Prevalence and Characteristics of Carriage of Neisseria meningitidis Among Young Israeli Adults.

Background: No updated data currently exist regarding Neisseria meningitidis carriage and genomic epidemiology among young Israeli adults. Methods: Oropharyngeal swabs were collected from 1801 military recruits on the day of recruitment during 2019. Neisseria meningitidis was detected and identified by culture and quantitative polymerase chain reaction (qPCR). Confirmed isolates were serotyped by qPCR, and encapsulated strains underwent whole-genome sequencing. Risk factors for carriage were determined by analyzing focused questionnaires using uni- and multivariate models. Genomic typing was performed by means of core genome multilocus sequence typing. Results: Carriage rates overall and of encapsulated strains were 20.1% and 6.7%, respectively. Genogroups B (49.2%) and Y (26.7%) were the most commonly encapsulated strains. Genogroups C, W, and X were scarce, and genogroup A was absent. The most notable clonal complexes (CCs) were CC23 (n = 30), CC32 (n = 16), and CC44/41 (n = 9). Carriage was significantly associated with smoking (odds ratio [OR], 1.82; 95% CI, 1.43-2.33) and boarding school attendance before recruitment (OR, 1.49; 95% CI, 1.14-1.96). Conclusions: The prevalence of meningococcal carriage among young Israeli adults is high, compared with similar studies in other developed countries. This might be due to sociocultural characteristics including smoking and boarding school attendance during and after high school. The dominant genogroups and CCs found were compatible with those implicated in invasive disease in Israel.

Being overweight and born in the spring are associated with an increased risk for rhinitis.

AIM: To explore the relationship between the season of birth and the prevalence of recurrent or chronic rhinitis (rhinitis). METHODS: The medical records of consecutive 17-year-old conscripts to the Israeli army were reviewed. We compared the prevalence of rhinitis between children born during different seasons. Multivariate analysis was performed with additional variables. RESULTS: The prevalence of rhinitis among the 1.1 million recruits was 7.1% in males and 5.3% in females. The association between birth season and the prevalence of rhinitis was highly significant (p < 0.001 for both genders). Spring was the birth season with the highest prevalence of rhinitis (7.4% in males and 5.5% in females). Males born in the winter and females born in the autumn had the lowest prevalence of rhinitis (6.7%, and 5.2% respectively). There was an increased odds ratio for rhinitis among those with a body mass index above 25, higher cognitive score and maternal birth country out of Israel or Africa. CONCLUSIONS: There was an increased risk of rhinitis among young Israeli adults who were born in the spring, were overweight and had a higher cognitive-score. Family planning to avoid a spring birth and preventing overweight may reduce the risk of chronic rhinitis.

"Stop & drop"- a modified "stop & chop" phacoemulsification technique for cataract surgery.

PURPOSE: To introduce a novel technique termed "stop and drop" for creating the first crack in the initial hemi-nucleus, eliminating the need to slip a chopper under the anterior capsular rim during horizontal chopping, hence lowering the risk of capsular or zonular damage. METHODS: Placing a blunt chopper tip on the upper surface of the hemisection proximal to the capsular edge and pressing it downward to initiate a crack in a pinching manoeuvre. Once a crack has formed, the chopper can slide to the side, widening the crack and assisting the phaco needle to pull out the first fragment. RESULTS: The technique was used in over 100 cases of cataracts successfully. No radial tear, posterior capsule rupture or zonulolysis occurred. CONCLUSIONS: "Stop and drop" is an effective and safe technique for performing phacoemulsification. It is not suitable for soft nuclei where the chopper will likely "cheese-wire" through the nuclear material.

Factors associated with resolution of childhood asthma by the age of 17: Large cohort analysis.

BACKGROUND: Many children with asthma will become asymptomatic during adolescence. In this study, we evaluated factors associated with recovery from asthma by the age of 17. METHODS: The medical records of 17-year-old conscripts to the Israeli army with asthma were compared with the records of conscripts with rigorously diagnosed resolved asthma. We assessed the association between the following parameters and asthma resolution: body mass index (BMI), recurrent rhinitis, birth season, socioeconomic level, and cognition. RESULTS: Sixty-eight thousand and ninety conscripts with active asthma were compared to 14,695 with resolved asthma. In univariate analysis, rhinitis, overweight, underweight, higher socioeconomic level, and lower cognitive score were associated with active asthma (p < 0.001 for both sexes), but not the season of birth. In multivariate analysis, only overweight, underweight, rhinitis, and lower cognitive score (p < 0.001 for both sexes) remained significantly associated with persistence of asthma. CONCLUSIONS: Although association does not prove causation, our finding is another reason to encourage adolescents with asthma to maintain a normal body weight. Prospective interventional studies are needed in order to decide whether changing weight to ensure BMI is within the ideal range and controlling rhinitis increases the odds of resolution of asthma in adolescence.

Reduced Activity and Quality of Life in Women Soldiers with Heavy Menstrual Bleeding and Dysmenorrhea.

STUDY OBJECTIVE: The aim of the study was to examine the effect of heavy menstrual bleeding (HMB) and dysmenorrhea on daily activity and quality of life (QoL) in young women engaged in demanding activities. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 422 Israeli women soldiers in combat and non-combat roles. INTERVENTIONS: Participants were asked to provide consent and to complete study questionnaires. MAIN OUTCOME MEASURES: A pictorial bleeding assessment chart (PBAC), visual analog scale (VAS), verbal multidimensional scoring system for assessment of dysmenorrhea, and approved Hebrew-translated age-appropriate Pediatric Quality of Life Inventory (PedsQL). RESULTS: HMB (PBAC >100) and severe HMB (PBAC >185) were demonstrated in 181 (50%) and 96 (26%) participants, respectively. A high PBAC score was recorded in 20% who answered "no" or "unknown" in the questionnaire on having HMB. Mild, moderate, and severe dysmenorrhea were demonstrated in 80 (21.5%), 115 (31%), and 142 (38%) participants, respectively. The prevalence of HMB and dysmenorrhea was similar in soldiers in combat and non-combat roles. Diagnosis of HMB was related to the lower fitness-for-service score, history of bleeding, and dysmenorrhea. Daily activity and QoL were both affected by the severity of HMB and dysmenorrhea. CONCLUSION: Underdiagnosis of HMB and dysmenorrhea results from a combination of unawareness from the women's side and inattention from the system. In an era of female empowerment, each woman should be at the optimal physiological and psychological level to start her career; thus, addressing the menstrual burden and providing effective treatment is needed in the military scenario and other settings with demanding activities.

Hemopneumothorax detection through the process of artificial evolution - a feasibility study.

BACKGROUND: Tension pneumothorax is one of the leading causes of preventable death on the battlefield. Current prehospital diagnosis relies on a subjective clinical impression complemented by a manual thoracic and respiratory examination. These techniques are not fully applicable in field conditions and on the battlefield, where situational and environmental factors may impair clinical capabilities. We aimed to assemble a device able to sample, analyze, and classify the unique acoustic signatures of pneumothorax and hemothorax. METHODS: Acoustic data was obtained with simultaneous use of two sensitive digital stethoscopes from the chest wall of an ex-vivo porcine model. Twelve second samples of acoustic data were obtained from the in-house assembled digital stethoscope system during mechanical ventilation. The thoracic cavity was injected with increasing volumes of 200, 400, 600, 800, and 1000 ml of air or saline to simulate pneumothorax and hemothorax, respectively. The data was analyzed using a multi-objective genetic algorithm that was used to develop an optimal mathematical detector through the process of artificial evolution, a cutting-edge approach in the artificial intelligence discipline. RESULTS: The in-house assembled dual digital stethoscope system and developed genetic algorithm achieved an accuracy, sensitivity and specificity ranging from 64 to 100%, 63 to 100%, and 63 to 100%, respectively, in classifying acoustic signal as associated with pneumothorax or hemothorax at fluid injection levels of 400 ml or more, and regardless of background noise. CONCLUSIONS: We present a novel, objective device for rapid diagnosis of potentially lethal thoracic injuries. With further optimization, such a device could provide real-time detection and monitoring of pneumothorax and hemothorax in battlefield conditions.

Medical Challenges in Underground Warfare.

INTRODUCTION: Throughout history, underground systems have served military purposes in both offensive and defensive tactical settings. With the advance of underground mining, combat tactics, and weapon systems, providing medical support in the subterranean battlefield is a constantly growing challenge. This retrospective cohort study describes the Israeli Defense Force (IDF) Medical Corps experience with treating casualties from underground warfare, as recorded in the IDF Trauma Registry. METHODS: A retrospective cohort study of all casualties engaged in underground warfare, between the years 2004-2018. Medical data were extracted from the IDF Trauma Registry and tactical data were obtained from operational reports. An expert committee characterized the most prevalent challenges. Recommendations were based on a literature review and the lessons learned by the IDF experience. RESULTS: During the study period, 26 casualties were injured in the underground terrain. Of casualties, 12 (46%) due to blast injuries, 9 (35%) were due to smoke inhalation, and 5 (19%) due to crushing injuries. All were males, and the average age was 21.6 years. Ten (38%) were killed in action (died before reaching a medical facility). All 16 casualties reaching the hospital survived (Table I). The expert committee divided the most common challenges into three categories-tactical, environmental, and medical. An overview of medical response planning, common injuries, and designated combat casualty care are discussed below. As in all combat casualty care, the focus should be on safety, bleeding control, and rapid evacuation. CONCLUSION: To plan and provide medical support, a thorough understanding of operational planning is essential. This manuscript presents the evolution of underground warfare, tactical and medical implications, environmental hazards, and common casualty care challenges.

Vildagliptin vs. insulin treatment alone in diabetic acute coronary syndrome patients.

BACKGROUND: Vildagliptin, an oral antidiabetic of the dipeptidyl peptidase-4 (DPP-4) inhibitor drugs, exhibits an overall low risk of hypoglycemia with less frequent hypoglycemic events in type 2 diabetes mellitus (T2DM) patients than other antidiabetic drugs. We hypothesized that among hospitalized acute coronary syndrome (ACS) patients, the addition of vildagliptin to subcutaneous insulin therapy would reduce the risk of hypoglycemic events. METHODS: One hundred ACS T2DM adult patients naive to DPP-4 inhibitors were enrolled during admission to the ICCU. Patients were divided into two randomized controlled groups: a subcutaneous rapid-acting insulin-only therapy group and an oral vildagliptin plus subcutaneous insulin group. The trial was open label with no placebo arm. Mean glucose values, insulin values given for correction per hospitalization, and the number of hypoglycemic events (glucose < 70 mg/dL) were documented. RESULTS: Eight hypoglycemia events occurred in the insulin-only group and none in the insulin plus DPP-4 inhibitor group (P < 0.001). Patients with acute myocardial infarction experienced a higher number of hypoglycemic events compared with unstable angina diagnosed patients. No significant differences were found regarding glucose level (P = 0.462) and administered insulin units (P = 0.639). CONCLUSIONS: In T2DM patients, the addition of DPP-4 inhibitors to routine subcutaneous insulin therapy may significantly reduce hypoglycemic events while maintaining acceptable recommended ranges of glucose. Further studies on a larger scale are required to verify these results and to support that DPP-4 inhibitors added to today's standard insulin-only treatment in hospitalized diabetic ACS patients may improve overall glycemic control and provide a potential treatment option in this challenging clinical setting.

Telemedicine in ophthalmology in view of the emerging COVID-19 outbreak.

PURPOSE: Technological advances in recent years have resulted in the development and implementation of various modalities and techniques enabling medical professionals to remotely diagnose and treat numerous medical conditions in diverse medical fields, including ophthalmology. Patients who require prolonged isolation until recovery, such as those who suffer from COVID-19, present multiple therapeutic dilemmas to their caregivers. Therefore, utilizing remote care in the daily workflow would be a valuable tool for the diagnosis and treatment of acute and chronic ocular conditions in this challenging clinical setting. Our aim is to review the latest technological and methodical advances in teleophthalmology and highlight their implementation in screening and managing various ocular conditions. We present them as well as potential diagnostic and treatment applications in view of the recent SARS-CoV-2 virus outbreak. METHODS: A computerized search from January 2017 up to March 2020 of the online electronic database PubMed was performed, using the following search strings: "telemedicine," "telehealth," and "ophthalmology." More generalized complementary contemporary research data regarding the COVID-19 pandemic was also obtained from the PubMed database. RESULTS: A total of 312 records, including COVID-19-focused studies, were initially identified. After exclusion of non-relevant, non-English, and duplicate studies, a total of 138 records were found eligible. Ninety records were included in the final qualitative analysis. CONCLUSION: Teleophthalmology is an effective screening and management tool for a range of adult and pediatric acute and chronic ocular conditions. It is mostly utilized in screening of retinal conditions such as retinopathy of prematurity, diabetic retinopathy, and age-related macular degeneration; in diagnosing anterior segment condition; and in managing glaucoma. With improvements in image processing, and better integration of the patient's medical record, teleophthalmology should become a more accepted modality, all the more so in circumstances where social distancing is inflicted upon us.

Adolescent obesity and midlife cancer risk: a population-based cohort study of 2·3 million adolescents in Israel.

BACKGROUND: Obesity has been established as a causal factor for several types of cancer, and adolescent obesity is increasing worldwide. We examined associations between measured body-mass index (BMI) at age 17 years and cancer incidence, and with mortality among those who developed cancer. METHODS: In a nationwide, population-based cohort of adolescents, height and weight were measured at pre-recruitment mandatory medical examination during 1967-2010. BMI was classified according to US Center for Disease Control and Prevention percentiles. We applied Cox proportional hazard models to estimate the hazard ratios (HRs) and 95% CIs for incident cases of cancer using the 5th-49th BMI percentile group as a reference. The primary outcome was any cancer diagnosis between Jan 1, 1967, and Dec 31, 2012, as recorded in the Israeli National Cancer Registry. Participants with a diagnosis of cancer at baseline (before military recruitment assessment) were excluded from this analysis. The secondary outcome of this study was all-cause mortality among cohort members who had cancer, between Jan 1, 1967, and Dec 31, 2017. FINDINGS: Of the 2 458 170 participants examined between Jan 1, 1967, and Dec 31, 2010, 160 040 were excluded. 2 298 130 participants of which 928 110 were women and 1 370 020 were men. During 29 542 735 person-years of follow-up in men, 26 353 incident cases of cancer were recorded and in 18 044 863 person-years of follow-up in women, 29 488 incident cases of cancer were recorded. Cancer incidence increased gradually across BMI percentiles. The adjusted HR was 1·26 (95% CI 1·18-1·35) among men with adolescent obesity. Among women, we found no association between obesity and overall cancer, driven by inverse associations of obesity with cervical and breast cancers. When these cancers were excluded, the adjusted HR for cancer was 1·27 (1·13-1·44) among women with adolescent obesity. In both sexes, high BMI (≥85th percentile) was associated with an increased cancer risk after 10 years. This association was accentuated in the late period of the cohort versus the early period of the cohort. BMI was positively associated with a higher risk of mortality. The projected population attributable risk for high BMI was 5·1% (4·2-6·1) for men and 5·7% (4·2-7·3) for women. INTERPRETATION: The increasing prevalence of adolescent obesity and the possible association between adolescent BMI and cancer incidence might increase the future burden of obesity-related cancers. BMI among adolescents could constitute an important intervention target for cancer prevention. FUNDING: None.

Does birth season influence the odds for asthma? Large cohort analysis.

BACKGROUND AND OBJECTIVE: Few studies have examined the possibility of a link between birth season and the risk for asthma. Those studies that mainly focused on young children, reached different conclusions regarding both the existence of such a link and the season with the highest risk. The purpose of this study was to reinvestigate the relationship between birth season and asthma in a very large cohort, larger than in all previous studies, focusing on adolescents. METHODS: The medical records of consecutive 17-year-old conscripts, born between 1978 and 1999, undergoing medical evaluation before their military service, were reviewed. The prevalence of asthma among conscripts was calculated according to the season of birth. RESULTS: Data from 6 26 460 males and 4 54 104 females were collected. Asthma prevalence was 6.6% of the males and 5.8% of the females. Asthma prevalence was highest among those born in the summer and was approximately 9% higher in women and 6% higher in men than those born in the winter. Those born in the winter had the lowest prevalence of asthma. June was the birth month with the highest prevalence of asthma in both genders together with September among males. CONCLUSIONS: Being born in the summer, especially in June, is associated with an increased risk of asthma compared with a winter birth among Israeli army conscripts. Further research is required to determine the impact of the season of birth on the risk of asthma in higher risk populations.

Implementation of Lean and Six Sigma principles in ophthalmology for improving quality of care and patient flow.

Lean management is a set of principles aimed at improving processes by identifying and eliminating steps that do not add value to the consumer. Such steps lead to wasted time, resources, and expenses and result in customer and employee dissatisfaction. Although initially invented and perfected for factory assembly lines in the automobile industry, it has since disseminated extensively and has repeatedly proven a powerful "engine" for improving quality and quantity in the health-care setting. Lean implementation benefits include improved safety, reduced waiting times, increased patient satisfaction, and cost reduction. Nevertheless, it appears to be less familiar and appreciated in ophthalmology and more specifically as a tool for managing an efficient eye care clinic. In this review, we explain what "Lean" and Six Sigma are and highlight their implementation in settings such as cataract surgery, laser capsulotomy, an ophthalmic emergency room and its role as a powerful tool for improving clinic patient flow. We discuss basic principles of Lean management, review examples of implementing these principles in an ophthalmology practice, and finally, offer physicians practical tools for identifying "wasteful" processes and ways to eliminate them.

Implementations of 3D printing in ophthalmology.

PURPOSE: The purpose of this paper is to provide an in-depth understanding of how to best utilize 3D printing in medicine, and more particularly in ophthalmology in order to enhance the clinicians' ability to provide out-of-the-box solutions for unusual challenges that require patient personalization. In this review, we discuss the main applications of 3D printing for diseases of the anterior and posterior segments of the eye and discuss their current status and implementation. We aim to raise awareness among ophthalmologists and report current and future developments. METHODS: A computerized search from inception up to 2018 of the online electronic database PubMed was performed, using the following search strings: "3D," "printing," "ophthalmology," and "bioprinting." Additional data was extracted from relevant websites. The reference list in each relevant article was analyzed for additional relevant publications. RESULTS: 3D printing first appeared three decades ago. Nevertheless, the implementation and utilization of this technology in healthcare became prominent only in the last 5 years. 3D printing applications in ophthalmology are vast, including organ fabrication, medical devices, production of customized prosthetics, patient-tailored implants, and production of anatomical models for surgical planning and educational purposes. CONCLUSIONS: The potential applications of 3D printing in ophthalmology are extensive. 3D printing enables cost-effective design and production of instruments that aid in early detection of common ocular conditions, diagnostic and therapeutic devices built specifically for individual patients, 3D-printed contact lenses and intraocular implants, models that assist in surgery planning and improve patient and medical staff education, and more. Advances in bioprinting appears to be the future of 3D printing in healthcare in general, and in ophthalmology in particular, with the emerging possibility of printing viable tissues and ultimately the creation of a functioning cornea, and later retina. It is expected that the various applications of 3D printing in ophthalmology will become part of mainstream medicine.

The Impact of Childhood and Adolescent Obesity on Cardiovascular Risk in Adulthood: a Systematic Review.

PURPOSE OF REVIEW: Adult obesity and cardiovascular diseases are closely linked. Yet, the relationship of childhood and adolescent obesities with cardiovascular diseases in adulthood requires additional evidence. The goal of the review is to inspect the relationship between childhood- and adolescent-increased body mass index (BMI) and cardiovascular risk factors, fatal and non-fatal cardiovascular diseases in adulthood. RECENT FINDINGS: Cardiovascular diseases in adulthood are linked by most of the studies to childhood and adolescent obesities. Studies showed that childhood and adolescent obesities increased the incidence of cardiovascular disease risk factors and were linked to higher risk of cardiovascular morbidity and mortality in adulthood. Childhood and adolescent obesities were also associated, likely with a causal relationship, with an increased likelihood for various cardiovascular morbidities including ischemic heart disease, stroke, but also non-ischemic heart disease-related cardiac pathologies.

Profile of Patients Presenting for Cataract Surgery in a Public Hospital: A 15 Year Perspective.

BACKGROUND: In recent decades cataract surgery has shifted slowly from public hospitals to ambulatory surgery centers, demonstrating changes in the profile of patients presenting to public hospitals for cataract surgery. These changes may potentially affect the complexity of surgeries, their volume, resident training, and perhaps also visual outcomes and patient satisfaction. OBJECTIVES: To assess the changes in the medical and demographic characteristics of patients undergoing cataract surgery in a public hospital over a period of 15 years. METHODS: We retrospectively reviewed the records of patients undergoing preoperative assessment before cataract surgery. Records for the period October 2000 to January 2001 (100 patients), October 2006 to January 2007 (100 patients), and October 2013 to January 2014 (150 patients) were assessed for demographic, systemic and ocular related parameters. RESULTS: There was a significant increase in the average age of patients (70.4, 72.4, 73.9 years, P = 0.026), with a significant increase in the percentage of patients of Arab ethnicity (17%, 11%, 28.7%, P = 0.002), and concomitant systemic co-morbidities (38%, 46%, 64.7%, P < 0.0001). There was an increase in the percentage of patients with narrow palpebral fissures (0%, 2%, 8%, P = 0.003), deep-set eyes (2%, 4%, 18%, P < 0.0001), dense nuclear sclerotic cataract (38%, 34.4%, 56.9%, P = 0.001), and a significant increase in the percentage of patients taking alpha-blocking medications (0%, 8%, 10.7 %, P = 0.004). CONCLUSIONS: Patients presenting for cataract surgery in 2013 compared to those in earlier periods are older, sicker and have more ocular conditions potentially affecting cataract surgery outcomes, patient satisfaction and residents' training.

Intralesional cryosurgery for the treatment of basal cell carcinoma of the lower extremities in elderly subjects: a feasibility study.

BACKGROUND: Incidences of basal cell carcinoma (BCC) on the lower extremities in elderly patients are rising. Surgical approaches to the treatment of BCC are subject to possible difficulties in healing, failure of skin grafts, and wound infection. This study assessed the efficacy of intralesional cryosurgery in the treatment of BCC of the lower limbs in elderly patients. METHODS: This study included eight patients aged >60 years in whom a total of 10 nodular or superficial BCCs of the lower limbs were confirmed by biopsy. The patients' medical histories revealed comorbidities including hypertension, diabetes, hypercholesterolemia, venous insufficiency, and deep vein thrombosis of the legs, congestive heart failure, chronic renal failure, and ischemic heart disease. Using liquid nitrogen, an intralesional cryosurgery needle (CryoShape) was inserted into the tumor to facilitate its complete freezing. Treatment success was confirmed by biopsy taken approximately 3 months after complete healing of the cryo-wound. RESULTS: The average size of the lesions treated was 2.49 cm(2) (16.4 × 15.2 mm). Mean recovery time was 79.9 days. Biopsies were obtained at a mean of 85.3 days after the wound had healed. All 10 biopsies verified the complete destruction of the tumor. There was no evidence of wound infection or tumor recurrence over a follow-up period of 28 months. CONCLUSIONS: This study demonstrates that a single intralesional cryosurgery session can completely eradicate BCC on the lower extremities in elderly patients. This technique is associated with relatively minor complications, is well tolerated, and represents a safe and effective therapeutic modality for BCC of the lower limbs.