Elderly bedridden patients with dementia use over one quarter of resources in internal medicine wards in an Israeli hospital.

BACKGROUND: Elderly bedridden patients with dementia (EBRPD) are a growing segment of the population. We aimed to describe acute care hospitalization of EBRPD in internal medicine wards: the prevalence of EBRPD, their impact on hospital resources and hospital ecology, one-year survival, and one-year readmission-free survival. METHODS: The study setting was the internal medicine division of one tertiary care hospital in Israel. We conducted a point-prevalence survey to measure the prevalence of EBRPD and the prevalence of multidrug-resistant organism (MDRO) carriage. We also conducted a retrospective chart review of EBRPD who were hospitalized in the internal medicine division in order to assess resource use, survival, and readmission. RESULTS: In the point prevalence surveys (N = 1667 patients), EBRPD comprised 24.3% of patients and 59.0% of mechanically ventilated patients. EBRPD were twice as likely to be colonized or infected by MDROs as other patients (39.3% vs. 18%, p < 0.001); thus, 41% of MDRO carriers during the survey days were EBRPD. In the retrospective study (N = 517 EBRPD), 80% of EBRPD received antibiotics; on average, they received an antibiotic on 87.7% of their hospital days. One-year survival was 35.6% and one-year readmission-free survival was 16.4%. CONCLUSIONS: Acute care hospitalization of EBRPD accounted for a high proportion of bed occupancy and ventilator use in internal medicine wards. EBRPD significantly increase the potential for MDRO transmission. Policymakers should seek alternatives to acute care hospitalization for EBRPD.

Dissemination of Kingella kingae in the community and long-term persistence of invasive clones.

BACKGROUND: Although Kingella kingae is being increasingly recognized as an important pediatric pathogen, our current understanding of the transmission of the organism is limited. The dissemination of K. kingae in the community was studied in 2 ethnic groups living side-by-side in Southern Israel. METHODS: Organisms recovered from oropharyngeal cultures, obtained from healthy young Jewish and Bedouin children during a 12-month period, were typed by pulsed-field gel electrophoresis and compared. RESULTS: Isolates from Bedouin children usually differed from those derived from Jews, confirming the relative social isolation of the 2 populations and the importance of close mingling in the spread of K. kingae. Significant clustering of genotypic clones in households and Bedouin neighborhoods was observed, indicating person-to-person transmission through intimate contact. Organisms detected in the study were identical to historical isolates recovered over the last 15 years from respiratory carriers and patients with bacteremia or skeletal infections. CONCLUSIONS: The present study demonstrates that children may be asymptomatically colonized in the respiratory tract by virulent K. kingae clones. The organism is transmitted from child-to-child through intimate contact. Some strains exhibit increased fitness and are maintained in the population for prolonged periods.

Effect of infections on 30-day mortality among critically ill patients hospitalized in and out of the intensive care unit.

BACKGROUND: This analysis is part of a multicenter study conducted in Israel to evaluate survival of critically ill patients treated in and out of intensive care units (ICUs). OBJECTIVE: To assess the role of infection on 30-day survival among critically ill patients hospitalized in ICUs and regular wards. DESIGN: All adult inpatients were screened on four rounds for patients meeting ICU admission criteria. Retrospective chart review was used to detect presence and type of infection. Mortality was ascertained from day of meeting study criteria to 30 days thereafter. ANALYSIS: The effect of infection on mortality among patients, treated in and out of the ICU, was compared using Kaplan Meier survival curves. Multivariate Cox models were constructed to adjust interdepartmental comparisons for case-mix differences. RESULTS: Of 641 critically ill patients identified, 36.8% already had an infection on day 0. An additional 40.2% subsequently developed a new infection during the follow-up period, ranging from 64.6% in the ICU to 31.5% in regular wards (p < .001). Resistant infections were more prevalent in ICUs. Infection was independently associated with an increase in mortality, regardless of whether the patient was admitted to the ICU. There was no difference in the adjusted risk of mortality associated with an infection diagnosed on day 0 vs. an infection diagnosed later. Risk of dying was similar in resistant and nonresistant infections. Adjusting for infections, survival of ICU patients was better relative to patients in regular wards (adjusted hazard ratio = 0.7). Among the different types of infection, risk of mortality from pneumonia was significantly lower in ICUs relative to regular wards. There was a protective effect in ICUs among noninfected patients. CONCLUSION: The risk of acquiring a new infection is greater in the ICU. However, risk of mortality among ICU patients was lower for the most serious infections and for those without any infection.

Ethnic ancestry and increased paternal age are risk factors for breast cancer before the age of 40 years.

To study the risk factors associated with breast cancer in women younger than 40 years, a cohort study (The Jerusalem Perinatal Study) of 42 822 female offspring born in hospitals in West Jerusalem during 1964-1976 was carried out. Hazard ratios of potential parental and perinatal risk factors for early breast cancer were measured. The overall incidence of breast cancer was 5.2/100 000 person-years. The highest incidence was found among Jewish women of West Asian ancestry (8.6/100 000 person-years), specifically those whose maternal grandfathers were born in Iraq, Iran or Afghanistan (9.5/100 000 person-years). Using Cox models we found independent risk factors for early breast cancer to be paternal age (relative risk/year=1.06, 95% confidence interval=1.02-1.10, P=0.005), and ancestry from Iraq/Iran/Afghanistan (relative risk=3.1, 95% confidence interval=1.50-6.52, P=0.002). The study confirms a previously observed effect of advanced paternal age on the occurrence of early breast cancer and identifies a novel population group at increased risk for the disease. The excess risk of early breast cancer associated with ancestry from Iraq, Iran and Afghanistan suggests involvement of genetic determinants, environmental exposures and/or lifestyle factors and mandates further investigation.

Regional variations in mortality and causes of death in Israel, 2009-2013.

BACKGROUND: Regional variations in mortality can be used to study and assess differences in disease prevalence and factors leading to disease and mortality from different causes. To enable this comparison, it is important to standardize the mortality data to adjust for the effects of regional population differences in age, nationality and country of origin. METHODS: Standardized mortality ratios (SMR) were calculated for the districts and sub-districts in Israel, for total mortality by gender as well as for leading causes of death and selected specific causes. Correlations were assessed between these SMRs, regional disease risk factors and socio-economic characteristics. Implications for health policy were then examined. RESULTS: Total mortality in the Northern District of Israel was not significantly different from the national average; but the Haifa, Tel Aviv, and Southern districts were significantly higher and the Jerusalem, Central, Judea and Samaria districts were lower. Cancer SMR was significantly lower in Jerusalem and not significantly higher in any region. Heart disease and diabetes SMRs were significantly higher in many sub-districts in the north of the country and lower in the south. SMRs for septicemia, influenza/pneumonia, and for cerebrovascular disease were higher in the south. Septicemia was also significantly higher in Tel Aviv and lower in the North, Haifa and Jerusalem districts. SMRs for accidents, particularly for motor vehicle accidents were significantly higher in the peripheral Zefat and Be'er Sheva sub-districts. CONCLUSION: The SMR, adjusted for age and ethnicity, is a good method for identifying districts that differ significantly from the national average. Some of the regional differences may be attributed to differences in the completion of death certificates. This needs to be addressed by efforts to improve reporting of causes of death, by educating physicians. The relatively low differences found after adjustment, show that factors associated with ethnicity may affect mortality more than regional factors. Recommendations include encouraging good eating habits, exercise, cancer screening, control of hypertension, reduction of smoking and improving road infrastructure and emergency care access in the periphery.

Graft survival and its determinants: a 3 year national experience with liver transplantation in Israel.

BACKGROUND: There is a dearth of organs for liver transplantation in Israel. Enhancing our understanding of factors affecting graft survival in this country could help optimize the results of the transplant operation. OBJECTIVES: To report 3 years national experience with orthotopic liver transplantation, and to evaluate patient and perioperative risk factors that could affect 1 year graft survival. METHODS: The study related to all 124 isolated adult liver transplantations performed in Israel between October 1997 and October 2000. Data were abstracted from the medical records. One-year graft survival was described using the Kaplan-Meier survival curve and three multivariate logistic regression models were performed: one with preoperative case-mix factors alone, and the other two with the addition of donor and operative factors respectively. RESULTS: Of the 124 liver transplantations performed, 32 failed (25.8%). The 1 year survival was lower than rates reported from both the United States and Europe but the difference was not significant. Of the preoperative risk factors, recipient age > 60 years, critical condition prior to surgery, high serum bilirubin and serum hemoglobin < or = 10 g/dl were independently associated with graft failure, adjusting for all the other factors that entered the logistic regression equation. Extending the model to include donor and operative factors raised the C-statistic from 0.79 to 0.87. Donor age > or = 40, cold ischemic time > 10 hours and a prolonged operation (> 10 hours) were the additional predictors for graft survival. A MELD score of over 18 was associated with a sixfold increased risk for graft failure (odds ratio = 6.5, P = 0.001). CONCLUSIONS: Graft survival in Israel is slightly lower than that reported from the U.S. and Europe. Adding donor and operative factors to recipient characteristics significantly increased our understanding of 1 year survival of liver grafts.

Survival of critically ill patients hospitalized in and out of intensive care.

OBJECTIVE: A lack of intensive care units beds in Israel results in critically ill patients being treated outside of the intensive care unit. The survival of such patients is largely unknown. The present study's objective was to screen entire hospitals for newly deteriorated patients and compare their survival in and out of the intensive care unit. DESIGN: A priori developed intensive care unit admission criteria were used to screen, during 2 wks, the patient population for eligible incident patients. A screening team visited every hospital ward of five acute care hospitals daily. Eligible patients were identified among new admissions in the emergency department and among hospitalized patients who acutely deteriorated. Patients were followed for 30 days for mortality regardless of discharge. SETTING: Five acute care hospitals. PATIENTS: A total of 749 newly deteriorated patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Crude survival of patients in and out of the intensive care unit was compared by Kaplan-Meier curves, and Cox models were constructed to adjust the survival comparisons for residual case-mix differences. A total of 749 newly deteriorated patients were identified among 44,000 patients screened (1.7%). Of these, 13% were admitted to intensive care unit, 32% to special care units, and 55% to regular departments. Intensive care unit patients had better early survival (0-3 days) relative to regular departments (p=.0001) in a Cox multivariate model. Early advantage of intensive care was most pronounced among patients who acutely deteriorated while on hospital wards rather than among newly admitted patients. CONCLUSIONS: Only a small proportion of eligible patients reach the intensive care unit, and early admission is imperative for their survival advantage. As intensive care unit benefit was most pronounced among those deteriorating on hospital wards, intensive care unit triage decisions should be targeted at maximizing intensive care unit benefit by early admitting patients deteriorating on hospital wards.

Negative impact of 'old-to-old' donations on success of cadaveric renal transplants.

The effect of 'old-to-old' cadaveric renal transplants on operative complications and graft survival was assessed in all 325 patients undergoing solitary cadaveric renal transplantations in Israel during a 3-yr period. Preoperative information and hospital course data were abstracted from the charts. Results were analyzed using Kaplan-Meyer survival curves, univariate and multivariate Cox models. Overall, 62 (19.1%) grafts failed within a year. Failure rate was 46.2% for 'old-to-old' transplants compared with 15.5% for all other donor/recipient age combinations (p < 0.0001). 'Old-to-old' transplants remained independently associated with graft failure in a multivariate Cox model after controlling the effect of other risk factors. 'Old-to-old' transplants were also associated with increased operative complications relative to other age combinations. The decision to use 'old-to-old' transplants, even when donors are scarce, is problematic and should be reconsidered.

Factors associated with primary and secondary graft failure following cadaveric kidney transplant.

The risk profile for primary renal graft failure is largely unknown because of its inclusion with secondary failures or its exclusion from analysis. This study compares characteristics of the cadaveric transplant recipients who experienced primary failure, secondary failures or survived with a functioning graft for at least 6 months. Medical records of all cadaveric kidney-transplant patients performed in Israel over a 3-yr period 1997-2000 were reviewed. Fisher's exact test and multinomial regression models were used to assess the association of demographic, pre-operative and operative risk factors with the two types of failure outcomes. Of 325 grafts, 54 (16.6%) failed of which half were primary failures. Univariate analysis demonstrated a significant trend of increasing proportion of patients with specific risk factors from the functioning grafts group to the secondary and to the primary graft failure groups. Independent risk factors for primary graft failure included 'surgical complications', 'donor's age > or =60 yr', 'waiting for transplant > or =6 yr', and 'human leukocyte antigen-DR (HLA-DR) mismatch', based on the multivariate model. These factors may reflect the scarcity of organ donations in Israel, which leads to a prolonged waiting time, higher tolerance for HLA-DR mismatches, and utilization of kidneys from elderly donors.