The need for cardiac surgery differential tariffs in Israel at the era of aging population and emerging technology: Importance of procedure type and patient complexity as assessed by EuroSCORE.

BACKGROUND: Reimbursement for cardiac surgical procedures in Israel is uniform and does not account for diversity in costs of various procedures or for diversity in patient mix. In an era of new and costly technology coupled with higher risk patients needing more complex surgery, these tariffs may not adequately reflect the true financial burden on the caregivers. In the present study we attempt to determine whether case mix and complexity of procedures significantly affect cost to justify differential tariffs. METHODS: We included all patients undergoing cardiac surgery at Shaare Zedek Medical Center between the years 1993-2016. Patients were stratified according to (1) type of surgery and (2) clinical profile as reflected by the predicted operative risk according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE). Approximate cost of each group of patients was estimated by the average number of days in the Intensive Care Unit and days in the postoperative ward multiplied by the respective daily costs as determined by the Ministry of Health. We then added the fixed cost of the components used in the operating room (manpower and disposables). The final estimated cost (the outcome variable) was then evaluated as it relates to type of surgery and clinical profile. ANOVA was used to analyze cost variability between groups, and backward regression analysis to determine the respective effect of the abovementioned variables on cost. Because of non-normal distribution, both costs and lengths of stay were Log-transformed. RESULTS: Altogether there were 5496 patients: 3863, 836, 685 and 112 in the isolated CABG, CABG + valve, 1 valve and 2 valves replacement groups. By ANOVA, the costs in all EuroSCORE subgroups were significantly different from each other, increasing with increased EuroSCORE subgroup. Cost was also significantly different among procedure groups, increasing from simple CABG to single valve surgery to CABG + valve surgery to 2-valve surgery. In backward stepwise multiple regression analysis, both type of procedure and EuroSCORE group significantly impacted cost. ICU stay and Ward stay were significantly but weakly related while EuroSCORE subgroup was highly predictive of both ICU stay and ward stay. CONCLUSIONS: The cost of performing heart surgery today is directly influenced by both patient profile as well as type of surgery, both of which can be quantified. Modern day technology is costly yet has become mandatory. Thus reimbursement for heart surgery should be based on differential criteria, namely clinical risk profile as well as type of surgery. Our results suggest an urgent need for design and implementation of a differential tariff model in the Israeli reimbursement system. We suggest that a model using a fixed, average price according to the type of procedure costs, in addition to a variable hospitalization cost (ICU + ward) determined by the patient EuroSCORE or EuroSCORE subgroup should enable an equitable reimbursement to hospitals, based on their case mix.

Trends in pemphigus research over 15 years.

BACKGROUND: Although pemphigus is a rare autoimmune blistering disease, it attracts the attention of physicians of many disciplines. OBJECTIVE: This study aims to assess the number of articles on pemphigus that have been published over 15 years in dermatology vs. non-dermatology medical journals, and to evaluate the quality of available evidence. METHODS: PubMed was searched for articles on pemphigus published between 1 January 1993 to 31 December 2007 using the search word pemphigus. Articles were characterized by publication type and journal type per year. Regression analysis was used to determine the effect of year of publication on number of publications of each type. RESULTS: The search yielded 2032 publications on pemphigus during the evaluation period. Sixty-one per cent were published in dermatology journals. Overall, the number of publications increased linearly with time. Most of this increase was accounted for by publications in non-dermatology journals. There was an increase in clinical trials over the course of the study period. The number of certain publications with lower quality of evidence, mainly case reports and letters to the editor, increased significantly in the last few years. There was no increase in publications with high quality of evidence. CONCLUSIONS: The increase on data from non-dermatology disciplines is a welcome contribution. Nevertheless, high-quality evidence on pemphigus is still lacking. We trust that the current trend towards evidence-based dermatology will impact future research on this severe disease.

From basic research to biological treatments: psoriasis publications over the past 15 years.

In the past few decades, great progress has been made in psoriasis research, culminating with the development of new, biological treatments. We designed this study to test the hypothesis that there is a linear increase in psoriasis publications over time. We evaluated all PubMed articles from 1 January 1993 to 31 December 2007. We categorized the search into basic science, traditional therapy and new biological treatments. We used regression analysis to determine the effect of year of publication upon number of publications of each type. There was a significant quadratic increase in the number of all types of psoriasis publications, with basic science-related publications being greatest, followed by relevant clinical publications. We conclude that better understanding of psoriasis immunopathology has led to a significant yearly increase in clinical studies, contributing approximately 60% of studies in the entire field of dermatology reports.

Bhutani-based nomograms for the prediction of significant hyperbilirubinaemia using transcutaneous measurements of bilirubin.

AIM: Prospectively establish the relationship between transcutaneous bilirubin (TcB) and total serum bilirubin (TSB), and develop nomograms similar to Bhutani's nomograms, based on our TcB data. METHODS: Our study sample was from a total population of 1069 infants, near term and term healthy newborns, admitted during 2.5 month period of the study. TSB was performed on all infants who were felt to be clinically jaundiced. Before obtaining the TSB, a TcB was performed (Jaundice Meter Minolta/Draeger JM-103). Measurements were performed on two sites: forehead and mid-sternum, and the mean of both measurements was calculated. RESULTS: A total of 1091 paired measurements were obtained from 628 infants. Linear regression showed a significant relation between TSB and TcB (R(2) of 0.846). In multiple regression analysis, all independent variables studied, i.e. gestational age (or birthweight), age at sampling and ethnicity had a negligible influence on the relationship. We subsequently developed our local-nomograms of hour-specific mean TcB with 40, 75 and 95 percentile lines. CONCLUSIONS: In our local settings and population, we found a reliable correlation between laboratory measurements of TSB and TcB. We were able to develop our local-Bhutani-based TcB nomograms for screening babies during hospital stay and pre-discharge for assessing the risk of hyperbilirubinaemia.

Decreased neonatal tibial bone ultrasound velocity in term infants born after breech presentation.

OBJECTIVE: Fetuses found to be in the breech presentation have limited motion of their lower limbs. The aim of this study was to test the hypothesis that bone speed of sound (SOS) would be lower in infants born after breech presentation than in those born after vertex presentation. STUDY DESIGN: We studied 127 singleton, appropriate for gestational age, term infants delivered by a scheduled cesarean delivery at approximately 38 weeks of gestation because of breech presentation or repeat elective cesarean section with vertex presentation. We used the Sunlight Omnisense 7000p device to measure axially transmitted SOS of the right tibia within the first 96 h of life. RESULT: Fifty-three infants studied (42%) were born by cesarean section after breech presentation compared to 74 vertex controls. Bone SOS was significantly lower in the breech presentation group, even after taking into account the effect of gender and parity (as well as gestational age at birth and birth weight). CONCLUSION: Bone SOS is lower in infants born after breech presentation than in those born after vertex presentation. We speculate that limited motion of lower limbs in fetuses found to be in the breech presentation leads to a decrease in bone mineralization and strength.

The effect of maternal habitus on macronutrient content of human milk colostrum.

OBJECTIVE: There is a paucity of studies on the impact of maternal body mass index (BMI) on macronutrient content of human milk colostrum (HMC). The objective of this study was to compare macronutrient content of HMC in healthy women of term infants in relation to their BMI. We hypothesized that mother habitus influences human milk colostrum content. METHOD: Colostrum was collected from 109 healthy mothers of hospitalized healthy term infants divided into four prepregnancy BMI groups: 12 underweight, 59 normal weight, 20 overweight, and 18 obese women between 24 and 72 h after birth. Macronutrient content was measured using mid-infrared spectroscopy. RESULTS: There were no significant differences in macronutrients between the BMI groups. We performed four separate stepwise backward multiple regression analyses taking into account fat, carbohydrate, protein or energy content as dependent variables and maternal BMI, parity, gestational age, infant gender, maternal age, maternal education, mode of delivery and time postdelivery. In these analyses, fat, carbohydrate and energy content were not related to maternal BMI, while protein content was significantly and positively correlated with BMI (P=0.008) and negatively correlated with gestational age (P=0.004) and time postdelivery (P<0.001). Colostrum carbohydrate content was positively correlated with parity. Colostrum fat and energy content were negatively correlated with maternal age and positively correlated with parity. CONCLUSION: Most macronutrient and energy content of colostrum are unaffected by prepregnancy maternal BMI, with the exception of protein content that is positively related to maternal BMI.

Publication outcomes of neonatology abstracts presented at the Pediatric Academic Societies meeting.

OBJECTIVE: To examine publication outcomes of neonatology abstracts presented at Pediatric Academic Society (PAS) meeting, and to analyze variables affecting publication. STUDY DESIGN: All neonatology studies accepted for presentation (oral or poster) at 2008 PAS meeting were identified. A biphasic manual PubMed search of published articles was performed using a pre-designed algorithm. RESULTS: A total of 1078 neonatology abstracts were presented at the meeting, among them 481 (44.62%) published by 2016. Abstracts presented orally versus posters (56.11 versus 42.32%; P<0.001) and basic science versus clinical abstracts (53.08 versus 40.2%; P<0.001) were more likely to be published. Positive or negative results of a study or its sample size did not predict rates of publication. CONCLUSIONS: Less than half of the abstracts presented at the PAS meeting were published within 8 years. Oral presentations were more likely to be published than posters.Journal of Perinatology advance online publication, 6 April 2017; doi:10.1038/jp.2017.46.

The effect of between-breast differences on human milk macronutrients content.

OBJECTIVE: Little is known about the effect of maternal handedness and preferential side of breastfeeding upon macronutrients concentration in human milk (HM). We aimed to compare macronutrients content of HM from both breasts, taking into account the self-reported preferential feeding ('dominant') breast, breast size and handedness (right versus left). We tested the null hypothesis that macronutrients content of HM is not affected by breast dominancy, breast size or maternal handedness. STUDY DESIGN: Fifty-seven lactating mothers were recruited. HM macronutrients were measured after mid manual expression using infrared transmission spectroscopy. RESULTS: Out of the 57 mothers recruited, 12 were excluded from the analyses because they brought in insufficient samples. Among the 22 who reported a size difference, 16 (73%) had a larger left breast (P<0.001). Approximately a third of women reported no breastfeeding side dominance, a third reported a right dominance and another third reported a left dominance. Breastfeeding side dominance was unaffected by either handedness or breasts size. When size asymmetry was reported (n=22) the dominant side was also the larger breast in 16 (73%) women, the smaller breast in 2 (9%) women, whereas 4 (18%) additional women with asymmetry had no preferential breastfeeding side. There were no statistically significant differences in macronutrients between the right and the left breasts. In multiple stepwise backward regression analysis, fat, carbohydrate, protein and energy contents were unaffected by maternal handedness, breast side dominance or breast size asymmetry. CONCLUSIONS: Macronutrients content of mid expression HM is unaffected by maternal handedness, breast size or breast side dominance.

Effect of maternal body mass index on cord blood erthropoietin concentrations.

OBJECTIVE: To examine the hypothesis that maternal body mass index (BMI) (an index of maternal adiposity) correlates with cord blood concentrations of erythropoietin (EPO). STUDY DESIGN: Cross-sectional cohort study of consecutively born singleton term healthy infants born to mothers with various BMIs. Excluded were infants with major factors known to be associated with a potential increase in fetal erythropoiesis. Prepregnancy maternal BMI was calculated from maternal recollection. RESULT: There was a significant correlation between EPO concentrations and maternal BMI (R = 0.427, P = 0.007). This correlation remained significant in multiple stepwise regression analysis using the EPO concentration as the dependent variable, and maternal age, parity, gestational age and Apgar scores (1 or 5 min) as potential confounders. CONCLUSION: Cord blood concentrations of EPO correlate with maternal BMI. We speculate that increasing maternal BMI may represent a relative hypoxic burden on the fetus.

Nucleated erythrocytes and intraventricular hemorrhage in preterm neonates.

OBJECTIVES: Increased circulating nucleated erythrocytes (NRBCs) in the newborn period can be markers of chronic fetal hypoxia, which in turn may be a risk factor for intracranial hemorrhage (IVH). To evaluate the relation between chronic intrauterine hypoxia and IVH, we compared the courses of the absolute NRBC (ANRBC) count in preterm newborns with and without intracranial hemorrhage. METHODS: We measured ANRBC counts in the first 6 days of life in appropriate for gestational age newborns at 32 weeks' gestation or earlier with (n = 46) and without (n = 103) IVH, who were not at risk for altered erythropoiesis. RESULTS: The ANRBC counts at birth were higher in infants who developed severe IVH than in control infants without IVH (P < .03). The ANRBC counts peaked on day 2 or 3 in newborns with IVH, but declined continuously from a peak on day 1 in the control group. Stepwise regression analysis of multiple variables revealed that the grade of IVH had the greatest impact on ANRBC counts. An ANRBC count of at least 2.0 x 10(9)/L on day 1 of life had a sensitivity of 63% and a specificity of 79% in predicting grade III or IV IVH: CONCLUSION: An elevated or increasing ANRBC count in a preterm newborn is a potential marker for an impending or present severe IVH, respectively, and may reflect a state of altered prenatal or postnatal erythropoiesis.

Nucleated red blood cells in healthy infants of women with gestational diabetes.

OBJECTIVE: To evaluate whether absolute nucleated red blood cell (RBC) counts are elevated in large-for-gestational-age (LGA) infants of women with gestational diabetes compared with appropriate-for-gestational-age (AGA) infants of women with or without gestational diabetes. METHODS: We compared absolute nucleated RBC counts during the first 12 hours of life in three groups of term, vaginally delivered infants, LGA infants of women with gestational diabetes (n = 20), AGA infants of women with gestational diabetes (n = 20), and AGA infants of nondiabetic women (n = 30). We excluded infants of women with hypertension, smoking, alcohol or drug abuse, and those with fetal heart rate abnormalities in labor, low Apgar scores, hemolysis, blood loss, or chromosomal anomalies. RESULTS: There were no significant differences among groups in gestational age, gravidity, parity, maternal analgesia, 1- and 5-minute Apgar scores, and lymphocyte counts. Corrected white blood cell counts and hematocrit were significantly higher in LGA infants of women with gestational diabetes than in the other groups. The median nucleated RBC count was significantly higher in LGA infants of women with gestational diabetes (0.56 x 10(9)/L, range 0-1.8 x 10(9)/L) than AGA infants of women with gestational diabetes (0.13 x 10(9)/L, range 0-0.65 x 10(9)/L) and controls (0.0005 x 10(9)/L, range 0-0.6 x 10(9)/L) (P < .001). Multiple regression analysis showed that absolute nucleated RBC count was significantly correlated with birth weight (or macrosomia) and maternal diabetic status (r2 = .25, P < .001 for the multiple regression, contribution of birth weight r2 = .19, and diabetes r2 = .06). CONCLUSION: At birth, term LGA infants born to women with gestational diabetes had higher absolute nucleated RBC counts compared with AGA infants born to women with gestational diabetes and controls.

Nucleated red blood cells in infants of smoking mothers.

OBJECTIVE: To evaluate whether the absolute nucleated red blood cell (RBC) count is elevated in term, appropriate for gestational age (AGA) infants born to smoking women. METHODS: We compared absolute nucleated RBC counts taken during the first 12 hours of life in two groups of term, vaginally delivered, AGA infants, one group born to mothers who smoked during pregnancy (n = 30) and the other born to mothers who did not smoke (n = 30). We excluded infants of women with diabetes, hypertension, or alcohol or drug abuse, and infants with heart rate abnormalities, hemolysis, blood loss, or chromosomal anomalies. RESULTS: There were no differences between the groups in birth weight, gestational age, maternal age, gravidity, parity, maternal analgesia during labor, 1- and 5-minute Apgar scores, corrected white blood cell counts, lymphocyte counts, or hematocrits. The median absolute nucleated RBC count in infants of smoking mothers was 0.5 x 10(9)/L (range 0 to 5.0) versus 0.0005 x 10(9)/L (range 0 to 0.6) in nonsmoking controls (P < .002). Regression analysis that included Apgar scores, gestational age, and number of cigarettes smoked per day showed a significant correlation of absolute nucleated RBC count only with the number of cigarettes smoked per day (P < .001). CONCLUSION: At birth, term AGA infants born to smoking mothers have increased circulating absolute nucleated RBC counts compared with controls. The absolute nucleated RBC count in newborns correlates with the number of cigarettes smoked during pregnancy.

Nucleated red blood cells in meconium aspiration syndrome.

OBJECTIVE: To evaluate whether the absolute nucleated red blood cell (RBC) count is higher in infants who had meconium aspiration with respiratory symptoms compared with infants with asymptomatic meconium aspiration and controls. METHODS: We compared the absolute nucleated RBC counts during the first 12 hours of life in three groups of term, vaginally delivered infants, including those who had meconium aspiration with respiratory symptoms (n = 11), asymptomatic meconium aspiration (n = 45), and control healthy infants (n = 32). We excluded infants of women with diabetes in pregnancy; hypertension; alcohol, tobacco, or drug abuse; and those with hemolysis, blood loss, or chromosomal anomalies. RESULTS: There were no significant differences among groups in gestational age; gravidity; parity; maternal analgesia; lymphocyte, platelet, and granulocyte counts; and hematocrit. The median nucleated RBC count was significantly higher in the meconium aspiration group with respiratory symptoms (0.007 x 10(9)/L) than the asymptomatic meconium aspiration group (0.004 x 10(9)/L) or controls (0.003 x 10(9)/L). CONCLUSION: At birth, infants with meconium aspiration syndrome had higher absolute nucleated RBC counts compared with infants with asymptomatic meconium aspiration and normal infants.

Normoblasts in large for gestational age infants.

Thirty one term large for gestational age (LGA) infants of non-diabetic mothers were compared with 30 appropriate for gestational age controls. Median absolute nucleated red blood cell counts, lymphocyte counts, and packed cell volumes were significantly higher in the LGA infants than the controls. It is possible that LGA babies of non-diabetic mothers are exposed to relative intrauterine hypoxia.

Nosocomial cutaneous abscesses in septic infants.

OBJECTIVE: To retrospectively study the epidemiology of nosocomial cutaneous abscesses in 46 consecutive septic infants. RESULTS: Ten infants had one abscess or more. Surviving infants with abscesses had a longer duration of bacteraemia, which disappeared within 24 hours of drainage. CONCLUSION: Infants with persistent bacteraemia should be examined regularly for the presence of abscesses.

Effect of ethnicity on mortality of very low birthweight infants in Israel.

BACKGROUND: Multiple demographic, genetic, and environmental factors differ between Muslim and Jewish infants in Israel. OBJECTIVE: To evaluate whether, after adjustment for perinatal factors associated with mortality, excess mortality occurs in very low birthweight (VLBW) Muslim compared with Jewish infants. DESIGN: The Israel National VLBW infant database includes data on 99% of all VLBW births in Israel. The study population comprised 5015 Jewish and 1549 Muslim VLBW infants of more than 23 weeks gestation, born between 1995 and 1999. The Mantel-Haenszel test was used for stratified analysis and logistic regression analysis to assess the effect of ethnic origin on mortality. RESULTS: The death rate was significantly higher among Muslim infants (22.7% v 17.2%; crude odds ratio 1.42; 95% confidence interval 1.24 to 1.63). Excess mortality in Muslims occurred mainly in the 32-33 week (8.0% v 2.8%) and >33 week (14.7% v 4.7%) gestational age groups, and in birthweight groups of 1000-1249 g (17.6% v 9.3%) and 1250-1500 g (9.1% v 3.6%). In VLBW infants without congenital malformations, there was a significantly higher risk of mortality among Muslim infants (odds ratio 1.28; 95% confidence interval 1.04 to 1.57) compared with Jewish infants, after adjustment for gestational age, birth weight, small for gestational age, prenatal care, prenatal steroid treatment, plurality, mode of delivery, and Apgar score. CONCLUSIONS: Excess mortality was present among Muslim VLBW infants without congenital malformations. Perinatal factors associated with increased risk of mortality were more prevalent in the Muslim VLBW population. The pattern of disparities suggests inadequate access to, or utilisation of, effective perinatal technology in the Muslim population in Israel.

Prognostic significance of hyperechogenic lesions in the basal ganglia and thalamus in neonates.

Neonatal cranial ultrasonography at times reveals hyperechogenic lesions in the basal ganglia and thalamus. These lesions have been attributed to a wide variety of pathologic states, among them toxoplasmosis, rubella, cytomegalovirus, and herpes simplex (TORCH) infections, chromosomal abnormalities, and asphyxia. The clinical significance in terms of the neurodevelopmental outcome of this radiologic abnormality is unknown. We performed a developmental evaluation on 16 children aged 2 to 6 years in whom neonatal cranial ultrasonography had demonstrated hyperechogenic lesions in the basal ganglia or thalamus and had no other neurodevelopmental risk factors. There was no significant difference between the average Developmental Quotient of the target population and the normal population in regard to developmental status. We conclude that in our population, an isolated finding of hyperechogenic lesions in the basal ganglia is probably not a predictor of poor neurodevelopmental outcome.

Feeding tolerance of ready-to-use versus powdered formulas in neonates.

BACKGROUND: Following the introduction of ready-to-use formula in our neonatal department, we observed an increase in the number of neonates regurgitating after feeding. OBJECTIVE: To compare the feeding tolerance of neonates, in terms of regurgitations, to ready-to-use versus powdered formulas. METHODS: We compared the number of regurgitations in 727 healthy neonates after feeding ready-to-use formulas and powdered formulas of two different manufacturers. Six groups of neonates were formed, three for each manufacturer. Each of the two groups was fed with either ready-to-use formula or with reconstructed powdered formula (using a two-compartment patented feeding bottle called Twist 'N Feed) and one group received both preparations during 2 successive days. RESULTS: The groups that were fed only with ready-to-use formulas had significantly more regurgitations than those fed with powdered formulas. Within the group that received both types of formulas there were significantly more regurgitations following the ready-to-use than the powdered formula. CONCLUSIONS: Feeding tolerance, in terms of regurgitations, was significantly better in neonates fed reconstituted powdered formula as opposed to ready-to-use formulas. More studies are required to determine the exact mechanism for these differences.

Financial impact of the introduction of erythropoietin in the treatment of anemia of premature infants in Israel.

BACKGROUND AND OBJECTIVE: Very low birthweight infants (< 1,500 g birthweight) often develop significant anemia that requires multiple blood transfusions, which carry a significant risk. Erythropoietin therapy is known to reduce the need for blood transfusions in preterm VLBW infants. Analysis of cost had been reported in prospective studies with conflicting results. No studies comparing the cost-effectiveness of EPO have been reported during routine use in preterm VLBW infants. METHODS: We compared the cost of treating anemia of prematurity in two consecutive 12-month periods: before and after the introduction of EPO therapy in our unit. The cost of blood bank charges as well as disposable items and the cost of EPO were compared. RESULTS: A significantly smaller number of infants required blood transfusions in the EPO group (2 of 25 vs. 9/21 before EPO was introduced). The cost of therapy for anemia of prematurity was significantly smaller in the EPO group (128 +/- 168 US$ per infant vs. 151 +/- 189 US$ per infant before the introduction of EPO). CONCLUSION: We conclude that EPO is an efficient and cost-effective alternative to blood transfusions in VLBW infants.

Bach music in preterm infants: no 'Mozart effect' on resting energy expenditure.

OBJECTIVE: To study whether Johan Sebastian Bach music has a lowering effect on resting energy expenditure (REE) similar to that of Wolfgang Amadeus Mozart music. STUDY DESIGN: Prospective, randomized clinical trial with cross-over in 12 healthy, appropriate weights for gestational age (GA), gavage fed, metabolically stable, preterm infants. Infants were randomized to a 30-min period of either Mozart or Bach music or no music over 3 consecutive days. REE was measured every minute by indirect calorimetry. RESULT: Three REE measurements were performed in each of 12 infants at age 20±15.8 days. Mean GA was 30.17±2.44 weeks and mean birthweight was 1246±239 g. REE was similar during the first 10-min of all three randomization periods. During the next 10-min period, infants exposed to music by Mozart had a trend toward lower REE than when not exposed to music. This trend became significant during the third 10-min period. In contrast, music by Bach or no music did not affect significantly REE during the whole study. On average, the effect size of Mozart music upon REE was a reduction of 7.7% from baseline. CONCLUSION: Mozart music significantly lowers REE in preterm infants, whereas Bach music has no similar effect. We speculate that 'Mozart effect' must be taken into account when incorporating music in the therapy of preterm infants, as not all types of music may have similar effects upon REE and growth.