epidemiological, and etiological changes have occurred in EN patients. The lowering in rate of fever, streptococcal infection, and joint involvement in patients with EN are probably explained by improvements in socioeconomic conditions. The significantly decreasing rate of idiopathic causes of EN is possibly due to the greater diagnostic accuracy of modern medicine. The results of the present study demonstrate the impact of improvements in socioeconomic conditions and access to healthcare on disease presentation.

Altruism and Religion: A New Paradigm for Organ Donation.

Activity of NGO's supporting living donor kidney donations can affect the shortage of kidneys. Matnat Chaim is a Jewish orthodox organization active in Israel since 2009. This is a voluntary organization with aims to shorten and eliminate the waiting list for kidneys. Since the beginning of its activity, it has said to play a key role in 379 kidney transplantations. In 2015, out of 174 live donor kidney transplantations that took place in Israel, Matnat Chaim had a key role in 88 of them (50.6%). We found some ethical issues concerning the organization's activity. The donor can restrict his or her donation to specific characteristics of recipient which can result in organs transplanted in a homogeneous group of the population. Another issue is the question of whether nudging people to kidney donation takes place and whether it is valid to do so. We found that Matnat Chaim does a great deal for promotion and intermediation of kidney donations in Israel. This form of promotion can be implemented by other organizations and countries.

Response to: 'Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies' by Schuklenk and Smalling.

The recent essay by Schuklenk and Smalling opposing respect for physicians' conscientious objections to providing patients with medical services that are legally permitted in liberal democracies is based on several erroneous assumptions. Acting in this manner would have serious harmful effects on the ethos of medicine and of bioethics. A much more nuanced and balanced position is critical in order to respect physicians' conscience with minimal damage to patients' rights.

Impact of a 3-Day Introductory Oncology Course on First-Year International Medical Students.

Although only some medical students will choose cancer as their specialty, it is essential that all students have a basic understanding of cancer and its treatment. The purpose of this study was to evaluate the impact of an introductory clinical oncology course on first-year international medical students. Evaluation of the course involved a quantitative survey designed for this study that was given pre- and post-course completion. Participants included 29 first-year international medical students. Students reported that the course affected them emotionally more than they anticipated it would prior to beginning the course. By the end of the course, students felt more comfortable focusing on how to live with cancer, felt less afraid of dealing with death, and were better able to cope with uncomfortable emotional situations. The course had no significant effect on students' interest in specializing in oncology in the future. Our study provides evidence that an introductory oncology course can increase student comfort with issues related to living with cancer, with confronting and dealing with death and dying, and with coping with uncomfortable emotional situations as related to cancer care. In anticipation of growing shortages in oncology specialists in the coming years, the ability of an early course in oncology to attract more students to the field is of interest. Future research should examine ethnic and cultural differences in uptake of the clinical oncology courses across continents and should use direct observation in addition to self-report in evaluating outcomes.

The Patient-Psychiatrist Relationship on the Axis of the Other and the Same.

The patient-psychiatrist relationship is a cornerstone of psychiatric professionalism and ethics. We discuss this topic along the axis of the Other and the Same, concepts defined by continental philosophy. The self of Anglo-American philosophy is typically described in individualistic terms. Individualism, autonomy and ideal self are valorized within the current model of care. These characteristics belong to the Lacanian Imaginary Order, which is the core of narcissism. Patients may yearn for another model of interaction. For Levinas, ethics should not involve a search for perfectionism and accomplishment but responsibility toward others. Ethics is, according to him, rooted in the calling into question of one's Sameness by the other's Otherness. The question of hospitality and of the welcoming of Otherness is central to his thought. Derrida further asks whether hospitality is not an interruption of the self. Hospitality may thus become a fundamental way of re-thinking clinical practices. A relationship to the Other as an-other is characterized as of Euclidian-type, establishing borders between the self and the Other, whereas a relationship to the Other as same is characterized as of fractal-type, emphasizing similarities between self and other as same and obliterating boundaries. Winnicott's object-relating versus use of object and Buber's I-you and I-it relations are also examined along the axis of Sameness and Otherness. Since psychiatric clinical practice requires to our view adequate and adaptive to and fro movements along this axis, the two forms of relating to the Other are discussed both theoretically and through a clinical case presentation.

Reflections on Cultural Preferences and Internal Medicine: The Case of Jehovah's Witnesses and the Changing Thresholds for Blood Transfusions.

Jehovah's witnesses oppose receiving blood transfusions based on religious grounds. This refusal raises complex medical, legal and ethical issues for the treating medical staff. In the past physicians attempted to force patients and children to accept transfusions when deemed medically necessary through the use of court orders. However, in recent years the threshold for blood transfusion has been gradually raised by medical experts as expressed in consensus guidelines, which means that Jehovah's witnesses' aversion to transfusion would have been partially justified medically. This article will further discuss these current trends.

The Ethics of Public Health Laws, and the Special Case of the New "Model Law".

The "model law" in Israel forbids underweight models (BMI below 18.5) to work. The stated goal of the law is to prevent eating disorders among the general audience of the models. Most public health laws that aim to encourage healthy lifestyles target issues related to unhealthy products, for instance taxes and limitations on advertisements. A law that aims to prevent the imitation of an unhealthy lifestyle is unique. A similar law against showing movies with smoking actors has previously passed in India. Notwithstanding the good intentions, these new laws and other similar legislation raise significant ethical issues, such as limitations on personal freedom and the potential for discrimination.

[HEALTH SCARES: A CHRONICLE UNNECESSARY ANXIETY].

INTRODUCTION: A health scare is an event characterized by fear of catastrophic consequences with little actual results. Regardless of these negligible results, the health, social and economic impacts of such events may be significant. Health scares are spread throughout four major groups: the media, relevant medical experts, policy makers and the public at large. In this review, we described two recent cases in Israel: the case of Eltroxin exchange that occurred in Israel as well as other countries, in addition to the polio virus spread in sewage, in the context of health scares. Furthermore, we summarized the interaction between these groups, focusing on their functioning in selected health scares from the previous two decades. There is increased need for creating a priori coordinating methods, in order to deal efficiently with such events in the future. In that way, the implications of health scares can be reduce to minimum.

The transplantation of solid organs from HIV-positive donors to HIV-negative recipients: ethical implications.

HIV-positive individuals have traditionally been barred from donating organs due to transmission concerns, but this barrier may soon be lifted in the USA in limited settings when recipients are also infected with HIV. Recipients of livers and kidneys with well-controlled HIV infection have been shown to have similar outcomes to those without HIV, erasing ethical concerns about poorly chosen beneficiaries of precious organs. But the question of whether HIV-negative patients should be disallowed from receiving an organ from an HIV-positive donor has not been adequately explored. In this essay, we will discuss the background to this scenario and the ethical implications of its adoption from the perspectives of autonomy, beneficence/non-maleficence and justice.

Maimonides Reincarnated.

The writings of Maimonides, the 12th-century physician, Talmudic and philosophic scholar, are remarkably relevant for modern medicine. Whereas the specific medical recommendations are obviously outdated, Maimonides' perceptive insights into professional responsibilities and medical ethics remain as useful guides even in our postmodern era.