Iftach Sagy

Briefly Trained Medical Students Can Effectively Identify Rheumatic Mitral Valve Injury Using a Hand-Carried Ultrasound

Rheumatic heart disease (RHD) is common and remains a major cause of morbidity, particularly in developing countries. Its diagnosis relies on expertise‐dependent echocardiographic studies. We evaluated the accuracy of briefly trained examiners in identifying RHD utilizing a hand‐carried cardiac ultrasound (HCU) device.

Use patterns of health information exchange systems and admission decisions: Reductionistic and configurational approaches

BACKGROUND Research that endeavors to identify the value of electronic health information exchange (HIE) systems to the healthcare industry and, specifically, to clinical decision making is often inconclusive or theory-based. Studies seeking to identify how clinical decisions relate to patterns of actual HIE use, often by analyzing system log files, generally rely on dichotomous distinctions between system use and no-use, disregard the availability of information in the system, and control for few user characteristics. OBJECTIVE We aim at empirically exploring the associations between use patterns of HIE systems and subsequent clinical decisions on the basis of broad definitions of use patterns, available information, and control variables. METHODS We examine the decision to admit critically-ill patients either to the intensive care unit (ICU) or to another ward at a busy emergency department in the period 2010-2012. Using HIE log files, use patterns are characterized by the variables of number of users, volume, diversity, granularity, duration, and content. We test the association between HIE use patterns and the admission decision, after controlling for multiple demographic, clinical, physician, and situational variables and for available HIE information. This association is examined by taking a reductionistic approach that focuses on independent use variables and a configurational approach that focuses on use profiles. RESULTS Five use profiles were identified, the largest of which (46.95% of encounters) described basic HIE access. ICU admission is more probable when the HIE system is perused by multiple users (odds increase by 31%) and when use profiles include prolonged screen viewing (odds increase by 159%) or access to diverse and multiple types of information, specifically on test results, procedures, and previous encounters. DISCUSSION Reductionistic and configurational approaches yield complementary insights, which advance the understanding of how actual HIE use is associated with clinical decision making. The study shows that congruent profiles of HIE use enhance the predictability of the admission decision beyond what can be explained by independent variables of HIE use.

Use patterns of health information exchange through a multidimensional lens

Insights about patterns of system use are often gained through the analysis of system log files, which record the actual behavior of users. In a clinical context, however, few attempts have been made to typify system use through log file analysis. The present study offers a framework for identifying, describing, and discerning among patterns of use of a clinical information retrieval system. We use the session attributes of volume, diversity, granularity, duration, and content to define a multidimensional space in which each specific session can be positioned. We also describe an analytical method for identifying the common archetypes of system use in this multidimensional space. We demonstrate the value of the proposed framework with a log file of the use of a health information exchange (HIE) system by physicians in an emergency department (ED) of a large Israeli hospital. The analysis reveals five distinct patterns of system use, which have yet to be described in the relevant literature. The results of this study have the potential to inform the design of HIE systems for efficient and effective use, thus increasing their contribution to the clinical decision-making process.

Dabigatran-induced nephropathy and its successful treatment with Idarucizumab - case report and literature review

BACKGROUND Anticoagulant induced renal injury has been previously described with Warfarin treatment. In the last decade direct oral anticoagulants (DOAC) were introduced. They include direct inhibitors of factor Xa (Rivaroxaban, Apixaban, Edoxaban) and a thrombin inhibitor (Dabigatran). There are isolated reports describing acute kidney injury (AKI) due to the use of DOACs. CASE REPORT We report a clinical case of an 80-year-old patient recently started on Dabigatran for new onset atrial fibrillation. She presented with AKI and hematuria, urine specimen showed RBC casts, and a working diagnosis of anticoagulant nephropathy due to Dabigatran was made. During hospitalization she was treated with Idarucizumab with a full recovery of renal function. To the best of our knowledge, there are 4 published case reports describing kidney injury produced by Dabigatran. CONCLUSION The use of DOACs is increasing rapidly, with increasing concern about its safety profile and, in particular, its potential harmful effect on renal function. As described in our case, treatment with Praxbind for Dabigatran induced kidney injury may be an acceptable management strategy that may obviate the need for urgent dialysis in selected cases by complete reversal of the AKI.

Balancing Volume and Duration of Information Consumption by Physicians: The Case of Health Information Exchange in Critical Care

BACKGROUND The realization of the potential benefits of health information exchange systems (HIEs) for emergency departments (EDs) depends on the way these systems are actually used. The attributes of volume of information and duration of information processing are important for the study of HIE use patterns in the ED, as cognitive load and time constraints may result in a trade-off between these attributes. Experts and non-experts often use different problem-solving strategies, which may be consequential for their system use patterns. Little previous research focuses on the trade-off between volume and duration of system use or on the factors that affect it, including user expertise. OBJECTIVES This study aims at exploring the trade-off of volume and duration of use, examining whether this relationship differs between experts and non-experts, and identifying factors that are associated with use patterns characterized by volume and duration. METHODS The research objectives are pursued in the context of critically-ill patients, treated at a busy ED in the period 2010-2012. The primary source of internal and external data is an HIE linked to 14 hospitals, over 1300 clinics, and other clinical facilities. We define four use profiles based on the attributes of duration and volume: quick and basic, quick and deep, slow and basic, and slow and deep. The volume and duration of use are computed using HIE log files as the number of screens and the time per screen, respectively. Each session is then classified into a specific profile based on distances from predefined profile centroids. Experts are physicians that are board-certified in emergency medicine. We test the distribution of use profiles and their associations with multiple variables that describe the patient, physician, situation, information available in the HIE system, and use dynamics within the encounter. RESULTS The quick and basic profile is the most prevalent. While available admission summaries are associated with quick and basic use, lab and imaging results are associated with slower or deeper use. Physicians who are the first to use the system or are sole users during an encounter are less inclined to quick and deep use. These effects are intensified for experts. DISCUSSION A trade-off between volume and duration is identified. While system use is overall similar for experts and non-experts, the circumstances in which a certain profile is more likely to be observed vary across these two groups. Information availability and multiple-physician dynamics within the encounter emerge as important for the prediction of use profiles. The findings of this study provide implications for the design, implementation, and research of HIE use.

Mass media effect on vaccines uptake during silent polio outbreak

BACKGROUND During 2013, isolation of a wild type 1 poliovirus from routine sewage sample in Israel, led to a national OPV campaign. During this period, there was a constant cover of the outbreak by the mass media. AIMS To investigate the association of media exposure and OPV and non-OPV vaccines uptake during the 2013 silent polio outbreak in Israel. METHODS We received data on daily immunization rates during the outbreak period from the Ministry of Health (MoH). We conducted a multivariable time trend analysis to assess the association between daily media exposure and vaccines uptake. Analysis was stratified by ethnicity and socio-economic status (SES). RESULTS During the MoH supplemental immunization activity, 138,799 OPV vaccines were given. There was a significant association between media exposure and OPV uptake, most prominent in a lag of 3-5 days from the exposure among Jews (R.R 1.79C.I 95% 1.32-2.41) and high SES subgroups (R.R 1.71C.I 95% 1.27-2.30). These subgroups also showed increased non-OPV uptake in a lag of 3-5 days from the media exposure, in all vaccines except for MMR. Lower SES and non-Jewish subgroups did not demonstrate the same association. CONCLUSION Our findings expand the understanding of public behaviour during outbreaks. The public response shows high variability within specific subgroups. These findings highlight the importance of tailored communication strategies for each subgroup.

Increase in Ischemic Stroke Incident Hospitalizations Among Bedouin Arabs During Ramadan Month

Background Previous studies have not shown any significant effect on stroke incidence during Ramadan. We aimed to investigate the association between ischemic stroke incident hospitalizations and Ramadan, accounting for seasonality and temperature. Methods and Results This retrospective cohort study included all patients admitted with acute ischemic stroke to Soroka University Medical Center from June 2012 to June 2016. We obtained daily mean temperatures and relative humidity rates from 2 monitoring stations in South Israel. We analyzed the association between stroke incidence and Ramadan month, adjusting for weekly temperature and seasonality using Poisson regression models. We compared the first versus the last Ramadan fortnight. We performed an effect specificity analysis by assessing stroke incidence in the non‐Bedouin population. We identified 4727 cases of ischemic stroke, 564 cases of which were Bedouin Arabs. Fifty‐one cases occurred during Ramadan. Ramadan was significantly associated with an increased risk for ischemic stroke (RR 1.48; 95% confidence interval, 1.04–2.09), mainly during the first fortnight (RR 1.73, 95% confidence interval, 1.13–2.66) when compared with non‐Ramadan periods. Mean weekly temperatures and the summer season were not associated with stroke incidence among Bedouin Arabs (RR 0.98; 95% confidence interval, 0.82–1.18 and RR 0.77; confidence interval 0.56–1.06 accordingly). Such association was not observed in the non‐Bedouin population. Conclusion The Ramadan month, particularly in its first 2 weeks, is an independent and ethnicity specific risk factor for ischemic stroke hospitalizations among the Bedouin Arab fasting population.

Characteristics and outcomes of critically-ill medical patients admitted to a tertiary medical center with restricted ICU bed capacity

Background: In the emergency department (ED) critically‐ill medical patients are treated in the resuscitation room (RR). No studies described the outcomes of critically‐ill RR patients admitted to a hospital with low capacity of intensive care unit (ICU) beds. Methods: We included all medical patients above 18 who were admitted to a RR of a tertiary hospital during 2011–2012. We conducted multivariate logistic and Cox regressions and propensity score (PS) matched analysis to analyze parameters associated with the study outcomes. Results: In‐hospital mortality rate was 32.4% in ICU admitted patients compared to 52.0% of the non‐ICU critically‐ill patients (p<0.001). Age above 80, female and recent ED encounters were associated with non‐ICU admissions (p<0.05 for all). ICU admission had a statistically significant effect on in‐hospital mortality in PS matched analysis (OR 0.36, 95% CI 0.21–0.61). A marginal effect was evident in one‐year survival in PS matched landmark analysis (HR 0.50 95% CI 0.23–1.06). Conclusion: ED critically‐ill medical patients who were treated in the RR had high mortality rates in an institute with restricted ICU beds availability. However, those who were admitted to an ICU showed prolonged short and perhaps long term survival compared to those who were not. Highlights:Paucity of studies described critically‐ill patients admitted to a hospital with low capacity of intensive care unit (ICU) beds.Emergency department critically‐ill patients had high mortality rates in an institute with restricted ICU beds availabilityPatients who were admitted to an ICU showed better in‐hospital and perhaps one year survival compared to those who were hospitalized to non‐ICU.

Ethical issues in medical cannabis use

The increasing use of medical cannabis (MC) in the past decade raises several ethical considerations for the clinician. Regulatory issues stem from a gap between MC registration and certification in each country. Professional issues derive from the lack of sufficient knowledge of MC characteristics and the intersection between the physician, the patient and commercial interests. Finally, there are medical and psychological implications which are related to the use of MC regimens. We will discuss these issues in the light of the current era, in which policy has rapidly shifted toward legalization of cannabis, which influences the decisions of both clinicians and patients.

Basal insulin for the management of diabetic ketoacidosis

Due to its pharmacokinetic properties, it has been suggested that long-acting insulin analogues may have a role in facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA for prevention of rebound hyperglycemia, particularly if there are high insulin requirements. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycemia. Several studies have investigated the use of basal insulin in the management of DKA. Studies have been instituted on pediatric patients and adult patients. These studies reveal that co-administration of basal insulin in combination with an insulin infusion in the acute management of DKA is feasible. Basal insulin co-administration with regular insulin infusion was well tolerated, associated with faster resolution of acidosis without any adverse effects; patients required a shorter duration of intravenous insulin infusion and had a lower total dose of intravenous insulin and significantly decreased hyperglycemia after discontinuation of the intravenous insulin. This could potentially lead to a shorter ICU length of stay and reduced costs in the treatment of DKA. However, this approach may be associated with an increased risk of hypokalemia. The current literature on this management approach is incomplete, due to its many limitations (retrospective nature, small sample size, nonrandomized design). Additional prospective randomized studies are needed on this new therapeutic approach in the management patients with DKA.