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INTRODUCTION: Outbreaks of COVID-19 in long-term care facilities (LTCFs) have resulted mainly from disease transmission by asymptomatic health care workers. This study examines whether routine screening tests carried out on health care workers can help in reducing COVID-19 outbreaks, morbidity, and mortality of LTCF residents. METHODS: The study followed a weekly, nationwide, government-funded screening program of LTCF personnel for SARS-CoV-2, by using reverse transcription polymerase chain reaction as the main testing technology. It included all residents and employees in Israeli LTCFs who were screened weekly during the second wave of COVID-19, during the period of time between July 13, 2020, and November 21, 2020. RESULTS: During the study period, 1,107 LTCFs were screened on a weekly basis, including 62,159 HCWs and 100,046 residents. The program screened a median of 55,282 (range 16,249, min 45,910, max 62,159) employees per week, 0.05-1.5% of which were positive for SARS-CoV-2. LTCF mortality in the first wave accounted for 45.3% of all COVID-19 deaths recorded nationally (252 of 556), and in the second wave, this ratio was reduced to 30.3% (709 of 2,337) representing a reduction of 33.8% in expected mortality (p < 0.001). A significant reduction was detected also in hospitalization rate (13.59 vs. 11.41%, p < 0.001) and elder (≥75 years old) mortality rate (52.89 vs. 41.42%, p < 0.001). 214 outbreaks in the second wave were avoided by early identification of SARS-CoV-2 positive HCWs and successful prevention of subsequent infections in the facility. CONCLUSION: Routine weekly SARS-CoV-2 RT-PCR testing of LTCF employees was associated with reduced national LTCF residents' hospitalizations and mortality rate.
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COVID-19 , SARS-CoV-2 , Humanos , Anciano , SARS-CoV-2/genética , COVID-19/diagnóstico , COVID-19/epidemiología , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Cuidados a Largo Plazo , Instituciones de Cuidados Especializados de Enfermería , Prueba de COVID-19RESUMEN
BACKGROUND: We assessed vaccine effectiveness (VE) of BNT162b2 mRNA coronavirus disease 2019 (COVID-19) vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) acquisition among healthcare workers (HCWs) of long-term care facilities (LTCFs). METHODS: This prospective study, in the framework of the "Senior Shield" program in Israel, included routine weekly nasopharyngeal SARS-CoV-2 RT-PCR testing from all LTCF HCWs since July 2020. All residents and 75% of HCWs were immunized between December 2020 and January 2021. The analysis was limited to HCWs adhering to routine testing. Fully vaccinated (14+ days after second dose; nâ =â 6960) and unvaccinated (nâ =â 2202) HCWs were simultaneously followed until SARS-CoV-2 acquisition or end of follow-up, 11 April 2021. Hazard ratios (HRs) for vaccination versus no vaccination were calculated (Cox proportional hazards regression models, adjusting for sociodemographics and residential-area COVID-19 incidence). VE was calculated as (1- HR)â ×â 100. RT-PCR cycle threshold (Ct) values were compared between vaccinated and unvaccinated HCWs. RESULTS: At >14 days post-second dose, 40 vaccinated HCWs acquired SARS-CoV-2 (median follow-up, 66 days; cumulative incidence, 0.6%) versus 84 unvaccinated HCWs (median follow-up, 43 days; cumulative incidence, 5.1%) (HR,â .11; 95% CI, .07-.17; unadjusted VE,â 89%; 95% CI, 83-93%). Adjusted VE >7 and >14 days post-second dose were similar. The median PCR Ct targeting the ORF1ab gene among 20 vaccinated and 40 unvaccinated HCWs was 32.0 versus 26.7, respectively (P value â =â .008). CONCLUSIONS: VE following 2 doses of BNT162b2 against SARS-CoV-2 acquisition in LTCF HCWs was high. The lower viral loads among SARS-CoV-2-positive HCWs suggest further reduction in transmission.
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Vacunas contra la COVID-19 , COVID-19 , Vacuna BNT162 , COVID-19/epidemiología , COVID-19/prevención & control , Personal de Salud , Humanos , Cuidados a Largo Plazo , Estudios Prospectivos , ARN Mensajero , SARS-CoV-2RESUMEN
INTRODUCTION: In early 2020, the novel SARS-CoV-2 virus began to spread around the world and claim victims. Initially, in the Western world, COVID-19-related mortality was due to illness in long-term care facilities (LTCFs). To manage the COVID-19 crisis in LTCFs in Israel, the Ministry of Health established a task force named "Senior Shield." The task force executed a screening program of weekly polymerase chain reaction (PCR) SARS-CoV-2 tests for LTCF residents and caregivers, and at a later stage, the task force led the Ministry of Health vaccination program at LTCFs. This study aimed to estimate the effectiveness of the BNT162b2 mRNA COVID-19 (Comirnaty) vaccine in reducing COVID-19 morbidity and mortality in LTCF residents. METHODS: We designed a nationwide cohort study utilizing data from the Senior Shield task force. Residents had received the vaccines starting December 2020. The study follow-up period was 5 months (ending May 2021). We defined four outcomes: (a) documented SARS-CoV-2 infection, defined by a positive PCR test, (b) COVID-19 death, defined by a positive PCR test followed by death, (c) all-cause mortality, defined as death regardless of the result of a PCR test, and (d) a composite endpoint which included documented SARS-CoV-2 infection or death, the earliest of both. We used Kaplan-Meier curves with a log-rank comparison and Cox regression with a time-dependent covariate model to estimate adjusted hazard ratios for vaccine effectiveness (VE). The index date was the date of the first vaccine dose. In unvaccinated residents, the index date was the first date of vaccination in their LTCF. RESULTS: A total of 43,596 residents with a mean age of 83 years living in 454 LTCFs were found eligible for this study. Ninety-one percent of the study population received the first vaccine dose (39,482) and 86% received the second vaccine dose (37,656). Estimated VE 28 days after the first vaccine dose (approximately 7 days after the second vaccine dose) was 81.2% for SARS-CoV-2 infection, 85.3% for COVID-related death, 63.7% for all-cause mortality, and 71.1% for the composite endpoint (SARS-CoV-2 infection or death). CONCLUSION: This study shows that the BNT162b2 mRNA COVID-19 vaccine effectively prevents SARS-CoV-2 infection, COVID-19-related death, and all-cause mortality in LTCF residents. Further research is warranted on the effect of the third vaccine (booster) in this population.
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COVID-19 , Anciano de 80 o más Años , Humanos , Vacuna BNT162 , Estudios de Cohortes , COVID-19/epidemiología , COVID-19/prevención & control , Vacunas contra la COVID-19/uso terapéutico , Cuidados a Largo Plazo , ARN Mensajero , SARS-CoV-2 , Eficacia de las VacunasRESUMEN
BACKGROUND: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. Previous studies showed that rhythm and rate control strategies are associated with similar rates of mortality and serious morbidity. Beta blockers (BB) and calcium channel blockers (CCB) are commonly used and the selection between these two medications depends on personal preference. OBJECTIVES: To compare real-time capability of BB and CCB for the treatment of rapid AF and to estimate their efficacy in reducing hospitalization duration. METHODS: We conducted a retrospective cohort study of 306 patients hospitalized at Soroka Hospital during a 5-year period with new onset AF who were treated by a rate control strategy. RESULTS: A significant difference between the two groups regarding the time (in hours) until reaching a target heart rate below 100 beats/min was observed. BB were found to decrease the heart rate after 5 hours (range 4-14) vs. 8 hours (range 4-18) for CCB (P = 0.009). Patients diagnosed with new-onset AF exhibited shorter duration of hospitalization after therapy with BB compared to CCB (median 72 vs. 96 hours, P = 0.012) in the subgroup of patients discharged with persistent AF. There was no significant difference between CCB and BB regarding the duration of hospitalization (P = 0.4) in the total patient population. CONCLUSIONS: BB therapy is more potent for rapid reduction of the heart rate compared to CCB and demonstrated better efficiency in shortening the duration of hospitalization in a subgroup of patients. This finding should be reevaluated in subsequent research.
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Fibrilación Atrial , Humanos , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/diagnóstico , Bloqueadores de los Canales de Calcio/uso terapéutico , Estudios Retrospectivos , Antagonistas Adrenérgicos beta/uso terapéutico , HospitalizaciónAsunto(s)
Vacuna BNT162/administración & dosificación , Vacunas contra la COVID-19 , COVID-19/epidemiología , Inmunización Secundaria , Cuidados a Largo Plazo , Eficacia de las Vacunas/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , COVID-19/prevención & control , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Incidencia , Israel/epidemiología , Masculino , Persona de Mediana Edad , Casas de SaludRESUMEN
BACKGROUND: Glucocorticosteroids (GCS) are known to cause the hematologic effect of leukocytosis and neutrophilia. Leukocytosis is a key parameter in establishing the diagnosis of sepsis and in the estimation of its severity. OBJECTIVE: To quantify the effect of chronic or acute GCS treatment on the level of leukocytosis in patients with acute infectious process. METHODS: We conducted a retrospective cohort study of patients with an acute infection hospitalized in tertiary medical center between the years 2003-2014. Patients were classified into three categories: chronic GCS treatment, acute GCS treatment, no GCS treatment. The primary outcome was the maximal WBC count within the first 24h from admission. RESULTS: We identified 5468 patients with acute infection: 333 of them with chronic GCS treatment, 213 with acute GCS treatment and 4922 with no GCS treatment. The overall maximal leukocytes count was higher in GCS therapy groups: 15.4±8.3×109/L for the acute GCS treatment, 14.9±7.4×109/L for chronic GCS treatment and 12.9±6.4×109/L for the no GCS group (P<0.001). CONCLUSION: In patients with acute infections chronically treated with GCS, an increase in the WBC is at average of 5×109/L. These data must be taken into consideration while using the level of leukocytosis as a parameter in the diagnosis of the infectious process.
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Bacteriemia/tratamiento farmacológico , Celulitis (Flemón)/tratamiento farmacológico , Glucocorticoides/efectos adversos , Leucocitosis/etiología , Neumonía/tratamiento farmacológico , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Progresión de la Enfermedad , Femenino , Glucocorticoides/administración & dosificación , Hospitalización , Humanos , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Esteroides/administración & dosificación , Esteroides/efectos adversos , Adulto JovenRESUMEN
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease, with major respiratory and systemic expressions. Obesity is defined as a BMI>30 kg/ m2 and its prevalence has doubled in recent decades. The possible relationship of obesity to COPD, and its influence on respiratory pathophysiology, is considered a mystery. Studies show obesity to be a survival advantage among COPD patients, unlike in the general population, in which obesity correlates to decreased life expectancy. This study aims to assess the differences between obese and non-obese COPD patients. The main clinical aspect assessed is the number of COPDexacerbation related hospital admissions. METHODS: We conducted a retrospective cohort study of 323 COPD patients (95 obese, 228 non-obese), who had been followed from 2003-2010 by the Pulmonology Institute at the Soroka Medical Center. We collected demographics, medical history, BMI, lung function tests, information about hospital admissions and mortality. RESULTS: Non-obese COPD patients are 1.6 times more likely to be hospitalized due to COPD exacerbation. Additionally, women are 1.8 times more likely to be hospitalized due to COPD exacerbation. The FEV1 and FEV1/FVC ratios, which were measured latest during the study period, were higher among obese COPD patients. There was no significant difference in mortality. CONCLUSIONS: Obesity and male gender act as protective factors against COPD exacerbations requiring hospitalization. Lung function test values are higher among obese patients. Despite this, obesity has no influence on COPD patient survival. Subsequent studies are required, in order to define nutrition recommendations and target weights for COPD patients.
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Hospitalización/estadística & datos numéricos , Obesidad/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Comorbilidad , Femenino , Humanos , Masculino , Pruebas de Función Respiratoria , Estudios Retrospectivos , Factores SexualesRESUMEN
BACKGROUND: Ventilator associated pneumonia (VAPI is a common complication leading to lengthier hospitalizations and higher mortality. Prompt adequate initial antibiotic coverage is the crucial issue affecting survival. Currently, there is no gold standard diagnostic test. No conclusive data regarding the benefit of bronchoscopy exists in the literature reviewed. AIM: This study aims to evaluate the change of prognosis for patients who developed VAP, following a positive culture from bronchoalveolar lavage (BAL). DESIGN: This is a retrospective cohort study. SETTING: General intensive care unit in a tertiary university healthcare center. PARTICIPANTS: All patients who were admitted to Surgical ICU and developed VAP and who then underwent diagnostic bronchoscopy with BAL between the period 01/02/2007 - 31/02/2011. MEASUREMENTS AND RESULTS: A total of 66 patients who were admitted to the ICU, developed VAP and underwent bronchoscopy while ventilated; 30 patients were excluded. The positive BAL culture group was compared to the negative BAL culture group; there was no difference between demographic and clinical characteristics, mortality rates (for 30 days) or therapy change between the two groups. No complications were reported regarding the bronchoscopy procedure. CONCLUSIONS: Our findings demonstrate that performing y a diagnostic bronchoscopy with BAL does not improve the prognosis of patients with VAP. Furthermore, expanded prospective studies will be needed to conclude regarding its benefit in diagnosis and subsequent rectifying of therapy.
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Antibacterianos/uso terapéutico , Broncoscopía/métodos , Neumonía Asociada al Ventilador/diagnóstico , Adulto , Anciano , Lavado Broncoalveolar/métodos , Líquido del Lavado Bronquioalveolar/microbiología , Estudios de Cohortes , Femenino , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Israel/epidemiología , Masculino , Pruebas de Sensibilidad Microbiana/métodos , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Selección de Paciente , Neumonía Asociada al Ventilador/microbiología , Neumonía Asociada al Ventilador/mortalidad , Neumonía Asociada al Ventilador/terapia , Valor Predictivo de las Pruebas , Pronóstico , Reproducibilidad de los Resultados , Estudios Retrospectivos , Centros de Atención Terciaria/estadística & datos numéricosRESUMEN
BACKGROUND: Tuberculous pleurisy is the most common form of extrapulmonary tuberculosis, and a common cause of exudative pleural effusion. Closed pleural biopsy can be used for diagnosis. In recent years, more invasive methods are used for the diagnostic process in the western world. Contrary to the global trend, physicians at the Pulmonary Institute of the Soroka University Medical Center still perform a closed pleural biopsy as the first diagnostic step. In this article, we report our experience in the diagnosis of tuberculous pleurisy by closed pleural biopsy. METHODS: A retrospective cohort analysis, conducted among patients, who were admitted for investigation of pleural effusion between 2008 and 2013, and underwent closed pleural biopsy with an Abrams needle in the evaluation of tuberculous pleurisy (n=25). Histopathological evidence of tuberculosis bacterium infection included a positive staining for acid-fast bacteria, identification of Langerhans giant cells, demonstration of chronic granulomatous inflammation or demonstration of granulomas with central necrosis in samples of pleural fluid or pleural biopsy. RESULTS: Closed pleural biopsy was performed in 22/25 (88%) of patients. In 15/22 subjects (68%) histopathotogical evidence of tuberculous pleurisy was found. No significant complications were evident after the procedure. In addition, it was found that acid-fast bacteria in sputum samples, gastric fluid and pleural fluid is of very low diagnostic yield for the diagnosis of tuberculous pleurisy, while in cultures of sputum, gastric fluid or pleural fluid infection it was diagnosed in 27, 28 and 28% of subjects respectively. CONCLUSIONS: In subjects with a high probability for tuberculous pleurisy, closed pleural biopsy using Abrams needle is available, inexpensive and has a good diagnostic yield and low complication rate. We believe that there is great importance in preserving the ability to perform a closed pleural biopsy in all. medical centers in Israel.
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Biopsia con Aguja/métodos , Mycobacterium tuberculosis/aislamiento & purificación , Pleura/patología , Tuberculosis Pleural/patología , Adulto , Investigación sobre la Eficacia Comparativa , Femenino , Granuloma/etiología , Granuloma/patología , Humanos , Masculino , Persona de Mediana Edad , Derrame Pleural/diagnóstico , Derrame Pleural/etiología , Reproducibilidad de los Resultados , Tuberculosis Pleural/complicaciones , Tuberculosis Pleural/diagnósticoRESUMEN
BACKGROUND AND OBJECTIVE: Previous studies had demonstrated association between Tiotropium therapy (once-daily inhaled anticholinergic) and reductions of exacerbations, improvements in dyspnoea and quality of life in chronic obstructive pulmonary disease (COPD) patients. Little is known about the influence of adherence to Tiotropium on health-care utilization. Our objective was to examine whether adherence to Tiotropium is associated with decreased health-care utilization. METHODS: A computerized medical database was used to identify patients with COPD registered in an academic pulmonology institute who began therapy of Tiotropium 18 mg between 2008 and 2011 (n = 193). Adherence was assessed by calculating the proportion of days covered and defined as coverage of at least 80% of the follow-up period. Adherence to long-acting beta-agonists and/or inhaled corticosteroids (LABA and/or ICS) and health-care utilization were analysed 1 year before and 2 years after initiation of Tiotropium. A multivariate regression model was applied to examine determinants of change in health-care utilization. RESULTS: The median age of study population was 67 (80% male). Forty-one percent of study population (n = 79) adhered to Tiotropium. Hospitalization costs decreased 1 year following treatment initiation only among adherent patient when their adherence to LABA and/or ICS improved (ß = -463.6, P = 0.033). This cost did not change significantly in the consecutive second year (ß = 206.3, P = 0.583). CONCLUSIONS: Adherence to Tiotropium was associated with decreased hospitalizations only among patients who improved their adherence to LABA and/or ICS as well. Exploring reasons for high non-adherence and ways to improve adherence may optimize utilization of the scarce hospital resources.
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Antagonistas Colinérgicos/uso terapéutico , Servicios de Salud/estadística & datos numéricos , Hospitalización/economía , Cumplimiento de la Medicación , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Bromuro de Tiotropio/uso terapéutico , Corticoesteroides/uso terapéutico , Agonistas Adrenérgicos beta/uso terapéutico , Anciano , Preparaciones de Acción Retardada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Estudios RetrospectivosRESUMEN
INTRODUCTION: Cardiac troponin (cTn) is the biomarker of choice for detection of myocardial injury. There is a great need for simple point-of-care (POC) troponin testing among patients with chest pain, mainly in the prehospital setting. The purpose of this study was to evaluate the presence of cardiac troponin I (cTnI) in saliva of patients with myocardial injury using alpha-amylase depletion technique. METHODS: Saliva samples were collected from 40 patients with myocardial injury who were tested positive for conventional high-sensitivity cardiac troponin T (cTnT) blood tests, and from 66 healthy volunteers. Saliva samples were treated for the removal of salivary alpha-amylase. Treated and untreated samples were tested with blood cTnI Rapid Diagnostic Test. Salivary cTnI levels were compared to blood cTnT levels. RESULTS: Thirty-six of 40 patients with positive blood cTnT had positive salivary samples for cTnI following alpha-amylase depletion treatment (90.00% sensitivity). Moreover, three of the four negative saliva samples were obtained from patients with relatively low blood cTnT levels of 100 ng/L or less (96.88% sensitivity for 100 ng/L and above). The negative predictive value was 93.65% and rose up to 98.33% considering the 100 ng/L cutoff. Positive predictive values were 83.72% and 81.58%, respectively. Among 66 healthy volunteers and 7 samples yielded positive results (89.39% specificity). CONCLUSION: In this preliminary work, the presence of cTnI in saliva was demonstrated for the first time to be feasibly identified by a POC oriented assay. The specific salivary alpha-amylase depletion technique was shown to be crucial for the suggested assay.
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alfa-Amilasas Salivales , Troponina I , Humanos , Estudios de Factibilidad , Saliva , Troponina T , Biomarcadores , Pruebas en el Punto de AtenciónRESUMEN
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is characterized by progressive exertional and resting dyspnea and is associated with major co-morbidities. Hemoglobin level disorders (anemia and polycythemia) prevalence among patients and the relationship between them and the clinical expression are still not characterized unequivocally. The main purpose of this work is to test the association between anemia and hospitalizations. The presence of such a link may promote the diagnosis and treatment aimed at the patient's hemoglobin levels. HYPOTHESIS: Anemia in patients with COPD is associated with an increased number of hospitalizations. METHODS: A retrospective cohort study analysis, conducted on a group of COPD patients (n = 333) followed in the Pulmonology Institute of the Soroka University Medical Center in the years 2003-2009. Demographic physiological and clinical characteristics were compared between anemic, polycythemic and normal hemoglobin patients. Using statistical models, we examined the relationship between the presence of anemia and clinical outcome. RESULTS: Anemia was found in 79 patients (24%) and polycythemia among seven patients (2%). No difference was found between the groups in terms of number of hospitalizations, number of hospitalization days and ventilator events. There was a higher rate of co-morbidities (such as heart failure, chronic kidney disease) among anemic patients. There were also lower values of BMI and lung function and a higher proportion of men among anemic patients. CONCLUSIONS: Anemia in patients with COPD was not associated with an increase in the number of severe exacerbations. More studies are needed to clarify the threshold of a hemoglobin level below which there is an increase in the rate of hospitalizations.
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Anemia/epidemiología , Hospitalización/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Centros Médicos Académicos , Anciano , Anciano de 80 o más Años , Índice de Masa Corporal , Estudios de Cohortes , Femenino , Hemoglobinas/metabolismo , Humanos , Incidencia , Israel/epidemiología , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Pruebas de Función Respiratoria , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores SexualesRESUMEN
Importance: COVID-19 vaccine might be less immunogenic and effective among residents of long-term care facilities (LTCFs). Objective: To examine the association of BNT162b2 third dose (first booster dose) with overall SARS-CoV-2 infection, COVID-19 hospitalizations, and mortality among LTCF residents during a nationwide surge of the Delta variant in Israel. Design, Setting, and Participants: This observational cohort study conducted nationwide COVID-19 surveillance in LTCFs in Israel between August and October 2021. Participants were residents of LTCFs aged 60 years or older. Exposures: Vaccination with the third dose of BNT162b2 vaccine vs receipt of 2 doses at least 5 months earlier, based on self-preference and choice. Main Outcomes and Measures: The cumulative incidences of reverse transcription-polymerase chain reaction (RT-PCR)-confirmed SARS-CoV-2 infection, COVID-19 hospitalizations, and COVID-19-related deaths more than 7 days after vaccination with the third dose were compared between the groups using Kaplan-Meier curves. Hazard ratios (HRs) and 95% CIs were obtained using multivariable Cox regression models. Results: Among 18â¯611 residents included in the analysis, 12â¯715 (68.3%) were female, 463 (2.5%) were from the Arab population, 16â¯976 (91.2%) were from the general Jewish population, and 618 (3.3%) were from the ultraorthodox Jewish population; the mean (SD) age was 81.1 (9.2) years; 16â¯082 residents received their first booster dose (third dose) and 2529 were vaccinated with 2 doses at least 5 months earlier. The median (IQR) follow-up durations were 66 (60-70) days among 3-dose recipients and 56 (53-62) days among 2-dose-only recipients; 107 residents had SARS-CoV-2 infection after 7 days following vaccination with the booster dose compared with 185 among the 2-dose only group (cumulative incidence: 0.7% vs 7.5%; adjusted HR, 0.11 [95% CI, 0.07-0.15]). The respective adjusted HRs were 0.07 (95% CI, 0.03-0.14) and 0.10 (95% CI, 0.04-0.24) for the associations of vaccination with the third dose with hospitalization for mild-to-moderate COVID-19 and severe illness. Five COVID-19-related deaths occurred among the third dose vaccinees during the follow-up period compared with 22 among the 2-dose-only vaccinees (cumulative rate: 0.04% vs 0.9%; adjusted HR, 0.04 [95% CI, 0.009-0.16]). Conclusions and Relevance: This cohort study found significant inverse associations between vaccination with the third dose of the BNT162b2 vaccine with overall SARS-CoV-2 infection, COVID-19 hospitalizations, severe disease, and COVID-19-related deaths among LTCF residents during a massive surge caused by the Delta variant in Israel.
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COVID-19 , Vacunas , Vacuna BNT162 , COVID-19/epidemiología , COVID-19/prevención & control , Vacunas contra la COVID-19 , Estudios de Cohortes , Femenino , Hospitalización , Humanos , Incidencia , Cuidados a Largo Plazo , Masculino , SARS-CoV-2RESUMEN
Importance: The administration of a fourth BNT162b2 COVID-19 vaccine dose was approved in Israel in December 2021 for individuals 60 years or older who were vaccinated with a third dose 4 months previously or earlier to control the substantial surge of the SARS-CoV-2 Omicron variant. Nonetheless, the association between receipt of the fourth dose and protection against infection remains elusive. Objective: To determine the association of the fourth BNT162b2 dose with protection against SARS-CoV-2-related infections, hospitalizations, and deaths during the Omicron surge in long-term care facility (LTCF) residents. Design, Setting, and Participants: This prospective cohort study was conducted in Israel between January 10 and March 31, 2022 and included LTCF residents 60 years or older. Exposures: Vaccination with the fourth dose of BNT162b2 vs 3 doses that were administered 4 months previously or earlier. Main Outcomes and Measures: Cumulative incidences of SARS-CoV-2 infections, hospitalizations, and deaths during the Omicron surge. The follow-up was initiated more than 7 days after receipt of the fourth dose, which was matched to the follow-up initiation date of those who had received 3 doses of vaccine in each facility. We obtained hazard ratios and 95% confidence intervals from multivariable Cox regression models. Results: The data of 43â¯775 residents (mean [SD] age, 80.1 [9.4] years; 29â¯679 women [67.8%]) were analyzed, of whom 24â¯088 (55.0%) and 19â¯687 (45.0%) received the fourth and third dose (4 months previously or earlier), respectively. The median follow-up time was 73 days (4-dose group: IQR, 6 days; 3-dose group: IQR, 56 days). More than 7 days postvaccination with the fourth dose, SARS-CoV-2 infection was detected among 4058 fourth-dose vs 4370 third-dose recipients (cumulative incidence, 17.6% vs 24.9%). The corresponding incidences of hospitalizations for mild-to-moderate COVID-19, severe illness, and mortality were 0.9% and 2.8%, 0.5% and 1.5%, and 0.2% and 0.5%, respectively. The adjusted protections were 34% (95% CI, 30%-37%), 64% (95% CI, 56%-71%), and 67% (95% CI, 57%-75%) against overall infection, hospitalizations for mild-to-moderate illness, and severe illness, respectively, and 72% (95% CI, 57%-83%) against related deaths. Conclusions and Relevance: The results of this cohort study suggest that receipt of a fourth BNT162b2 dose conferred high protection against COVID-19 hospitalizations and deaths among LTCF residents during a substantial Omicron variant surge, but protection was modest against infection. These findings are relevant to the control of COVID-19 pandemic globally, especially among the population of LTCFs.
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COVID-19 , Anciano de 80 o más Años , Vacuna BNT162 , COVID-19/epidemiología , Vacunas contra la COVID-19 , Estudios de Cohortes , Femenino , Hospitalización , Humanos , Cuidados a Largo Plazo , Pandemias , Estudios Prospectivos , SARS-CoV-2RESUMEN
BACKGROUND: Chronic obstructive pulmonary disease (COPD) imparts a substantial economic burden on western health systems. Our objective was to analyze the determinants of elevated healthcare utilization among patients with COPD in a single-payer health system. METHODS: Three-hundred eighty-nine adults with COPD were matched 1:3 to controls by age, gender and area of residency. Total healthcare cost 5 years prior recruitment and presence of comorbidities were obtained from a computerized database. Health related quality of life (HRQoL) indices were obtained using validated questionnaires among a subsample of 177 patients. RESULTS: Healthcare utilization was 3.4-fold higher among COPD patients compared with controls (p < 0.001). The "most-costly" upper 25% of COPD patients (n = 98) consumed 63% of all costs. Multivariate analysis revealed that independent determinants of being in the "most costly" group were (OR; 95% CI): age-adjusted Charlson Comorbidity Index (1.09; 1.01-1.2), history of: myocardial infarct (2.87; 1.5-5.5), congestive heart failure (3.52; 1.9-6.4), mild liver disease (3.83; 1.3-11.2) and diabetes (2.02; 1.1-3.6). Bivariate analysis revealed that cost increased as HRQoL declined and severity of airflow obstruction increased but these were not independent determinants in a multivariate analysis. CONCLUSION: Comorbidity burden determines elevated utilization for COPD patients. Decision makers should prioritize scarce health care resources to a better care management of the "most costly" patients.
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Costos de la Atención en Salud/estadística & datos numéricos , Servicios de Salud/estadística & datos numéricos , Evaluación de Procesos y Resultados en Atención de Salud/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/terapia , Anciano , Estudios de Casos y Controles , Distribución de Chi-Cuadrado , Comorbilidad , Estudios Transversales , Femenino , Servicios de Salud/economía , Humanos , Israel/epidemiología , Análisis de los Mínimos Cuadrados , Modelos Logísticos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud/economía , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Enfermedad Pulmonar Obstructiva Crónica/economía , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Calidad de Vida , Medición de Riesgo , Factores de Riesgo , Sistema de Pago Simple/estadística & datos numéricos , Encuestas y Cuestionarios , Resultado del TratamientoAsunto(s)
Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/secundario , Melanoma/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Biopsia/métodos , Bronquios/patología , Neoplasias de los Bronquios/diagnóstico , Neoplasias de los Bronquios/secundario , Broncografía/métodos , Broncoscopía/métodos , Diagnóstico Diferencial , Resultado Fatal , Humanos , Pulmón/diagnóstico por imagen , Pulmón/patología , Masculino , Persona de Mediana EdadRESUMEN
Global Initiative for Asthma 2019 guidelines recommend to avoid strengthening patients' reliance on relievers since they increase exacerbation risk. Our aim was to examine the association between reliever inhalers overuse and all-cause healthcare utilization (HCU). A retrospective study among Clalit Health Services (CHS) adult enrollees (n = 977) for 2012-2017. Reliever inhalers overuse was defined as consistent prescription refills of ≥ 3 canisters annually. Adherence to controllers was calculated using the proportion of days covered. HCU included: hospitalizations, diagnostic and surgical procedures, medications, emergency room (ER) visits, and clinic visits. 27% of the study population (n = 264) consistently refilled ≥ 3 relievers prescriptions annually, and had higher adherence to controllers (0.38 vs. 0.24, p < 0.001). Their total 6-year HCU costs were not higher than that of others ($5,550 vs. $5,562, p = 0.107). Most HCU components [including hospitalization (p = 0.405) and ER visits (p = 0.884)] were comparable; however, medication costs were higher ($1734 vs. $1504, p < 0.001). A multivariable ordered-logit model revealed that frequent and regular use of relievers was not associated with higher HCU costs (OR = 0.82, 95% CI 0.62-1.09, p = 0.175). Higher adherence to maintenance and reliever therapy (OR = 2.18, 95% CI 1.44-3.28, p < 0.001), other controllers (OR = 3.30, 95% CI 2.11-5.16, p < 0.001), and nebulized SABAs and SAMAs (OR = 1.08, 95% CI 1.02-1.14, p = 0.007) was associated with higher costs. Overuse of reliever inhalers was prevalent and associated with higher adherence to controllers, yet not associated with higher all-cause HCU. This highlights the need to examine the sources of elevated usage in order to develop intervention strategies to optimize pharmaceutical therapy of asthma patients.
Asunto(s)
Antiasmáticos/uso terapéutico , Asma/tratamiento farmacológico , Nebulizadores y Vaporizadores , Aceptación de la Atención de Salud/estadística & datos numéricos , Adulto , Femenino , Servicios de Salud , Humanos , Masculino , Cumplimiento de la Medicación , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenRESUMEN
Systematic glucocorticosteroids (GCS) are used to treat chronic obstructive pulmonary disease (COPD) and can cause leukocytosis. Distinguishing the effect of GCS on leukocyte level from infection-induced leukocytosis is important. We sought to quantify the effect of chronic GCS treatment on leukocytosis level in patients with COPD exacerbation. We reviewed the records of patients with COPD exacerbation and fever hospitalized in a tertiary medical center in 2003-2014. Patients were classified according to the GCS treatment they received: chronic GCS treatment (CST), acute GCS treatment (AST), and no prior GCS treatment (NGCS). We used the eosinophil absolute count as a marker of compliance and efficacy of steroid treatment. The primary outcome was the maximal white blood cell (WBC) count within the first 24 h of admission. Of 834 patients, 161 were categorized as CST, 116 AST, and 557 NGCS. The overall maximal leukocyte count was higher and the eosinophil count lower in the two GCS therapy groups. In patients with COPD exacerbation and fever, acutely treated with GCS, the mean increase in the WBC count was more evident when the eosinophils were undetectable (absolute count of zero). This supports leukocytosis level as a marker of disease course in COPD and fever.
RESUMEN
STUDY OBJECTIVES: Women are underrepresented and thus sleep conditions are underdiagnosed at sleep clinics that evaluate sleep-disordered breathing. The most common sign of obstructive sleep apnea (OSA) is snoring; therefore, it is one of the main red flags for suspected OSA. The aim of this study is to determine whether self-reported snoring and snoring intensity by women and men correlates with snoring volume measured objectively during sleep laboratory study. METHODS: Consecutive patients who were referred to a polysomnography (PSG) study in a university hospital over a 2-year period had their snoring volume quantified by means of a calibrated digital sound survey meter. Participants were given a questionnaire in which they were asked to rate the severity of their snoring. The correlation between objective snoring intensity as measured during PSG and the self-reported snoring intensity was evaluated. RESULTS: A total of 1,913 patients were enrolled in the study. A positive correlation was found between objectively measured snoring intensity and the intensity listed by each participant in the questionnaire. Measurement of the volume of snoring revealed that women snored as loudly as men; however, 28% of the females (189/675) considered themselves to be nonsnorers compared to only 6.9% of men (P < .05). Furthermore, 36.5% of women (69/189) who reported themselves as nonsnorers turned out to have severe or very severe snoring intensity, whereas, in contrast, only 11.7% of men (10/85) of men had this discrepancy. These findings are in concordance with the finding that fewer women quantified their snoring as very severe or severe (38.4%), significantly less than men of whom 61.5% reported their snoring to be severe or very severe. CONCLUSIONS: In a population of individuals referred to a PSG study, although no difference in snoring intensity was found between sexes, women tend to underreport the fact that they snore and to underestimate the loudness of their snoring. Improved awareness of this discrepancy may increase women's access to sleep laboratories, and improve diagnostic rates of sleep apnea in females.
Asunto(s)
Ronquido/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Polisomnografía , Autoinforme , Índice de Severidad de la Enfermedad , Factores Sexuales , Ronquido/epidemiología , Ronquido/psicología , Encuestas y CuestionariosRESUMEN
Central nervous system tuberculosis (CNS TB), uncommon in developed countries, still constitutes a significant proportion of brain mass lesions in developing countries. With the consistent increase in TB in the third world and the increase in immigration to Western countries, we can also expect to see an increase in the incidence of CNS TB. We present a case of cerebral TB in a patient two years after immigrating to Canada. A timely diagnosis of cerebral TB was even more complicated in this patient, who was known to have chronic migraine. There was no evidence of pulmonary involvement and the only abnormality on chest CT scan was mediastinal lymphadenopathy.