Adherence to diabetes quality indicators in primary care and all-cause mortality: A nationwide population-based historical cohort study.

BACKGROUND: In the last three decades, much effort has been invested in measuring and improving the quality of diabetes care. We assessed the association between adherence to diabetes quality indicators and all-cause mortality in the primary care setting. METHODS: A nationwide, population-based, historical cohort study of all people aged 45-80 with pharmacologically-treated diabetes in 2005 (n = 222,235). Data on annual performance of quality indicators (including indicators for metabolic risk factor management and glycemic control) and vital status were retrieved from electronic medical records of the four Israeli health maintenance organizations. Cox proportional hazards and time-dependent models were used to estimate hazard ratios (HRs) for mortality by degree of adherence to quality indicators. RESULTS: During 2,000,052 person-years of follow-up, 35.8% of participants died. An inverse dose-response association between the degree of adherence and mortality was shown for most of the quality indicators. Participants who were not tested for proteinuria or did not visit an ophthalmologist during the first-5-years of follow-up had HRs of 2.60 (95%CI:2.49-2.69) and 2.09 (95%CI:2.01-2.16), respectively, compared with those who were fully adherent. In time-dependent analyses, not measuring LDL-cholesterol, blood pressure, HbA1c, or HbA1c>9% were similarly associated with mortality (HRs ≈1.5). The association of uncontrolled blood pressure with mortality was modified by age, with increased mortality shown for those with controlled blood pressure at older ages (≥65 years). CONCLUSIONS: Longitudinal adherence to diabetes quality indicators is associated with reduced all-cause mortality. Primary care professionals need to be supported by health care systems to perform quality indicators.

[PHOTOKERATITIS AS RESULT OF DOMESTIC EXPOSURE TO ULTRAVIOLET-C (UVC) LIGHT].

INTRODUCTION: During the global outbreak of coronavirus disease 2019 pandemic, people sought ways to disinfect their domestic and public surroundings. One of the sanitation options included the usage of ultraviolet-C (UVC) lamps since UVC radiation has been shown to effectively inactivate the SARS-Coronavirus. UVC radiation may also be effective against the SARS-CoV-2 virus. Here we report four cases of bilateral photokeratitis due to the improper usage of UV lamps during the first outbreak of COVID-19 in Israel. METHODS: We collected 4 case reports from patients who were diagnosed with bilateral photokeratitis due to improper usage of UV lamps in their domestic environment from May to December 2020 during the first outbreak of COVID-19 in Israel. RESULTS: A total of four patients presented with signs and symptoms of bilateral photokeratitis after exposure to UV lamps. DISCUSSION: Acute exposure of UVC to the cornea may cause "burns", known as photokeratitis. The signs of photokeratitis usually appear a few hours after the exposure. Precautious steps to educate the population must include using protective eyewear in any exposure to UV light and avoiding the use of germicidal lamps in public locations with exposure to the population.

The Jerusalem tribune collapse incident: Challenges in the management of a pediatric mass casualty incident.

OBJECTIVES: Children comprise up to 30-50 percent of all disaster victims. Pediatric disaster medicine is a poorly established field, and most protocols are designed without adequate emphasis on the special needs of the pediatric population. During the 2021 Shavuot holiday in Israel, the collapse of temporary steel bleachers in a partially constructed synagogue resulted in a mass casualty incident (MCI) with a majority of pediatric casualties. This study analyzed the differences in post-incident casualty management, treatment, and outcomes in three Jerusalem medical centers. METHODS: Multicenter retrospective data were collected from two tertiary level 1 trauma centers and one secondary hospital in Jerusalem. The data included demographics, triage scores, injury mechanisms, medical workups, and the management of the pediatric patients. RESULTS: A total of 171 children and adolescents aged 9-18 years presented to three centers. In two institutions, the triage was performed by a senior emergency medicine physician, and in the third institution, by a senior trauma physician. Different protocols were applied, resulting in significant differences in triage, identification and documentation, admission strategies, adherence, and analgesic treatment. Most patients presented with orthopedic injuries (115/171, 67 percent). A small number had head, chest, abdominal, and multisystem injuries (11, 5, 2, and 2 percent, respectively). CONCLUSION: Pediatric MCI management presents specific challenges. The lack of consistency in triage, registry, and management highlights the need for robust pediatric MCI training programs.

Maternal distress during the COVID-19 outbreak: A socio-ecological perspective.

INTRODUCTION: Mothers faced an increased risk of adverse mental health outcomes during the COVID-19 pandemic compared to other populations. However, there is little data on the factors that placed mothers at increased risk of distress. AIMS: The present study explored a range of individual, familial, and environmental factors associated with psychological distress in mothers during the COVID-19 pandemic. METHOD: This repeated cross-sectional study was composed of a convenience sample of mothers who completed an online survey that included a demographic questionnaire, an emotion regulation questionnaire, and the Depression, Anxiety, and Stress scale. The survey was administered during the second and third lockdowns in Israel in 2020-2021. RESULTS: The study included 575 mothers (M age = 39). The findings of a hierarchical regression indicated that individual-level factors, composed of age and emotion regulation tendencies predicted psychological distress. The family-level factors of household income and number of children in the family also predicted distress. In terms of environmental-level factors, COVID-19-related media consumption and school status (open or closed) were also significant predictors of psychological distress. Importantly, the results showed that the most important predictors of psychological distress in mothers during the COVID-19 outbreak were school closures, household income, and the use of adaptive and maladaptive emotion regulation strategies. CONCLUSIONS: The findings highlight the intersection of individual, familial, and environmental factors in mothers' mental health during crises.

Diet-omics in the Study of Urban and Rural Crohn disease Evolution (SOURCE) cohort.

Crohn disease (CD) burden has increased with globalization/urbanization, and the rapid rise is attributed to environmental changes rather than genetic drift. The Study Of Urban and Rural CD Evolution (SOURCE, n = 380) has considered diet-omics domains simultaneously to detect complex interactions and identify potential beneficial and pathogenic factors linked with rural-urban transition and CD. We characterize exposures, diet, ileal transcriptomics, metabolomics, and microbiome in newly diagnosed CD patients and controls in rural and urban China and Israel. We show that time spent by rural residents in urban environments is linked with changes in gut microbial composition and metabolomics, which mirror those seen in CD. Ileal transcriptomics highlights personal metabolic and immune gene expression modules, that are directly linked to potential protective dietary exposures (coffee, manganese, vitamin D), fecal metabolites, and the microbiome. Bacteria-associated metabolites are primarily linked with host immune modules, whereas diet-linked metabolites are associated with host epithelial metabolic functions.

Nitrous Oxide-induced Myeloneuropathy Due to Recreational Abuse.

BACKGROUND: The recreational use of nitrous oxide (N2O) has increased in recent years with a noticeable surge in the incidence of nitrous oxide-related myeloneuropathy. OBJECTIVES: To raise awareness of increasing myeloneuropathy due to recreational nitrous oxide misuse in Israel. METHODS: We conducted a case series documenting the clinical and investigative features of eight patients presenting with nitrous oxide-induced myeloneuropathy who were admitted to our departments. RESULTS: Paresthesia was the chief complaint in all patients, with sensory gait ataxia being a common feature, which was often accompanied by Romberg's sign and mild lower limb weakness. Vitamin B12 levels were below the normal range in seven patients, accompanied by elevated homocysteine and methylmalonic acid levels. Magnetic resonance imaging scans revealed hyperintense signals in the dorsal columns of the cervical spine. All patients improved following vitamin B12 injections. CONCLUSIONS: Enhancing awareness, prompting the use of appropriate investigations, and advocating for timely treatment are needed to overcome the risks associated with nitrous oxide misuse.

Outcomes of Transvenous Lead Extraction in a Referral Center in Northern Israel.

BACKGROUND: Cardiac implantable electronic devices (CIEDs) are increasingly being used; thus, there is an increasing need for transvenous lead extraction (TLE). OBJECTIVES: To summarize our experience with TLE at single referral center in northern Israel. METHODS: The study included all patients who underwent TLE at our center between 2019 and 2022, regardless of the indication. RESULTS: The cohort included 50 patients. The mean age was 69 ± 10.36 years; 78% were males. A total of 99 electrodes were targeted. The mean number of electrodes was 1.96 (range 1-4) per patient. The time between lead implantation and extraction ranged between 1.1 and 34 years with an average of 8.14 ± 5.71 years (median of 7.5 years). Complete lead removal was achieved in 98% of patients and in 98.99% of leads. The complete procedural success rate as well as the clinical procedural success rate was 96%. The procedural failure rate was 4% (1 patient died 2 days after the index procedure and 1 patient remained with large portion of lead). The indication for TLE was infection in 78% of the cohort group. Powered mechanical sheaths were used in 36 patients (72%), laser sheaths in 27 (54%), and a combination of laser and mechanical sheaths in 16 (32%). CONCLUSIONS: The clinical and procedural success rates of TLE, primarily for CEID-related infection, were high. A combination of laser and mechanical sheaths was needed in one-third of patients.

A Comparison of Hidradenitis Suppurativa Characteristics Among Israeli Arabs and Jews: Analysis of Two Cohorts.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease involving apocrine gland-bearing regions. There is an under-representation of non-Caucasians in epidemiologic studies of HS. The characteristics of HS in Israeli Arabs have not yet been studied. OBJECTIVES: To investigate the demographic and clinical profile of HS in the Israeli Arab population. METHODS: A retrospective analysis was conducted in two cohorts of patients with HS in Israel. The patients were derived from the database of a large health management organization (n=4191, 639 Arabs; population-based) and a major tertiary medical center (n=372, 49 Arabs). Demographic and clinical data were compared between ethnic groups. RESULTS: The prevalence of HS in Israeli Arabs was found to be 0.5%, fivefold higher than in Jews. Arab patients were younger (35.3 vs. 40.5 years, P < 0.001) and mostly male (52% vs. 35.7%, P < 0.001), with lower rates of co-morbidities, including smoking (40.8% vs. 55.7%, P < 0.001), hyperlipidemia, and depression as well as a higher rate of dissecting cellulitis (10.2% vs. 1.9%, P = 0.008). HS was more severe in Arabs, but of shorter duration, with mainly axillary involvement (79.6% vs. 57.9%, P = 0.004). Treatment with hormones was more common in Jews, and with biologic agents in Arabs. CONCLUSIONS: The findings suggest a different phenotype of HS in Arabs, warranting further study.

A Longitudinal Investigation of the Association Between Stroke and Loneliness.

OBJECTIVES: The present research examined associations between stroke and long-term trajectories of loneliness. METHODS: We conducted secondary analyses in 3 large representative panel studies of adults 50 years and older in the United States, Europe, and Israel: the English Longitudinal Study of Aging (ELSA; analytic N = 14,992); the Survey of Health, Aging, and Retirement in Europe (SHARE; analytic N = 103,782); and the Health and Retirement Study (HRS; analytic N = 22,179). Within each sample, we used discontinuous growth curve modeling to estimate loneliness trajectories across adulthood and the impact of stroke on loneliness trajectories. RESULTS: Across all 3 samples, participants who experienced stroke reported higher levels of loneliness relative to participants who did not experience stroke. In ELSA and HRS (but not SHARE), loneliness levels were higher after stroke onset relative to before stroke onset. DISCUSSION: This research adds to a growing body of evidence demonstrating elevated loneliness among stroke survivors and highlights the need for interventions to increase social connectedness after stroke.

Trust in public health policy in the time of the COVID-19 epidemic in Israel.

The government of Israel provides universal health care through four health care organizations ("sick funds") that enjoy general public trust. In hindsight, the response of the government to the COVID-19 epidemic seems reasonable. In the first year of the epidemic, tests and vaccines were developed and other measures were taken, including social distancing, focusing on risk factors for infection and disease severity, and improving treatment. The COVID-19 mortality rate between January 2000 and June 2021 was around 750 per million inhabitants, well below the OECD average of 1300. Still, although the control measures were largely well received, the media and an ad hoc non-governmental Emergency Council for the coronavirus crisis in Israel criticized the government's response to the epidemic thereby contributing to a decline in public trust in government policy. This commentary provides an overview of the importance of trust in medical institutions and the difficulties of evaluating healthcare decisions in an attempt to justify three conclusions. First, when physicians and self-appointed experts publicly disapprove of a government policy, they should consider the trade-off between improving care and undermining public trust. Second, when evaluating a medical decision, experts should not ask, "Would I have acted differently?" but rather, "Was the decision under review completely unreasonable?" Thirdly, criticism is certainly worth listening to. However, I believe that by calling for organized resistance against the government, the publicly announced establishment of the Emergency Council for the Corona crisis blatantly crossed the line between constructive criticism and destructive mistrust.

Improved Survival of Patients With Chronic Lymphocytic Leukemia Between 1998-2022, Including the Era of Target Therapies With BCL2 and BTK Inhibitors.

BACKGROUND/AIM: The treatment for chronic lymphocytic leukemia (CLL) has changed dramatically over the last two decades. The current study aimed to investigate the impact on overall survival (OS) and time to next treatment (TTT) among CLL patients from 1998 to 2022. PATIENTS AND METHODS: The cohort was based on data obtained from electronic medical records of Maccabi, the second largest healthcare organization in Israel. All included patients were diagnosed with CLL based on the IWCLL criteria and complete clinical, laboratory, and treatment data were available. The study encompassed 3,964 patients diagnosed with CLL during the specified study period. RESULTS: Patients with CLL who required therapy were divided into three eras based on the dominant treatment approach: chemotherapy alone before 2010, therapy with chemotherapy and anti-CD20 between 2010 and 2017, and therapy with targeted agents between 2017 and 2022. Median OS was 4.1 years, 7.5 years, and not reached, respectively. The six-year OS rates were 40%, 55%, and 69%, respectively, (p=0.0001). The median time to the next treatment improved from 5.5 years before 2010, to 8.3 between 2010-2017, to not reached after 2017 (p=0.0021). CONCLUSION: Marked improvements in survival subsequent to fundamental changes in first-line therapy were found in patients with CLL from before 2010 to after 2017.

Measles outbreak associated with a preschool setting among partially vaccinated children in the Tel Aviv District, Israel, October 2023.

In October 2023, the Tel Aviv District was notified of ten cases of measles. The outbreak initiated in a preschool with high vaccination coverage with one dose of MMR vaccine. Serological testing was available for eight patients (six children and two adults). Among the six children vaccinated with one dose of MMR vaccine, primary vaccine failure was demonstrated. Among the adults, secondary vaccine failure was confirmed. The outbreak was successfully contained due to a combination of factors, notably its occurrence within a population characterized by high vaccination coverage in Tel Aviv, during a period of restricted public interactions due to the prevailing state of war in the country. Despite challenging wartime conditions, effective prophylactic measures were promptly executed, encompassing a 2-dose MMR vaccination schedule for close contacts and the broader community of children in the TA district, successfully curbing the outbreak and preventing widespread infections.

Severity of gambling behaviors: exploring associations with venues, legality, and substance use.

INTRODUCTION: The COVID-19 pandemic has been linked to an increase in gambling behaviors, potentially leading to Gambling Disorder (GD) and adverse health and social consequences. Problematic gambling has received little research attention over the years in Israeli society and the issue of gambling is not high on the list of priorities of Israeli policymakers. The present study examined gambling behavior in Israel on a continuum of severity and its association with venues where the gambling occurs, legality, attitude toward the legalization of casinos and poker, and substance use. METHODS: The study questionnaires were distributed to approximately 15,000 Jewish-Israeli adults via internet panel. From 3,088 Israeli adults who answered the questionnaire, 1,251 (40.5%) reported gambling in the last year and were included in the analyses. RESULTS: Based on the Problem Gambling Severity Index, 60% of participants were classified as non-problem gamblers, 25% as at low-risk for a gambling problem, 11% as at moderate risk, and 4% as having a gambling problem. Most online gambling was practiced by non-problem gamblers (40%) and most illegal gambling was by low-risk gamblers (34%). The more severe the gambling behavior was on the continuum, the more it was associated with illegal substance use and positive attitudes toward legalized casinos in Israel. Logistic regression showed the odds of developing moderate and problem gambling were 3.8 times higher for online gamblers (OR = 3.8; CI 2.6-5.4; p < 0.000) and 3.3 times higher for illegal gamblers (OR = 3.3; CI 2.2-4.9; p < 0.000). CONCLUSION: Though more research attention should be paid to gambling behaviors, harm reduction gambling interventions should be made available to all categories on the continuum of severity of gambling behaviors. The present study provides evidence-based information to promote health policies that aim to prevent and reduce harm for Israeli gamblers.

Group A Streptococcus Carriage in Adults in Southern Israel: A Prospective Study.

BACKGROUND: The prevalence of Group A streptococcus (GAS) carriage among adults is studied less than in children. The variability of reported carriage rates is considerably large and differs among diverse geographic areas and populations. OBJECTIVES: To evaluate the prevalence of GAS carriage among adults in Israel. METHODS: In this prospective study, conducted in a large healthcare maintenance organization in Israel, we obtained pharyngeal cultures from adults attending the clinic without upper respiratory tract complaints or fever. Patient data included sex, age, number of children, and religious sectors. RESULTS: From May to December 2022, eight family physicians collected a total of 172 throat swabs (86% response rate). The median age was 37 years (range 18-65); 72.7% were females, 22.7% were ultra-Orthodox Jewish, and 69.2% had children. The prevalence of GAS carriage was 6.98%, 95% confidence interval (95%CI) 3.7%-11.9%. GAS carriers were younger (31.7 vs. 39.3 years, P = 0.046), and the majority were ultra-Orthodox Jews (58.3% vs. 20%, P = 0.006). All GAS carriers were from lower socioeconomic status. When assessing risk factors for GAS carriage using multivariate analysis, only being an ultra-Orthodox Jew was positively related to GAS carriage (adjusted odds ratio 5.6, 95%CI 1.67-18.8). CONCLUSIONS: Being an ultra-Orthodox Jew was the single variable associated with a GAS carriage, which may be related to having many children at home and living in overcrowded areas. Primary care physicians in Israel should recognize this situation when examining patients with sore throats, mainly ultra-Orthodox Jews.

Receipt of prescription opioid medication is associated with increased mortality in an Israeli population.

BACKGROUND: Despite Israel's increased use of prescription opioids, reported deaths resulting or associated with opioids have decreased, in fact dramatically, since 2005. This contrast is unique and difficult to explain. We sought to examine whether higher prescribed opioid dosages among adults without oncologic diagnoses were associated with higher all-cause mortality rates. METHODS: A historical cohort study in Clalit Health Services, using a data repository including all adult patients prescribed opiates between 2010 and 2020, excluding patients with oncologic diagnoses. Patients were classified into three groups according to opioid use: below 50 Morphine milligram equivalents (MME) per day, 50 to 90 MME per day, and above 90 MME per day. Sex, Charlson comorbidity score, age and socioeconomic status were recorded. Mortality rates were compared between the dosage groups and compared to age-standardized mortality rates in the general population. RESULTS: On multivariate analysis, patients receiving 90 or more MME per day were 2.37 (95%CI 2.1 to 2.68) more likely to have died compared to patients receiving below 50 MME per day. The respective hazard ratio among patients receiving between 50 and 90 MME per day was 2.23 (2.01 to 2.46). Among patients aged 18 to 50, standardized mortality ratios (SMRs) compared to the general population ranged between 5.4 to 8.6 among women, receiving between 50 and 90 MME per day, and between 8.07 and 10.7 among women receiving 90 or more MME per day. The respective SMRs among men were 1.2 to 3.8 and 2.7 to 5.4. CONCLUSION: Increased opioid use is independently associated with increased all-cause mortality among non-oncological patients. This result is most notable among young adults with little or no known comorbidities. These findings are consistent with results in other countries and seem more credible than previous Israeli reports. Healthcare regulators and providers should, therefore, act to curtail the increasing opioid prescriptions and devise and enhance controls in the healthcare system, which, until 2020, had very limited mechanisms in place.

Maternal hybrid immunity and risk of infant COVID-19 hospitalizations: national case-control study in Israel.

Hybrid immunity, acquired through vaccination followed or preceded by a COVID-19 infection, elicits robust antibody augmentation. We hypothesize that maternal hybrid immunity will provide greater infant protection than other forms of COVID-19 immunity in the first 6 months of life. We conducted a case-control study in Israel, enrolling 661 infants up to 6 months of age, hospitalized with COVID-19 (cases) and 59,460 age-matched non-hospitalized infants (controls) between August 24, 2021, and March 15, 2022. Infants were grouped by maternal immunity status at delivery: Naïve (never vaccinated or tested positive, reference group), Hybrid-immunity (vaccinated and tested positive), Natural-immunity (tested positive before or during the study period), Full-vaccination (two-shot regimen plus 1 booster), and Partial-vaccination (less than full three shot regimen). Applying Cox proportional hazards models to estimate the hazard ratios, which was then converted to percent vaccine effectiveness, and using the Naïve group as the reference, maternal hybrid-immunity provided the highest protection (84% [95% CI 75-90]), followed by full-vaccination (66% [95% CI 56-74]), natural-immunity (56% [95% CI 39-68]), and partial-vaccination (29% [95% CI 15-41]). Maternal hybrid-immunity was associated with a reduced risk of infant hospitalization for Covid-19, as compared to natural-immunity, regardless of exposure timing or sequence. These findings emphasize the benefits of vaccinating previously infected individuals during pregnancy to reduce COVID-19 hospitalizations in early infancy.

Pfizer COVID19 vaccine is not associated with acute cardiovascular events excluding myocarditis- a national self-controlled case series study.

BACKGROUND: Despite publications assuring no increased risk for acute cardiovascular events (excluding myocarditis) and sudden death following administration of COVID19 vaccines, these issues still stir much public ado. We assessed the risk for acute cardiovascular events that require hospitalization (excluding myocarditis) and for mortality in the short-term following administration of the second dose of the Pfizer COVID19 vaccine in Israel. METHODS: Using a self-controlled case series (SCCS) study design and national databases, all second-dose vaccinees, who had not been diagnosed with COVID19 and who had an acute cardiovascular event (acute myocardial infarction/acute stroke/acute thromboembolic event) that required hospitalization in the 60 days following vaccine administration between Jan 11th, 2021 and Oct 31st 2021, were included. A similar analysis was carried out for mortality. The first 30 days following vaccination were defined as risk period while the next 30 days were defined as control period. The probability for an event between these periods was compared using a conditional logistic regression model, accounting for sex, age group, background morbidity and seasonal risk. RESULTS: Out of 5,700,112  second dose vaccinees, 4,163 had an acute cardiovascular event in the 60 days following vaccine administration. Following exclusion of 106 due to technical considerations, 1,979 events occurred during the risk period and 2,078 during the control period: Odds ratio, OR = 0.95, 95% confidence interval, CI 0.90-1.01, p = 0.12. Adjusted OR was similar (OR = 0.88, 95%CI 0.72-1.08). Stratifying by age showed no increased risk in any age group. Mortality assessment indicated low number of events in both periods. These results were consistent in sensitivity analyses. CONCLUSIONS: There was no increased risk for acute cardiovascular events (excluding myocarditis) in the risk period compared to the control period following administration of the second dose of Pfizer COVID19 vaccine. Mortality data raised no concerns either, but may have been biased.