Israel Medical Association Journal

Background: Salmonella, Shigella, and Campylobacter are highly prevalent among children. Reports on risk factors of patients infected with all three pathogens, not simultaneously, are scarce.

Objectives: To identify risk factors for multiple infection with Salmonella, Shigella, and Campylobacter in the same child.

Methods: Using the Israel Sentinel Laboratory-Based Surveillance Network, we conducted a retrospective observational case-case–control study among children aged 0–9 years. A case was defined as a child infected with Salmonella, Shigella, and Campylobacter at different occasions between January 1999 and December 2020. A control was defined as a child infected with a single pathogen once, during the same period. Logistic regression models were applied to determine the association between multiple infections and demographic characteristics.

Results: We identified 109 cases (0.1%) infected with Salmonella, Shigella, and Campylobacter, and 86,511 controls (99.9%) infected with only one bacteria type. In a multivariable analysis, we showed that being Jewish (odds ratio [OR] 2.4, 95% confidence interval [95%CI] 1.3–4.4), having residency in Jerusalem (OR 3.2, 95%CI 1.3–7.7), or in the southern district (OR 3.7, 95%CI 1.5–8.8) were independent risk factors for multiple infection.

Conclusions: Although very rare, non-simultaneous infection with multiple bacteria does occur in Israel. National and local authorities should promote programs to encourage proper hygiene practices, which are culture-adjusted.

Background: Environmental, social, and governance (ESG) is a form of international private business self-regulation that aims to contribute to society from a philanthropic, activist, or charitable nature by engaging in or supporting volunteering or ethically oriented practices. The major benefit of ESG is having the organization’s workers recruited for the goal of making the world a better place. There is a growing understanding regarding the extent of the environmental impacts of health services. Therefore, the interest in measuring and reporting the sustainability of health system performance is becoming crucial. As population aging and growth in healthcare demand are two of the main challenges of the current and mainly future health services, performance, and quality measurement as well as sustainability metrices are relevant more than ever.

Objectives: To review the ESG activities at Assuta Medical Centers (AMC) that helped the organization earn the Maala Index Platinum + grade in 2021.

Methods: We reviewed the ESG elements that were implemented at AMC.

Results: AMC entered an ESG process in November 2019 and earned Platinum and Platinum+ grades from the Maala Index in 2020 and 2021, respectively. AMC won the Workforce Diversity prize for having many employees over 60 years of age. AMC activities are detailed as a case study for other health organizations in Israel and worldwide.

Conclusions: A big leading health organization can spearhead sustainable development goals model in Israel and worldwide.

Background: Low back pain has been the leading cause for disability worldwide for several decades, and clinical guidelines for its management clearly emphasize a multifactorial approach. Yet, current guidelines are still not well implemented by clinicians.

Objectives: To explore the attitudes of family medicine residents regarding low back pain and to determine whether they positively correlate with their treatment approaches. To test if these attitudes can be affected by the Enhanced Transtheoretical Model Intervention (ETMI), a guideline-based workshop.

Methods: Participants completed an online questionnaire regarding their attitudes toward low back pain and clinical habits, after which they attended an online ETMI educational workshop. One month later all participants were asked to complete the questionnaire a second time. Statistical analysis was conducted to explore the attitudes of the residents and clinical approaches, as well as any associations between them, as well as possible differences pre- and post-intervention.

Results: The participants exhibited highly psychologically oriented attitudes. Correlations between the attitudes and treatment did not show consistent coherency. Results regarding the participants clinical approaches were revealed to have two distinct and opposed inclinations: biomedically and biopsychosocially. Last, results for the re-activation subscale were significantly higher post-intervention.

Conclusions: Family medicine residents seem to be highly psychologically oriented regarding low back pain; however, they do not necessarily treat their patients accordingly. Their clinical choices seem to follow two different approaches: guideline-consistent and non-guideline-consistent. An ETMI guideline-based workshop may sway their attitudes toward re-activation of patients. Further research is needed to determine whether similar results would arise in larger physician populations.

Background: Self-management, an active life routine, and adherence to physical activity are effective in the management of low back pain (LBP). However, delivering effective education and reassurance to patients can be a difficult for practitioners. The enhanced transtheoretical model intervention (ETMI) has shown to be successful and cost effective. The intervention focuses on educating practitioners to reassure patients, empower them to increase physical activity, and improve their self-efficacy.

Objectives: To assess whether ETMI can be implemented among primary care practitioners and to examine whether it reduces pain, disability, and fear avoidance as well as decreasing healthcare utilization. This protocol outlines the methodology for the implementation of ETMI through a hybrid implementation–effectiveness design.

Methods: Two qualitative and mixed-method studies provided a basis for an implementation prospective cohort study. Discussions are followed by a prospective cohort study with pre-and post-intervention measures as well as descriptions retrieving economic and therapeutic outcome data from the Maccabi Healthcare Services (MHS) databases. In addition, a fourth qualitative study was conducted at the midpoint of the implementation to evaluate the process by measuring the perceptions and practice of practitioners. The intervention group was 220 primary care practitioners and their patients (~n=10,000) from the central district of MHS. The control data was provided by other care districts with similar socioeconomic makeup (~n=40,000).

Conclusions: We evaluated the process and outcomes of the implementation of ETMI. We investigated the relationship between the care received (ETMI against treatment as usual) and healthcare utilization, costs, and patient-clinical outcomes.

Background: Over the past several years there has been a marked increase in the number of Israel Defense Forces (IDF) soldiers having hip arthroscopy based on magnetic resonance arthrography diagnosis of hip labral tears and/or impingement.

Objectives: To detail characteristics of soldiers who underwent hip arthroscopy and assess outcomes and rate of return to duty.

Methods: A retrospective chart review was conducted of all soldiers who underwent hip arthroscopy 2018 to 2020, and soldiers referred for hip arthroscopy during 2021. Demographic, medical, and military service data were collected from the computerized patient record.

Results: Our study comprised 117 soldiers (29% combatants, 24% females) who underwent hip arthroscopy, mean age 22 ± 3 years, range 18–42; 45% had physiotherapy before surgery; 31% were diagnosed during or within 3 months of having back pain and 20% had been referred for psychological assistance (not related to the hip pain); 15.4% had serious adverse events. The mean time to return to any duty (including clerical work) was 8.0 ± 0.6 months; 56% of the soldiers never returned to service and were discharged from the military. During the one-year follow-up, only 6% returned to their full pre-symptom activity.

Conclusions: The short-term results of IDF soldiers who underwent hip arthroscopy during the study period were much inferior to those reported among athletes. The lack of specificity of the diagnostic tools (history, examination, and imaging) used to determine whether surgery for hip pain is likely to be beneficial in this population may be contributing to over-diagnosis and over-treatment.

Overuse of healthcare services is a common phenomenon defined as: “a healthcare service that is provided under circumstances in which its potential for harm exceeds the possible benefit.” It is expressed in the gap between desired services and available ones and is accompanied by high financial and human life costs. One-fifth to one-third of patients receives unnecessary, ineffective, or potentially harmful treatments or services. One of the greatest challenges to understanding overuse is the lack of definition for appropriate use. Apart from the physical and mental damage caused by overuse or improper use of medical services, this phenomenon has many implications, such as increasing waiting times for services, creating long queues, and incurring considerable financial costs as over 10% of hospital expenses are used to correct medical errors or preventable infections. Government intervention through economic arrangements such as deductibles and pre-authorization of services by the insurer are partially effective in reducing the overuse of health services. Additional solutions include ensuring safety and quality of care as well as shared decision-making.

Dear unique individual:

Really very sorry to hear that you are living with shoulder pain. I’m writing this open letter to you to support decisions you will need to make about how best to manage your symptoms. Shoulder pain never comes at the right time, it always interferes with important work, sports, or social events, and like any pain, we want it gone the moment it starts. In this letter I present to you information that I hope may support you with decisions you will need to make about how best to find an answer for your symptoms. I would like to share with you information about shoulder pain and information about imaging investigations, injections, surgical, and nonsurgical management. I would also like to share with you important lifestyle factors that you need to be aware of, that may also help make sense of the symptoms you are experiencing. This letter focuses on the 90% of people who experience non-traumatic shoulder pain. This letter includes important questions you should ask when you see a clinician. Remember, it is you, not the health professional, who is the most important person in healthcare. No decision should be made without you being fully and truthfully informed of the anticipated benefits, timeframes, and commitments you will need to address and the possible harm of any intervention. I hope you find this letter helpful.

Cannabis and cannabinoids have been known for thousands of years for their promising potential as analgesics. Chronic pain is a common complaint among many patients with rheumatic conditions. These disorders have revisited the medical approach toward cannabis and its potential role in pain relief. In addition, in recent years, information has mounted about the immunomodulatory effects of cannabis. In this review we discuss findings on the benefits cannabis may have in rheumatic and autoimmune disorders.

Background: On 18 March 2020, the Israeli Health Ministry issued lockdown orders to mitigate the spread of coronavirus disease 2019 (COVID-19).

Objectives: To assess the association of lockdown orders on telemedicine practice and the effect of social distancing on infectious diseases in a primary care community pediatric clinic as well as the rate of referrals to emergency departments (ED) and trends of hospitalization.

Methods: Investigators performed a retrospective secondary data analysis that screened for visits in a large pediatric center from 1 January to 31 May 2020. Total visits were compared from January to December 2020 during the same period in 2019. Visits were coded during the first lockdown as being via telemedicine or in-person, and whether they resulted in ED referral or hospitalization. Month-to-month comparisons were performed as well as percent change from the previous year.

Results: There was a sharp decline of in-person visits (24%) and an increase in telemedicine consultations (76%) during the first lockdown (p < 0.001). When the lockdown restrictions were eased, there was a rebound of 50% in-person visits (p < 0.05). There was a profound decrease of visits for common infectious diseases during the lockdown period. Substantial decreases were noted for overall visits, ED referrals, and hospitalizations in 2020 compared to 2019.

Conclusions: COVID-19 had a major impact on primary care clinics, resulting in fewer patient-doctor encounters, fewer overall visits, fewer ED referrals, and fewer hospitalizations

Background: Healthcare workers (HCWs) have close interaction with confirmed or suspected coronavirus disease 2019 (COVID-19) patients. Infection rates reported among HCWs is between 3% and 17%, and asymptomatic HCWs are a potential source of nosocomial transmission to vulnerable patients and colleagues. Universal mask use and good supply of personal protective equipment was implemented early at our institution.

Objectives: To determine the rate of infection by the serologic status of HCWs during first three COVID-19 waves, based on occupation and risk of exposure, compared to Israeli general population.

Methods: We conducted a prospective cohort study at Emek Medical Center from April 2020 to April 2021. A total of 101 HCWs volunteered to be followed at six time points by a serology test and a questionnaire.

Results: A total of 101 HCWs completed six serologic tests. All participants were seronegative at the four initial tests. The cumulative seropositivity rate for COVID-19 in HCWs was 9.9% (10/101). Only three seropositive HCWs (2.97%) were hospital-acquired.

Conclusions: Seroprevalence and seroconversion dynamics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in 101 HCWs during COVID-19 outbreaks at Emek Medical Center were similar to the epidemiological curve of positive polymerase chain reaction results of the Israeli population, as published by the Israeli Ministry of Health, at each time point. Universal mask use and infection control measures may have contributed to a low hospital infection rate.

Background: The association between use of renin-angiotensin-aldosterone (RAAS) inhibitors and both SARS-CoV-2 infection and the development of severe COVID-19 has been presented in the recent medical literature with inconsistent results.

Objectives: To assess the association between RAAS inhibitor use and two outcomes: infection with SARS-CoV-2 (Model 1) and severe COVID-19 among those infected (Model 2).

Methods: We accessed used electronic health records of individuals from Israel who were receiving anti-hypertensive medications for this retrospective study. For Model 1 we used a case-control design. For Model 2 we used a cohort design. In both models, inverse probability weighting adjusted for identified confounders as part of doubly robust outcome regression.

Results: We tested 38,554 individuals for SARS-CoV-2 who had hypertension and were being treated with medication; 691 had a positive test result. Among those with a positive test, 119 developed severe illness. There was no association between RAAS inhibitor use and a positive test. Use of RAAS inhibitors was associated with a decreased risk for severe COVID-19 (adjusted odds ratio [OR] 0.47, 95% confidence interval [95%CI] 0.29–0.77) compared with users of non-RAAS anti-hypertensive medication. The association remained significant when use of angiotensin-converting-enzyme inhibitors (adjusted OR 0.46, 95%CI 0.27–0.77) and angiotensin II receptor blockers (adjusted OR 0.39, 95%CI 0.16–0.95) were analyzed separately.

Conclusions: Among individuals with hypertension using RAAS inhibitors, we found a lower risk of severe disease compared to those using non-RAAS anti-hypertensive medications. This finding suggests that RAAS inhibitors may have a protective effect on COVID-19 severity among individuals with medically treated hypertension.