Shachaf Shiber

Introduction: The use of medicinal cannabis is increasing worldwide and has applications in managing a wide range of conditions, including neurological, rheumatological, and gastrointestinal diseases. Despite its growing prevalence, there are limited data on patterns of cannabis prescription across varying disease groups and demographic subgroups. Methods: This retrospective observational cohort study analysed cannabis usage patterns among 263 patients from the cannabis user clinic at Rabin Medical center (RMC), a tertiary hospital in Israel. To minimise the inclusion of recreational cannabis users, only patients aged 30 years and older were included. Patients were categorised into three groups based on their primary medical condition: neurological (n = 63), rheumatological (n = 106), and gastrointestinal (n = 94). Data collected included: demographic information, cannabis dosage, Tetrahydrocannabinol (THC) content, cultivated variety preference (sativa vs. Indica), and method of consumption (smoking vs. oil). Statistical analyses were conducted using ANOVA, Kruskal-Wallis, chi-square, and t-tests to compare cannabis prescription patterns between disease and demographic groups. Results: Significant differences in cannabis prescription patterns were observed across disease groups. Patients with gastrointestinal conditions were prescribed the highest mean monthly cannabis dose (22.26 ± 13.60 g), while those with neurological conditions had the highest oil consumption (31.75%). Sex-based differences were notable, with male patients being prescribed significantly higher doses of cannabis (25.48 ± 15.15 g) and higher THC content (14 ± 6.56%) compared to female patients (17.32 ± 9.93 g; THC: 11.39 ± 6.48%). Discussion: The study highlights variations in cannabis prescription patterns based on both medical conditions and demographic factors. Male patients received higher doses and THC-rich formulations, while patients with gastrointestinal conditions had the highest cannabis prescription overall. These findings suggest the need for individualised cannabis therapy based on patient characteristics and the specific condition being treated. Conclusion: Medicinal cannabis usage patterns vary significantly across disease and demographic groups. Personalised cannabis treatment plans, informed by both clinical and demographic factors, are essential to optimising patient outcomes. Further research is needed to develop more precise guidelines for prescribing medicinal cannabis.

Gout and type 2 diabetes mellitus (T2DM) often coexist and are associated with chronic kidney disease (CKD) and increased mortality. Dipeptidyl peptidase-4 (DPP-4) inhibitors, commonly used in T2DM, may offer additional benefits, such as reducing inflammation and uric acid levels. This study aimed to assess the impact of DPP-4 inhibitors on gout flare frequency, serum uric acid (sUA) levels, and survival in patients with gout, T2DM, and CKD.A cross-sectional, retrospective, longitudinal study was conducted over 6 years between 2016 – 2022, including patients with gout and T2DM from the largest healthcare provider in Israel. Patients were divided into treatment and control groups based on DPP4-inhibitor status treatment. The primary outcome was the number of gout arthritis attacks over 1 year, reflected by the number of emergency room visits. Secondary outcomes included mean serum high-sensitive C-reactive protein (hs-CRP) levels and survival rates over the study period.DPP-4 inhibitor treatment significantly reduced sUA levels (5.2±1.3 mg/dL vs. 5.9±2.2 mg/dL, p=0.05) and hs-CRP levels (0.50±0.19 mg/dL, p<0.001). Kaplan-Meier survival analysis suggested a trend towards improved survival in the DPP-4 inhibitor group (HR=0.834, 95% CI: 0.6–1.04, p=0.05), particularly among patients with chronic kidney disease (CKD), although without statistical significance. The emergency room visits due to gout attacks were fewer in the DPP-4 inhibitor group, although this difference did not achieve statistical significance.DPP-4 inhibitors may offer benefits beyond glycemic control in T2DM and gout, including reduced sUA and hs-CRP levels and improved survival in CKD patients. Larger, randomized trials are warranted to explore these potential benefits.

Objectives: Rhabdomyolysis is characterized by muscle breakdown and the release of myocyte contents into the bloodstream, which can lead to severe complications. Elevated troponin levels, typically a marker of heart muscle injury, have been observed in rhabdomyolysis, but their clinical significance in this context remains unclear. This study aimed to evaluate the association between elevated troponin levels and mortality in patients with rhabdomyolysis, specifically those with normal kidney function and left ventricular function. Methods: This single-centre, retrospective study was conducted at a tertiary university medical centre from 2010 to 2022. The study included 252 patients diagnosed with rhabdomyolysis, defined by a creatine phosphokinase (CPK) level at least five times the upper normal limit. Patients were stratified into troponin-positive and troponin-negative groups. Only patients with an estimated glomerular filtration rate (eGFR) above 90 ml/min and normal left ventricular function were included. The primary outcome was 90-day survival, with secondary outcomes including 30-day survival and in-hospital mortality. Results: Patients with elevated troponin levels had significantly higher 90-day mortality rates, longer hospital stays, and were older with more comorbidities compared to the troponin-negative group. These patients had worse outcomes despite lower CPK levels in the troponin-positive group. The receiver operating characteristic (ROC) analysis showed a limited predictive value for CPK levels for troponin positivity. Conclusions: Elevated troponin levels in rhabdomyolysis, particularly in older patients, are associated with increased mortality, independent of kidney and left ventricular function. This suggests the need for heightened monitoring and potentially more aggressive management of these patients.

Objective: Hospital-at-home schemes have been widely adopted as an alternative to in-hospital treatment for acutely ill patients. However, their impact on hospital costs remains unclear. Study setting: we calculated the costs during the index admission and 30 days later of 131 randomly selected acutely ill patients attending a tertiary medical center in 2011-2021 who met the inclusion criteria for hospital-at-home care. study design: findings were compared to a simulation of the same cohort based on assumptions of potential costs and outcomes under a hospital-at-home program. principal findings: hospital-at-home care was found to incur higher costs during the index admission (+30%) and 30 days after (+14%). It remained costlier on most subpopulation and sensitivity analyses, except when patients were readmitted within 30 days of the index admission (-27%), owing to 30% lower hospital-at-home labor costs, and if the predicted index admission days were decreased by 10% in the hospital-at-home scheme (-11%). Conclusions: under the assumptions made, there may not be a clear and robust cost reduction to hospitals by the mere application of a hospital-at-home scheme.

Objective: Survival after out-of-hospital cardiac arrest (OHCA) depends on multiple factors, mostly quality of chest compressions. Studies comparing manual compression with a mechanical active compression-depression device (ACD) have yielded controversial results in terms of outcomes and injury. The aim of the present study was to determine whether out-of-hospital ACD cardiopulmonary resuscitation (CPR) use is associated with more skeletal fractures and/or internal injuries than manual compression, with similar duration of cardiopulmonary resuscitation (CPR) between the groups. Methods: The cohort included all patients diagnosed with out-of-hospital cardiac arrest (OHCA) at a tertiary medical center between January 2018 and June 2019 who achieved return of spontaneous circulation (ROSC). The primary outcome measure was the incidence of skeletal fractures and/or internal injuries in the two groups. Secondary outcome measures were clinical factors contributing to skeletal fracture/internal injuries and to achievement of ROSC during CPR. Results: Of 107 patients enrolled, 45 (42%) were resuscitated with manual chest compression and 62 (58%) with a piston-based ACD device (LUCAS). The duration of chest compression was 46.0 minutes vs. 48.5 minutes, respectively (p=0.82). There were no differences in rates of ROSC (53.2% vs.50.8%, p=0.84), cardiac etiology of OHCA (48.9% vs.43.5%, p=0.3), major complications (ribs/sternum fracture, pneumothorax, hemothorax, lung parenchymal damage, major bleeding), or any complication (20.5% vs.12.1%, p=0.28). On multivariate logistic regression analysis, factors with the highest predictive value for ROSC were cardiac etiology (OR 1.94;CI 2.00– 12.94) and female sex (OR 1.94;CI 2.00– 12.94). Type of arrhythmia had no significant effect. Use of the LUCAS was not associated with ROSC (OR 0.73;CI 0.34– 2.1). Conclusion: This is the first study to compare mechanical and manual out-of-hospital chest compression of similar duration to ROSC. The LUCAS did not show added benefit in terms of ROSC rate, and its use did not lead to a higher risk of traumatic injury. ACD devices may be more useful in cases of delayed ambulance response times, or events in remote locations.

Objectives: The HEART Pathway is a diagnostic protocol designed to identify low-risk patients with chest pain who can be safely discharged from the emergency department (ED) without hospitalization. Studies have reported a negative bias in identifying myocardial ischemia in females versus males and a different clinical pattern of cardiac ischemia across genders. This study sought to determine if the HEART Pathway recommendations are affected by negative bias in females. Materials and Methods: A retrospective cohort study was conducted in the ED of an academic tertiary medical center. Admission/discharge decisions made by physicians in male and female patients presenting with chest pain in 4/2014–7/2019 were compared with HEART Pathway protocol predictions. Probabilities were estimated with logistic regression analysis, and odds ratios and 95% confidence intervals were calculated. Results: The cohort included 772 patients, 485 male (63%) and 287 female (37%), of median age 54 years. On the basis of their presenting symptoms, 278 patients (36%) were admitted by the ED physician and 494 (64%) were discharged. Using the HEART Pathway protocol, 227 patients (29.4%) would be expected to be admitted and 545 (70.6%) discharged. The real-life admission rate was higher than possible with the HEART Protocol ( p = 0.001). In a regression model, male sex was a significant factor favoring admission among the patients for whom the HEART Pathway predicted admission ( p = 0.007). Conclusions: As the HEART Pathway is a validated risk-stratification tool, there is a high likelihood that serious coronary artery disease may be overlooked in women, even those who seek timely medical assistance.

Background Necrotizing soft tissue infection (NSTI) is a life-threatening infection associated with high morbidity and mortality. Treatment consists of surgery and antibiotics. Many studies have addressed NSTI and its subtypes, but few have reviewed the clinical, radiological, and pathological differences between the polymicrobial and monomicrobial diseases. The objective of our study was to evaluate the clinical, radiological, and pathological features of patients with polymicrobial (NSTI I) and monomicrobial (NSTI II) infections and their association with outcome. Methods The cohort consisted of patients hospitalized with NSTI at a tertiary medical center in 2002–2019. The medical charts were reviewed for clinical, radiological, and pathological features. Findings were compared between patients in whom blood/tissue bacterial cultures yielded one or more than one pathological isolate. The primary clinical outcome measure of the study was all-cause mortality at 90 days. Secondary outcomes were duration of hospitalization, intensive care unit (ICU) admission, score on the LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis), and need for vasopressor treatment. Results A total of 81 patients met the inclusion criteria: 54 (66.6%) with monomicrobial NSTI and 27 (33.3%) with polymicrobial NSTI. There were no significant between-group differences in in-hospital and 90-day mortality. On multivariate analysis, the monomicrobial disease group had a significantly higher 90-day mortality rate in addition to higher rates of in-hospital mortality, ICU admission, and vasopressor use than the polymicrobial disease group. Conclusion Our study is the first to compare the clinical, radiological, and pathological differences between the two most common types of NSTI. The results demonstrate better prognosis for polymicrobial NSTI, with minimal ICU stay, lower mortality, and lower use of vasopressors. Level of evidence Prognostic and epidemiological, level III.

Background: Necrotizing fasciitis (NF) is a life-threatening infection with high morbidity and mortality rates which should be diagnosed and treated with surgical and antibiotic therapy. Many studies have addressed NF and its subtypes, but few have reviewed the clinical, radiological and pathological differences between the poly-microbial and the mono-microbial groups. Objective: The objective of our study is to describe a relatively large cohort of patients with NF and study and compare the clinical, radiological and pathological differences between the poly-microbial (Pm) and the mono-microbial (Mm) groups.Methods: The charts of hospitalized patients with NF diagnosis from 2002-2019 at the Rabin Medical Center were reviewed. The primary outcome was all-cause mortality at 90 days, secondary outcomes included duration of hospitalization, intensive care unit (ICU) admission, LRINEC score and the need for vasopressor use. Results: 81 patients with NF were included in the study, 54(66.6%) had Mm growth and 27(33.3%) had Pm growth. There were no significant differences between the two groups in the 90 days mortality, and moreover in hospital mortality was also insignificantly different. In a multivariate analysis, we found that 90 days mortality was more prevalent in the Mm group compared to Pm group. In addition, we found that in hospital mortality, ICU admission and vasopressors use were more frequent among the Mm-group compared to the Pm-group. Conclusions: our study is the first to compare the differences between the two most prevalent entities of NF. The results demonstrate better prognosis for Pm-NF, with minimal ICU stay, lower mortality, and lower use of vasopressors.

Few studies have addressed external validity of randomized controlled trials in infectious diseases. We aimed to assess the external validity of an investigator-initiated trial on treatment for unc...