Physical Activity and Long-Term Mortality Risk in Older Adults with and without Cardiovascular Disease: A Nationwide Cohort Study.

AIMS: To evaluate the association between physical activity (PA) levels and mortality among older adults, to determine whether it differs according to cardiovascular disease (CVD) status, and to assess the optimal weekly duration of PA associated with subsequent survival. METHODS: Participants (n = 1,799) were drawn from a national survey conducted from 2005 to 2006, constituting Israeli adults aged ≥65 years. Sociodemographic, clinical, behavioral, and psychosocial data were collected via interview at study entry. Based on a detailed PA questionnaire and according to published guidelines, participants were classified as sufficiently active, insufficiently active, and inactive. CVD status was self-reported. Mortality data (last follow-up, December 2016) were obtained from the Israeli Ministry of Health. Using Cox models, inverse probability weighted hazard ratios (HRs) for mortality, based on propensity score, were estimated for PA categories. RESULTS: Among the participants at baseline (mean age, 74.6 years), 559 (31.1%) were sufficiently active, 506 (28.1%) were insufficiently active, and 734 (40.8%) were inactive. During follow-up (mean, 9.0 years), 684 participants (38.0%) died. PA was inversely associated with mortality, with propensity score-adjusted HRs (95% confidence intervals) of 0.84 (0.71-1.01) in insufficiently and 0.73 (0.61-0.88) in sufficiently active participants (ptrend < 0.001). No PA-by-CVD interaction was detected on multiplicative scale (p = 0.36) or additive scale (p = 0.58). A monotonic survival benefit was observed until ∼150 min of PA per week, beyond which no further gain was apparent. CONCLUSIONS: In a nationwide cohort of older adults, nearly 70% did not meet the guideline for PA. PA engagement was inversely associated with long-term mortality risk, similarly in individuals with and without CVD. A maximum survival advantage was achieved at around 150 min of exercise per week.

Preexisting coronary heart disease and susceptibility to long-term effects of traffic-related air pollution: A matched cohort analysis.

BACKGROUND: Individuals with coronary heart disease are considered susceptible to traffic-related air pollution exposure. Yet, cohort-based evidence on whether preexisting coronary heart disease modifies the association of traffic-related air pollution with health outcomes is lacking. AIM: Using data of four Israeli cohorts, we compared associations of traffic-related air pollution with mortality and cancer between coronary heart disease patients and matched controls from the general population. METHODS: Subjects hospitalized with acute coronary syndrome from two patient cohorts (inception years: 1992-1993 and 2006-2014) were age- and sex-matched to coronary heart disease-free participants of two cycles of the Israeli National Health and Nutrition Surveys (inception years: 1999-2001 and 2005-2006). Ambient concentrations of nitrogen oxides at the residential place served as a proxy for traffic-related air pollution exposure across all cohorts, based on a high-resolution national land use regression model (50 m). Data on all-cause mortality (last update: 2018) and cancer incidence (last update: 2016) were retrieved from national registries. Cox-derived stratum-specific hazard ratios with 95% confidence intervals were calculated, adjusted for harmonized covariates across cohorts, including age, sex, ethnicity, neighborhood socioeconomic status, smoking, diabetes, hypertension, prior stroke and prior malignancy (the latter only in the mortality analysis). Effect-modification was examined by testing nitrogen oxides-by-coronary heart disease interaction term in the entire matched cohort. RESULTS: The cohort (mean (standard deviation) age 61.5 (14) years; 44% women) included 2393 matched pairs, among them 2040 were cancer-free at baseline. During a median (25th-75th percentiles) follow-up of 13 (10-19) and 11 (7-17) years, 1458 deaths and 536 new cancer cases were identified, respectively. In multivariable-adjusted models, a 10-parts per billion nitrogen oxides increment was positively associated with all-cause mortality among coronary heart disease patients (hazard ratio = 1.13, 95% confidence interval 1.05-1.22), but not among controls (hazard ratio = 1.00, 0.93-1.08) (pinteraction = 0.003). A similar pattern was seen for all-cancer incidence (hazard ratioCHD = 1.19 (1.03-1.37), hazard ratioCHD-Free = 0.93 (0.84-1.04) (pinteraction = 0.01)). Associations were robust to multiple sensitivity analyses. CONCLUSIONS: Coronary heart disease patients might be at increased risk for traffic-related air pollution-associated mortality and cancer, irrespective of their age and sex. Patients and clinicians should be more aware of the adverse health effects on coronary heart disease patients of chronic exposure to vehicle emissions.

Leisure-Time Physical Activity and Cancer Risk Among Older Adults: A Cohort Study.

OBJECTIVE: To examine the association between leisure-time physical activity (LTPA) and long-term cancer risk in a nationwide cohort of older adults. PARTICIPANTS AND METHODS: The cohort comprised participants of a national survey conducted between July 2005 and December 2006, constituting a random sample of Israeli community-dwelling adults aged 65 years or older. Based on self-reported LTPA habits, participants were classified as sufficiently active, insufficiently active, or inactive according to published guidelines. Cancer diagnosis was assessed via the Israeli National Cancer Registry through September 2015. Inverse probability weighted hazard ratios for incident cancer, based on propensity score, were estimated for LTPA categories. RESULTS: Analysis included 1542 participants with no history of cancer at baseline (median [25th-75th percentile] age, 73 years [69-78 years]; 826 [53.6%] women). Inactive participants (n=641 [41.6%]) were more likely to be female, of lower socioeconomic status, and with higher body mass index and poorer perceived health compared with their insufficiently active (n=443 [28.7%]) and sufficiently active (n=458 [29.7%]) counterparts. In the propensity score-weighted synthetic sample, the distribution of measured baseline covariates was similar across LTPA categories. Over a median follow-up of 9 years, 254 new cancer cases (16.5%) were diagnosed. Leisure-time physical activity was inversely associated with incident cancer, with adjusted hazard ratios (95% CIs) of 0.66 (0.46-0.93) in insufficiently active and 0.59 (0.42-0.82) in sufficiently active participants compared with inactive individuals (P value for trend = .002). CONCLUSION: Among older adults, engaging in LTPA, even at lower levels than officially recommended, may have a beneficial effect on primary prevention of cancer.

Diet quality in relation to healthy ageing: the Israeli Longitudinal Study on Aging (ILSA)-a study protocol.

INTRODUCTION: Population ageing is accelerating rapidly in Israel as well as worldwide, necessitating adaptation of the healthcare system and consideration of new approaches that serve the specific needs of older adults. In addition to cognitive function, frailty is one of the most challenging expressions of physical and mental ageing, a multidimensional syndrome of increased vulnerability. Several studies have shown that low intake of certain micronutrients and protein is associated with higher risk of frailty and cognitive impairment. However, whether global diet quality is involved in the aetiology of the latter outcomes is unclear. METHODS AND ANALYSIS: We are conducting, among older adult subjects who took part in 'Mabat Zahav' (Israeli National Health and Nutrition Survey of Older Adults) in 2005-2006 (T0, n=1852), an extensive follow-up interview (T1) that includes comprehensive geriatric assessment and evaluation of general health and quality of life. Diet quality is evaluated using the Healthy Eating Index (HEI) 2010, based on 24-hour diet recall measured at T0 and T1. Frailty is assessed using two different approaches: the phenotype framework and the accumulation of deficits model. Cognitive function is assessed by Mini-Mental State Examination (MMSE) and cognitive decline is assessed by the difference between repeated MMSE measurements. Different analytic methods will be applied to evaluate the role of diet quality in development of frailty and cognitive decline with inverse probability weighting used to minimise attrition bias. About 600 subjects are expected to be interviewed between May 2017 and December 2019. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Helsinki Committee of Sheba Medical Center, Tel Hashomer, Israel and the Ethical Committee of Tel-Aviv University. All participants sign an informed consent form. The findings of the study will be published in peer-reviewed journals.

Association of Adolescent Hypertension With Future End-stage Renal Disease.

Importance: Hypertension is a leading risk factor of cardiovascular morbidity and mortality. The role of nonmalignant hypertension as the sole initiating factor of end-stage renal disease (ESRD) in non-African American populations has recently been questioned. Objective: To investigate the association between hypertension and future ESRD in otherwise healthy adolescents. Design, Setting, and Participants: This retrospective cohort study examined the data of 16- to 19-year-old healthy candidates for military service in the Israel Defense Forces between January 1, 1967, and December 31, 2013. Data were obtained from the central conscription registry of the Israel Defense Forces and the ESRD registry of the Israel Ministry of Health. Participants underwent a comprehensive medical assessment prior to their military service. Individuals with evidence of renal damage or kidney-related risk factors were excluded. The data analysis was conducted from February 12, 2017, to October 16, 2018. Main Outcomes and Measures: End-stage renal disease as recorded by the Israeli ESRD registry, including hemodialysis, peritoneal dialysis, renal transplant diagnosed between January 1, 1990, and December 31, 2014. Results: The cohort included 2 658 238 adolescents (1 596 709 [60.1%] male with a mean [SD] age of 17.4 [0.5] years), of whom 7997 (0.3%) had an established hypertension diagnosis. Half of the individuals in the hypertensive group were overweight (1559 [20.1%]) or obese (2243 [28.9%]), and most (7235 [90.5%]) were male. During a median follow-up of 19.6 years (52 287 945 person-years), 2189 individuals developed ESRD, with an incidence rate of 3.9 per 100 000 person-years. Adolescent hypertension was found to be associated with future ESRD (crude hazard ratio [HR], 5.07; 95% CI, 3.73-6.88). In a multivariable model adjusted for sex, age, years of education, body mass index, and other sociodemographic variables, the HR was 1.98 (95% CI, 1.42-2.77). When excluding participants with severe hypertension, the association with ESRD remained statistically significant (HR, 1.93; 95% CI, 1.37-2.70). In the subanalysis of nonoverweight adolescents, the association between hypertension and ESRD was statistically significant as well (HR, 2.11; 95% CI, 1.05-4.24). Conclusions and Relevance: Hypertension appears to be associated with a doubling of the risk of future ESRD in an otherwise healthy adolescent population.

Prehypertension among 2.19 million adolescents and future risk for end-stage renal disease.

OBJECTIVE: Persistent hypertension in adulthood is a leading cause of end-stage renal disease (ESRD). Whether lower blood pressure (BP) values, in the range of prehypertension, are also associated with future occurrence of ESRD is unclear. Even less clear is the potential risk of early prehypertension appearing in adolescence. To address this question, we examined whether BP measurements in the prehypertensive range at age 16-19 years predict adult ESRD. METHODS: Medical data on 2194 635 16-19-year-old adolescents examined for medical fitness prior to military service from 1977 to 2013 were linked to the Israeli ESRD registry in this nationwide population-based cohort study. Incident cases of ESRD were recorded. Survival models were applied. RESULTS: During 35 007 506 person-years of follow-up (median follow-up 16.8 years), there were 690 ESRD cases, with an overall incidence rate of 1.97 cases per 100 000 person-years. Examinees with elevated BP readings in the prehypertensive range (BP between the 90th and 95th percentiles or between 120 and 139/80-89 mmHg) had increased incidence of ESRD with a hazard ratio of 1.32 (95% confidence interval, 1.11-1.58) adjusted for year of birth, age at examination, sex, BMI, education, socioeconomic status, and country of origin. Hypertension (BP above the 95th percentile or above 140/90 mmHg) was associated with a hazard ratio of 1.44 (95% confidence interval, 1.17-1.79). A spline model demonstrated a nadir of risk at SBP values as low as 94 mmHg. CONCLUSION: Asymptomatic, healthy adolescents with prehypertension have a 32% increased risk for subsequent ESRD, compared with adolescents with optimal BP.

Influenza A(H1N1)pdm 2009 and influenza B virus co-infection in hospitalized and non-hospitalized patients during the 2015-2016 epidemic season in Israel.

BACKGROUND: Influenza A and B viruses co-infections are rare events and mainly occurred in immunocompromised patients. OBJECTIVES: In this study we report an unusually high occurrence of influenza A (H1N1)pdm 2009 and influenza B virus co-infections during the epidemic year 2015-2016. STUDY DESIGN: Nasopharyngeal swabs were collected from 1919 patients visiting 26 outpatient clinics distributed throughout Israel and presenting with influenza-like illness. In addition, hospitalized patient tested for influenza viruses were also included in the study. Patients samples collected between October 2015 and April 2016 were tested for the presence of influenza viruses by real-time PCR. RESULTS: Of the 1919 patient samples tested, 11 (0.6%) were co-infected with both influenza A(H1N1)pdm 2009 and influenza B/Victoria viruses. Similar observation was noted in four hospitalized patients during the same period. Patients at ages 1-72 years, and their clinical symptoms were similar to that of patients infected with either influenza A or B viruses. Of all patients, only one hospitalized patient was immunocompromised. IN CONCLUSION: Co-infection of influenza A(H1N1)pdm 2009 and influenza B viruses is an increasingly recognized phenomenon. This co-infection can occur not only in immunocompromised individuals, but also in immunocompetent patients. Although co-infection appears to be a rare event, it may still play a role in the epidemiology, pathogenicity and evolution of influenza viruses.

Variations in death certification practices distort international comparisons of mortality from diabetes.

Background: Israel is ranked second among OECD countries in diabetes mortality despite good performance on diabetes care measures. This study assessed whether variations in death certification practices could explain differences in diabetes mortality rates between countries, using a comparison between the USA and Israel as an example. Methods: Multiple cause mortality data for Israel and the USA were analyzed. The proportions of cases with diabetes coded as the underlying cause of death (UCOD), of all certificates with diabetes listed as one of the multiple causes of death (MCOD), were calculated by age-group, and compared between the USA and Israel, with emphasis on cases in which cardiovascular events were reported in part I of the certificate. Results: The diabetes UCOD/MCOD ratio was higher in Israel for all age groups. The differences in proportions were larger when cardiovascular events were reported in part I. Diabetes mortality rate ratio between the countries would be 49% lower if the UCOD/MCOD ratios in US data were applied to the Israeli data. Conclusions: Half of the difference in the reported diabetes mortality rate between the USA and Israel is explained by different coding practices. International comparisons could be improved by using multiple cause data or by clarifying guidelines regarding certification of diabetes deaths.

Epidemiological and Virological Characterization of Influenza B Virus Infections.

While influenza A viruses comprise a heterogeneous group of clinically relevant influenza viruses, influenza B viruses form a more homogeneous cluster, divided mainly into two lineages: Victoria and Yamagata. This divergence has complicated seasonal influenza vaccine design, which traditionally contained two seasonal influenza A virus strains and one influenza B virus strain. We examined the distribution of the two influenza B virus lineages in Israel, between 2011-2014, in hospitalized and in non-hospitalized (community) influenza B virus-infected patients. We showed that influenza B virus infections can lead to hospitalization and demonstrated that during some winter seasons, both influenza B virus lineages circulated simultaneously in Israel. We further show that the influenza B virus Yamagata lineage was dominant, circulating in the county in the last few years of the study period, consistent with the anti-Yamagata influenza B virus antibodies detected in the serum samples of affected individuals residing in Israel in the year 2014. Interestingly, we found that elderly people were particularly vulnerable to Yamagata lineage influenza B virus infections.

Trends in the Epidemiology of Campylobacteriosis in Israel (1999-2012).

The objective of this study was to examine the recent trends in the epidemiology of campylobacteriosis in Israel. A Sentinel Laboratory-Based Surveillance Network for Bacterial Enteric Diseases was established in Israel by the Israel Center for Disease Control (ICDC). This network generated data on subjects from whom Campylobacter spp. was isolated in community and hospital laboratories. Further characterization of the isolates was done at the Campylobacter National Reference Laboratory. Data from these two sources were integrated and analyzed at the ICDC. Between 1999 and 2012, 40,978 Campylobacter stool isolates were reported to the ICDC by the sentinel laboratories. The incidence rate of campylobacteriosis increased from 65.7 per 100,000 in 1999 to 101.7 per 100,000 in 2012. This increase resulted from a significant rise in the incidence of campylobacteriosis in the Jewish population which, since 2009, surpassed the consistent higher incidence of the disease in Israeli Arabs. The peak morbidity in Israel consistently occurred in late spring, with a risk excess in males compared with females, in younger age groups and earlier in the life span among Arabs than among Jews and others. These results suggest that further analytical studies should be carried out to identify risk factors responsible for the increased incidence of campylobacteriosis and better direct prevention and control of the disease in Israel.

Adolescent BMI at Northern Israel: From Trends, to Associated Variables and Comorbidities, and to Medical Signatures.

The increasing prevalence of abnormal body mass index (BMI), mainly obesity, is becoming a significant public health problem. This cross-sectional study aimed to provide a comprehensive view of secular trends of BMI, and the associated socio-demographic variables and comorbidities among adolescents with abnormal BMI. Individuals of the study population were born mainly between 1970 and 1993, and were examined at 16 to 19 years of age during the years 1987 to 2010, at 1 conscription center in the northern district of Israel.The study population included 113,694 adolescents. Univariate and multivariable logistic regression models were used to investigate the associations between BMI categories, socio-demographic variables, and medical conditions.A downward trend in the prevalence of normal BMI among both male and female adolescents was obtained, while trends of overweight and obesity (in both genders) and underweight (only among females) rose. Socio-demographic variables such as religion, education, family-related parameters, residential environment, country of birth, and origin were all associated with different risks for abnormal BMI. Obesity was associated with higher risk for hyperlipidemia, endocrine disorders (only in males), knee disorders, and hypertension type I + II (in both genders). Overweight was associated with knee disorders (only in females). Underweight, exclusively in males, was associated with increased risk for endocrine disorders, proteinuria, and cardiac disorders. Hierarchical clustering analysis revealed the intricate relations between gender, BMI, and medical signatures. It brought to light novel clusters of diseases that were abundant among populations having above-normal BMI or underweight males. Furthermore, above-normal BMI was associated with a lower rate of cardiac anomalies and scoliosis/kyphosis, whereas being underweight was associated with a lower risk for hypertension and flat foot.This study provides a reliable and in-depth view of secular trends in height, weight, and BMI of male and female adolescents. It supports previous associations between abnormal BMI and demographic variables and comorbidities, while uncovering novel associations, mainly regarding medical signatures of each gender-BMI group. This might lead to better monitoring, early detection, prevention, and treatment of various conditions associated to abnormal BMI categories and gender groups.

Self-Reported Type 2 Diabetes and Diabetes-Related Eye Disease in Jews and Arabs in Israel.

Prevalence rates of diabetes and its complications may be higher in minorities. We assessed these rates in Jews and Arabs living in Israel. Data were pooled from the first and second Israeli national health interview surveys. 9625 Jews and 2401 Arabs participated in the analysis. The age adjusted rate of self-reported diabetes was 10.7 % among Arabs and 5.7 % among Jews [odds ratio (OR) 2.14, 95 % confidence interval 1.77-2.60]. After adjustment for risk factors the OR decreased to 1.28 (95 % CI 1.04-1.59). The rate of self-reported diabetes-related eye disease was 37.6 % among Arabs with diabetes and 18.3 % among Jews (OR 2.69, 95 % CI 1.84-3.93). After adjustment the odds among Arabs were still double that of Jews (OR 2.26, 95 % CI 1.44-3.56). Self-reported type 2 diabetes and diabetes-related eye disease were higher among Arabs. Multi-disciplinary and cultural sensitive approach is required in order to improve diabetes care among the Arab population.

Ineffectiveness of the 2014-2015 H3N2 influenza vaccine.

The seasonal influenza vaccine is currently the most effective preventive modality against influenza infection. Nasopharyngeal samples of vaccinated and non-vaccinated patients presenting with Influenza-like-illness (ILI) were collected from over 20 outpatient clinics located in different geographic parts of Israel and were tested for the presence of influenza viruses (influenza A and influenza B). Here we show, that in the 2014-2015 season, the vaccine that included the A/Texas/50/2012 H3N2 virus was ineffective. Significant numbers of individuals vaccinated with the 2014-2015 vaccine, of all ages, were infected with influenza A (H3N2), manifesting similar symptoms as the non-vaccinated group. We further demonstrate that the Israeli circulating influenza A(H3N2) virus was different than that included in the 2014-2015 northern hemisphere vaccine, and that antibodies elicited by this vaccine were significantly less efficient in neutralizing influenza A(H3N2) infection.

Urinary concentrations of polycyclic aromatic hydrocarbons in Israeli adults: demographic and life-style predictors.

Polycyclic aromatic hydrocarbons (PAHs) are ubiquitous environmental pollutants associated with adverse health outcomes, including cancer, asthma, and reduced fertility. Because data on exposure to these contaminants in Israel and the Middle East are very limited this study was conducted to measure urinary levels of PAHs in the general adult population in Israel and to identify demographic and life-style predictors of exposure. We measured concentrations of five PAH metabolites: 1-hydroxypyrene (1OH_pyrene) and four different hydroxyphenanthrenes (1-hydroxyphenanthrene, 2-hydroxyphenanthrene, 3-hydroxyphenanthrene, 4-hydroxyphenanthrene), as well as cotinine in urine samples collected from 243 Israeli adults from the general population. We interviewed participants using structured questionnaires to collect detailed demographic, smoking and dietary data. For over 99% of the study participants, urinary concentration of at least one of the PAHs was above both the limit of detection (LOD) and the limit of quantification (LOQ). All PAHs were significantly correlated (rho=0.67-0.92). Urinary concentration of hydroxyphenanthrenes, but not 1OH_pyrene, was significantly higher among Arabs and Druze study participants (N=56) compared to Jewish participants (N=183). For 4-hydroxyphenanthrene, concentration in Arabs and Druze was 1.95 (95% CI 1.50-2.52) that of Jews, after controlling for creatinine, age and cotinine levels. Urinary concentrations of all PAHs were significantly higher among current smokers or participants with higher cotinine levels and increased significantly with smoking frequency. While PAHs concentrations were not associated with cotinine concentrations in nonsmokers in the overall study population, PAHs concentration was significantly higher among nonsmoking Jews with cotinine ≥LOQ (1µg/L), which represents exposure to environmental tobacco smoking, compared to nonsmoking Jews with cotinine concentrations

Characteristics of suicide completers with a psychiatric diagnosis before death: a postmortem study of 98 cases.

The objective of this research was to classify the deaths of 98 victims of suicide in Tel Aviv, Israel between the years 2007 and 2010. This was done by examining background features and clinical characteristics among suicide completers with histories of a prior psychiatric hospitalization using logistic regression modeling. 34% of the sample (33/98) was given at least one psychiatric diagnosis upon discharge from a prior psychiatric hospitalization. Throughout their lifetime, those with psychiatric diagnoses were significantly more likely to have histories of mental health treatment (psychotherapy and psychotropic medication), psychopathology and suicidality among family members, prior suicide attempts and familial or emotional crisis as compared with those without a psychiatric diagnosis. During their last life phase, those with prior psychiatric diagnoses were also significantly more likely to have received psychotherapeutic treatment, expressed a lack of desire to live and presented with affective symptoms (e.g. depression, anxiety, adaptation difficulty and nervousness) as compared with those without such histories. Thus, focusing on high risk populations, such as those with psychiatric illnesses and deciphering the role of mental health treatment, familial predisposition, prior suicide attempt and sub-clinical symptoms in relation to suicide can inform future prevention practices.

Significant cross reactive antibodies to influenza virus in adults and children during a period of marked antigenic drift.

BACKGROUND: Little is known about the development of cross-reactive antibodies following natural exposure to pathogens. Such knowledge is critical in the development of new universal influenza vaccines. METHODS: To study the possibility of the presence of cross-reactive antibodies to influenza viruses which underwent a major antigenic drift between the years 1999 and 2007 sera from samples of 80 children and 400 adults were selected at random from the Israeli national serum bank. The sera was obtained in 2002 and in 2007, two time points that followed a major drift in the infectious H3N2 influenza virus strain (A/Panama/2007/99 to A/Wisconsin/67/2005). RESULTS: In the summer of 2002, 13% of the children had Hemagglutination Inhibition (HI) antibody titers of at least 40 and these antibodies recognized both A/Panama/2007/99 and A/Wisconsin/67/2005, where the latter strain only began to circulate in Israel in 2006. In 2007, 29% of the children had HI antibody titers of at least 40 directed against both A/Wisconsin/67/2005 and A/Panama/2007/99, even though they had never been exposed to the latter virus. Anti-A/Panama/2007/99 antibodies were detected in 58% and 68% of the 2002 and 2007 adult samples, respectively, while 8% and 39% had antibodies against A/Wisconsin/67/2005, respectively. CONCLUSIONS: The presence of naturally occurring cross-reactive influenza virus antibodies in a significant percentage of children has important implications for the development of a universal influenza vaccine.

Regional gaps in the provision of inpatient rehabilitation services for the elderly in Israel: Results of a national survey.

BACKGROUND: Medical events, such as stroke, limb fractures, joint replacements and spinal injuries, can lead to acute functional disability at all ages and to chronic disability, especially among the elderly. Rehabilitation is, therefore, essential for the prevention of permanent disability among older individuals. There are international practice guidelines for stroke and hip fracture management, including recommendations that rehabilitation services be an integral part of the provision of treatment in either an inpatient setting or in the community. There are no organized data on provision of rehabilitation services in Israel or on the distribution of these services throughout the country. Such information would be of great assistance in designing these services where they are needed and in making changes in the existing ones where necessary. METHODS: Patients aged 65 years or older with stroke or hip fracture were identified through one-day surveys conducted in 2009-2010 in all 26 acute care hospitals in Israel. Data on inpatient and ambulatory rehabilitation services were collected from discharge medical summaries, telephone interviews with the patients or their relatives and reports from the healthcare provider. The extent of rehabilitation services was described and the association between receipt of inpatient rehabilitation and the geographic district based on the patients' listed address was examined in a multivariate analysis. RESULTS: A total of 570 patients with stroke and 768 patients with hip fracture were identified and interviews were conducted in regards to 421 and 672 respectively. Out of the stroke patients 238(56.5%) received inpatient rehabilitation, 46(10.9%) received ambulatory rehabilitation treatment without inpatient phase and 137 (32.5%) received no rehabilitation. In fracture these rates were 494(73.5%), 96(14.3%) and 82(12.2%) respectively. Patients living in districts with lower availability of rehabilitation beds were less likely to receive inpatient rehabilitation after controlling for patient characteristics. CONCLUSIONS: Regional disparities in the provision of inpatient rehabilitation care for elderly after an acute episode of stroke or hip fracture were identified and could be partially attributed to the distribution of rehabilitation beds. These findings highlight the need to plan the rehabilitation resources based on the population needs and to routinely monitor the provision of these services.

The dynamics of infection and the persistence of immunity to A(H1N1)pdm09 virus in Israel.

BACKGROUND: Influenza virus A(H1N1)pdm09 first appeared in Israel in late April 2009, disappeared in mid-March 2010, and reappeared in late October 2010. Symptoms were mostly mild without need for medical care. OBJECTIVES: To provide targets for future pandemic preparedness and response by evaluating the dynamics and cumulative incidence of A(H1N1)pdm09 infection, the virus-specific seroprevalence (HI antibody titer >1:40) at the height of the pandemic, during its decline and thereafter. METHODS: A cross-sectional seroepidemiological study was conducted on 6911 serum samples collected before, during, and after the pandemic. RESULTS: Cumulative incidence of infection derived from the differences between post- and pre-pandemic seroprevalence was 54.1%, 32.9%, 22.9%, 14.8%, and 6.3% in age-groups 0-9, 10-19, 20-49, 50-79, and ≥ 80 years, respectively, and 28.5% for all age-groups combined. Vaccination could have contributed at the most 4.6% to the post-pandemic population seroprevalence. High pre-pandemic immune response (47.4%) found in a cohort aged 15-18 year was strongly associated with birth years 1990-1993. Morbidity began to decline in mid-November 2009 at 32.8% population seroprevalence (45% in ages 0-19 year) and stopped in March 2010 at 43.4% population seroprevalence in February 2010 (70% in ages 0-19 year). Between February and September 2010, seroprevalence declined by 12.2% allowing virus recirculation from October 2010. CONCLUSIONS: Our study provides targets for controlling future influenza pandemics in Israel. Vaccination should focus on the younger age-groups (0-19 year) which played a key role in transmission of the A(H1N1)pdm09 due to lack of background immunity (ages 0-9 year) and high exposure rates (ages 10-19 year).

A case-crossover study of infectious diseases and new diagnosis of type 1 diabetes.

BACKGROUND: Infectious diseases have been associated with increased risk of type 1 diabetes (T1D). The objective of this case-crossover was to quantify the role of infectious diseases as triggers for T1D, 1 and 2 yr preceding disease diagnosis. METHODS: All children aged 2-18 yr diagnosed with T1D between 2004 and 2009 among a two million member Israeli healthcare organization were identified (n = 368). For each patient, visits to physicians with symptomatic infectious diseases during 1 and 2 yr before T1D diagnosis were collected and compared. A similar analysis was conducted in a population of non-diabetic members matched on exact date of birth, sex and socioeconomic status (n = 307). RESULTS: The rate of systemic viral infections was significantly higher in the year before T1D onset, as compared to the prior year [27 vs. 7%, respectively, odds ratio (OR) = 4.7, 95% confidence intervals (CI): 2.9-8.2]. This difference was most significant among patients diagnosed with T1D at the age of 2 to 6 (5 vs. 46%, respectively, OR = 27.0, 95% CI: 4.5-1105.4). Among non-T1D patients of the same age group, no difference was found in the proportion of patients with viral diseases 1 and 2 yr prior to T1D diagnosis (44 vs. 49%, respectively, OR = 0.8, 95% CI: 0.4-1.6). This unique association was limited only to viral diseases and to patients diagnosed with T1D at young age. CONCLUSIONS: Our results indicate that T1D occurring in toddlers is characterized with a relatively low incidence of viral disease 2 yr prior to diagnosis and a much higher incidence in the subsequent year.

Trends in management and outcome of hospitalized patients with acute stroke and transient ischemic attack: the National Acute Stroke Israeli (NASIS) registry.

BACKGROUND AND PURPOSE: Improving stroke management, guideline adherence, and outcome is a global priority. Our aim was to examine trends in nationwide use of reperfusion therapy, stroke in-hospital management, and outcome. METHODS: Data were based on the triennial 2-month period of the National Acute Stroke Israeli registry (February to March 2004, March to April 2007, April to May 2010). The registry includes unselected patients admitted to all hospitals nationwide. There were in total 6279 patients: ischemic stroke, 4452 (70.9%); intracerebral hemorrhage, 485 (7.7%); undetermined stroke, 97 (1.6%); and transient ischemic attacks, 1245 (19.8%). RESULTS: Overall use of reperfusion therapy for acute ischemic stroke increased from 0.4% in 2004% to 5.9% in 2010 (P<0.001; adjusted OR, 17.0; 95% CI, 7.5-38.7). Use of CT or MR angiography for ischemic events increased from 2.1% in 2004% to 16.6% in 2010 (P<0.001; adjusted OR, 9.7; 95% CI, 6.8-13.9). Overall use of antithrombotics and anticoagulation for atrial fibrillation did not differ between periods, whereas clopidogrel use increased nearly 3-fold to 41% and statin use nearly 2-fold to 68%. The relative odds of providing reperfusion therapy, using CT or MR angiography, and prescribing anticoagulants for atrial fibrillation were higher among hospitals with large as compared with small stroke patient volumes. In-hospital mortality after acute ischemic stroke decreased from 7.2% in 2004 to 3.9% in 2010 (P<0.001; adjusted OR, 0.7; 95% CI, 0.4-1.0), whereas there was no significant change in odds of poor functional outcome. CONCLUSIONS: Based on a nationwide stroke registry, use of reperfusion therapy, vascular imaging, and statins is steadily increasing, whereas in-hospital mortality is decreasing.