Early Referral to Coronary Artery Bypass Grafting Following Acute Coronary Syndrome, Trends and Outcomes from the Acute Coronary Syndrome Israeli Survey (ACSIS) 2000-2010.

BACKGROUND: Limited information exists on whether changes in medical practices over the study decades have affected the outcomes of acute coronary syndrome (ACS) patients who undergo early coronary artery bypass surgery (CABG) during index hospitalisation. METHODS: Data on trends for early CABG referral and associated outcomes were obtained among 11,485 ACS patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) 2000-2010. RESULTS: Among 11,485 patients, 566 (5%) were referred to early CABG. These patients displayed higher risk characteristics, including Killip class >II, anterior myocardial infarction, greater left ventricular dysfunction, and more frequent use of mechanical ventilation and intra-aortic balloon pump (all p<0.01). Nevertheless, mortality rates of patients referred to early CABG vs. treated with percutaneous coronary intervention (PCI) or medically, was similar (11.4% vs. 10.2%; log-rank p-value=0.40). There was a significant decline in the referral trend over the study decade (6.7% - 1.7%; p<0.001). One year survival was similar between patients referred to early CABG during the late (years: 2006-2010) vs. early (years: 2000-2005) period (85.7% vs. 90%; log-rank p-value=0.15), whereas, among patients who didn't undergo early CABG, and underwent percutaneous coronary intervention (PCI) or medical management only, enrolment during the late periods was associated with a significant survival benefit (91.5% vs. 88.1%; log-rank p-value<0.001). CONCLUSIONS: Over the study decade there was a significant decline in referral for early CABG, without a difference in the one-year mortality between the early and non-early CABG group.

Causality Assessment of Serious Neurologic Adverse Events Following bOPV National Vaccination Campaign in Israel.

BACKGROUND: During 2013-2014 Israel experienced a continuous circulation of wild poliovirus type 1 (WPV1) but with no clinical cases. WPV1 circulation was gradually terminated following a national vaccination campaign of bivalent oral poliovirus vaccine (bOPV) for 943,587 children < 10 years. Four cases of children with neurological manifestations that appeared following bOPV vaccinations were reported during the campaign: three of Guillain-Barré syndrome (GBS) and one of acute disseminated encephalomyelitis (ADEM). OBJECTIVES: To present an analysis of these cases, the rapid response and the transparent publication of the results of this analysis. METHODS: The clinical, laboratory and epidemiological data of these four patients were available during the analysis. In addition, data regarding the incidence of GBS and ADEM during previous years, and reported cases of acute flaccid paralysis (AFP) and the incidence of Campylobacter jejuni enteritis were collected from the Epidemiology Department of the Israel Ministry of Health. RESULTS: The incidence of GBS among bOPV-vaccinated children was not higher than among bOPV-unvaccinated children. For all the cases reviewed the "incubation period" from vaccination to the event was longer than expected and other more plausible causes for the neurologic manifestations were found. There is no evidence in the literature of a causal relationship between bOPV and ADEM. CONCLUSIONS: There was no association between the bOPV vaccine and the reported neurological manifestations. We believe that our experience may assist other public health professionals when confronting a similar problem of alleged side effects during a mass medical intervention.

Laboratory challenges in response to silent introduction and sustained transmission of wild poliovirus type 1 in Israel during 2013.

Wild poliovirus type 1 (WPV1) introduction into southern Israel in early 2013 was detected by routine environmental surveillance. The virus was identified genetically as related to the South Asian (SOAS) R3A lineage endemic to Pakistan in 2012. Intensified, high-throughput environmental surveillance using advanced molecular methods played a critical role in documenting and locating sustained transmission throughout 2013 and early 2014 in the absence of any acute flaccid paralysis. It guided the public health responses, including stool-based surveillance and serosurveys, to determine the point prevalence in silent excretors and measured the effect of vaccination campaigns with inactivated polio vaccine and bivalent oral polio vaccine on stopping transmission.

The Israel Nationwide Heart Failure Survey: Sex differences in early and late mortality for hospitalized heart failure patients.

BACKGROUND: Current data on the influence of sex on the prognosis of heart failure (HF) are conflicting, possibly owing to the use of different end points and a heterogeneous heart failure population in earlier studies. We sought to evaluate the effect of sex on the risk of early and late mortality outcomes after hospitalization for acute heart failure. METHODS AND RESULTS: The prospective cohort study population comprised 2,212 hospitalized patients with acute HF enrolled in a multicenter national survey in Israel. Cox proportional-hazards regression modeling was used to evaluate the effect of sex on the risk of early (≤6 months) and late (>6 months to 4 years) mortality after the index hospitalization. Among the study patients, 998 (45%) were women. Women with HF displayed significantly different clinical characteristics compared with men, including older age, higher frequency of HF with preserved ejection fraction and hypertensive heart disease, and lower percentage of coronary artery disease (all P < .001). The fully adjusted multivariable analyses for mortality outcomes showed that women tended toward an increased risk for early (≤6 months) mortality (hazard ratio [HR] 1.16, 95% confidence interval [CI] 0.96-1.41; P = .13), whereas men had significantly increased risk for late (>6 months) mortality (HR 1.25, 95% CI 1.09-1.43; P = .001). CONCLUSIONS: There are important differences in the clinical characteristics and the short- and long-term outcomes between men and women hospitalized with acute HF after adjusting for multiple confounding variables.

Estimating mortality in survivors of the acute coronary syndrome by the 4-drug score.

OBJECTIVE: Four drug classes, platelet inhibitors, ß-blockers, statins, and angiotensin-converting enzyme inhibitors (or angiotensin receptor blockers), have been shown to reduce mortality in clinical trials. We sought to evaluate whether the simple number of secondary prevention drugs at discharge is independently associated with 1-year mortality in acute coronary syndrome (ACS) patients. METHODS: We analyzed a prospective cohort study using data of all 5 Acute Coronary Syndrome Israeli Surveys (ACSIS) conducted between 2002 and 2010 in all Israeli cardiology departments. All 9,107 hospital survivors of ACS participated. RESULTS: A score from 1 to 4 discharge drugs was significantly associated with gradual decreasing rates of 1-year mortality (14.4, 9.0, 5.1, and 3.6%, respectively; p for trend <0.001). Only when the number of discharge drugs increased to 3-4 as a result of the intervention during hospitalization in patients initially admitted with 0-2 drugs, a significant multivariate-adjusted decrease in the hazard ratio (HR), independent of multiple baseline, admission presentation, and in-hospital course characteristics, was measured (HR, 0.66; 95% confidence interval, 0.50-0.87). CONCLUSION: The use of a higher number of secondary prevention drugs at discharge following ACS was associated with significantly lower mortality rates, particularly in patients with mono- or dual-baseline therapy.

Temporal trends in the use of high-dose potent statins following acute coronary syndrome in Israel.

OBJECTIVES: This study aimed to evaluate factors associated with the prescription of high-dose potent statin (HDPS) therapy following hospitalization for acute coronary events. STUDY DESIGN: Sub-analysis was made using the data of 3,525 patients enrolled in the 2008 and 2010 Acute Coronary Syndrome Israeli Surveys (ACSIS). METHODS: Analyses were carried out to identify demographic and clinical factors associated with the prescription of HDPS therapy (atorvastatin 40-80 mg/day or rosuvastatin 20-40 mg/day) at discharge compared with the prescription of lower-dose statins. RESULTS: Among the study patients, 1,387 (39%) were discharged on HDPS, 1,860 (53%) with lower-dose statin regimens and 278 (8%) with no recommendation for statin therapy. Multivariate logistic regression analysis showed that pre-admission usage of HDPS and participation in the more recent (2010) ACSIS survey were independently associated with a higher likelihood of HDPS prescription at discharge from the index event (odds ratio, OR, 21.07, p < 0.001, and 5.61, p < 0.001, respectively), whereas factors independently associated with a lack of HDPS prescription included age >75 years (OR 0.76, p = 0.03), low-density lipoprotein-cholesterol levels <100 mg/dl on admission (OR 0.67, p < 0.001) and a history of heart failure prior to the index hospitalization (OR 0.54, p = 0.0018). The 30-day compliance with the HDPS regimen was 98%. CONCLUSIONS: The findings show increased use of HDPS therapy in acute coronary syndrome (ACS) patients, although this mode of medical therapy is still underutilized in the important subset of high-risk ACS patients.

Higher Syntax score is not predictive of late mortality in "real-world" patients with multivessel coronary artery disease undergoing coronary artery bypass grafting.

BACKGROUND: The Syntax score (SS) is a helpful tool for determining the optimal revascularization strategy regarding coronary artery bypass surgery (CABG) vs. percutaneous coronary intervention (PCI) in patients with complex coronary disease. While an association between higher SS and mortality was found for PCI patients, no such association was found for CABG patients. OBJECTIVES: To assess whether the SS predicts late mortality in patients undergoing CABG in a real-world setting. METHODS: The study included 406 consecutive patients referred for CABG over a 2 year period. Baseline and clinical characteristics were collected. Angiographic data SS were interpreted by an experienced angiographer. Patients were divided into three groups based on SS tertiles: low ≤ 21 (n = 205), intermediate 22-31 (n = 138), and high ≥ 32 (n = 63). Five year mortality was derived from the National Mortality Database. RESULTS: Compared with low SS, patients with intermediate and high scores were significantly older (P = 0.02), had lower left ventricular ejection fraction (64% vs. 52% and 48%, P < 0.001) and greater incidence of acute coronary syndrome, left main disease, presence of chronic total occlusion of the left anterior descending and/or right coronary artery, and a higher EuroSCORE (5% vs. 5% and 8%, P < 0.01). Patients with intermediate and high SS had higher 5 year mortality rates (18.1% and 19%, respectively) compared to patients with low score (9.8%, P = 0.04). On multivariate analysis, SS was not an independent predictor of late mortality. CONCLUSION: Patients with lower SS had lower mortality after CABG, which is attributable to lower baseline risk. SS is not independently predictive of late mortality in patients with multi-vessel coronary artery disease undergoing CABG.

Cigarette smoking and correlates among ultra-orthodox Jewish males.

INTRODUCTION: Ultra-orthodox Jews compose a segregated group that struggles to preserve its centuries-old way of life by strictly adhering to the Jewish religious law in every aspect of life. Their health habits were infrequently studied to date. We sought to determine the smoking prevalence and to find its significant correlates in the ultra-orthodox Jewish population of Israel. METHODS: The study was conducted in a cross-sectional design of men as smoking prevalence among ultra-religious women was found to be negligible in previous studies. Following a random ultra-orthodox households sampling and a phone survey, a total of 782 adult men were recruited. RESULTS: The age-adjusted smoking prevalence was 12.8% (95% confidence interval [CI] = 10.3%-15.3%). The multivariate model demonstrated that being single (odds ratio [OR] = 5.83; 95% CI = 2.44-13.98), being of Israeli (OR = 2.10; 95% CI = 1.18-3.71), or North African/Asian origin (OR = 2.92; 95% CI = 1.55-5.53) was positively correlated with smoking while being a full-time Yeshiva student (OR = 0.51; 95% CI = 0.30-0.85) was negatively correlated with smoking. CONCLUSION: The Israeli ultra-orthodox Jewish men have very low prevalence of smoking when compared with the general population. The study contributes to a better understanding of habitual smoking correlates in ultra-religious minorities.

Effect of the Dead Sea climatotherapy for psoriasis on quality of life.

BACKGROUND: It is well known that quality of life is an integral part in the outcome evaluation process of psoriasis treatment. Very few studies, however, examined the effect of climatotherapy at the Dead Sea on quality of life of such chronically ill patients. OBJECTIVES: To determine the effect of the Dead Sea climatotherapy on the quality of life of patients with psoriasis vulgaris and psoriatic arthritis. METHODS: A total of 119 patients participated in an observational prospective study carried out at the Deutsches Medizinisches Zentrum clinic, a medical skin care center specializing in climatotherapy. The patients completed questionnaires (Skindex-29) to quantify their quality of life at different time points: the day of arrival, the day of departure, and 3 and 6 months after the end of treatment. RESULTS: Marked improvement in the quality of life scores was measured between the time of arrival to time of departure and to 3 months after the end of treatment. CONCLUSIONS: Dead Sea climatotherapy has a significant positive influence on the quality of life of patients with psoriasis vulgaris and psoriatic arthritis.

Inadequate antibody response to rabies vaccine in immunocompromised patient.

We describe an inadequate antibody response to rabies vaccine in an immunocompromised patient. A literature search revealed 15 additional immunocompromised patients, of whom 7 did not exhibit the minimum acceptable level of antibodies after a complete postexposure prophylaxis regimen. An international rabies registry is needed to provide a basis for determining appropriate vaccination protocols.

Surveillance of invasive meningococcal disease in the Tel Aviv District, Israel, 2007-2017.

Invasive meningococcal disease (IMD) is one of the leading causes of bacterial meningitis and septicemia in Israel. The purpose of the study was to describe the IMD in the Tel Aviv District and to identify specific populations who could benefit from vaccine introduction. In the Tel Aviv District, the incidence rates ranged from 0.4 to 1.4 cases per 100,000 population per year during 2007-2017. During the study period, seventy-nine patients (65%) occurred among children younger than four years of age. Eight deaths occurred (7%), most of them among children under the age of 1 year (5 deaths; 15%). A serogroup was identified in 82 isolates. Most of the isolates (69 cases - 84%) belonged to serogroup B (NmB). IMD clustered geographically in the city of Bnei Brak, with a predominantly Ultra-Orthodox Jewish population. It is the youngest and most densely populated city in the district. The overall incidence rates of IMD among children in Bnei Brak were more than seven times higher in children up to nine years, compared to the rest of the district. Specifically for NmB, disease rates were 9.08 times higher in children up to the age of four, and 7.74 times higher in children from five to nine years old in Bnei Brak, compared to the rest of the district. Our findings describe the burden of a vaccine-preventable disease and reinforce the need for routine 4CmenB introduction, especially in groups where the disease clusters.

Vaccination uptake and income inequalities within a mass vaccination campaign.

BACKGROUND: In July 2013, Israel was swept with fear of a polio outbreak. In response to the importation of wild polio virus, the Ministry decided to take preventive action by administering oral poliovirus vaccine (OPV) to all children born after 1 January 2004 who had received at least one dose of inactivated poliovirus vaccine (IPV) in the past. This study analyzes the vaccination uptake rates resulting from the mass polio vaccination campaign on the basis of health inequality parameters of socioeconomic status (SES), principles of solidarity, and the Gini inequality index. The research explores understanding the value of the Gini inequality index within the context of SES and solidarity. METHODS: The study is based on data gathered from the Israeli Ministry of Health's administrative records from mother-and-child clinics across Israel. The research population is comprised of resident infants and children whom the Ministry of Health defined as eligible for the OPV between August and December 2013 (the "campaign period"). The analysis was carried out at the municipality level as well as the statistical area level. RESULTS: The higher the SES level of the municipality where the mother-and-child clinic is located, the lower the OPV vaccination uptake is. The greater the income inequality is in the municipality where the mother-and-child clinic is situated, the lower the vaccination uptake. CONCLUSIONS: Public health professionals promoting vaccine programs need to make specially-designed efforts both in localities with high average income and in localities with a high level of income diversity/inequality. Such practice will better utilize funds, resources, and manpower dedicated to increasing vaccination uptake across varying populations and communities.