Alina Vodonos

Autoimmune hepatitis in southern Israel: A 15-year multicenter study

In this study we aimed to assess the incidence, prevalence and clinical outcomes of patients with autoimmune hepatitis (AIH) in southern Israel.

Primary biliary cirrhosis in Southern Israel: a 20 year follow up study.

BACKGROUND The epidemiology of primary biliary cirrhosis (PBC) in Israel is unknown. We aimed to determine the epidemiology, long-term survival and outcomes of PBC in Southern Israel from 1990 to 2010. METHODS Case-finding methods and population-based administrative data were used to estimate and evaluate the incidence, prevalence and prognostic factors of outcome in our PBC cohort. RESULTS 138 cases of PBC were identified. The average annual prevalence of PBC was 255 cases per million. The overall age/sex-adjusted annual incidence of PBC was 10 cases per million from 1990 through 1999 and 20 cases per million from 2000 to 2010. Among 138 incident cases with a total follow-up of 960 persons-years from diagnosis, 30 patients (21.7%) died. Survival in PBC patients was significantly lower than that of the age/sex-matched Israeli population. Mortality was significantly increased in patients with an initial MELD score greater than 8 (P<0.001), with portal hypertension (P<0.001), and in non-responders to ursodeoxycholic acid (UDCA) therapy according to Barcelona criteria (P=0.005). Out of 138 patients, 95 patients (68.0%) responded to UDCA therapy according to Barcelona and Paris criteria. None of the responders died during the follow-up period as opposed to 30 out of 43 (69.8%) of non-responders. In multivariate analysis the factors associated with response to UDCA were: albumin levels above 3.5 g/dL (P<0.001) and lower degree of fibrosis per liver biopsy (P=0.003). CONCLUSIONS This study addresses the increasing burden of PBC in Israel and confirms the importance of some clinical and therapeutic factors as predictors of long-term prognosis.

The impact of exposure to particulate air pollution from non-anthropogenic sources on hospital admissions due to pneumonia.

Community-acquired pneumonia is a significant cause of morbidity and mortality among older adults [1]. The role of air pollution as a risk factor for pneumonia hospitalisations and mortality has been investigated [2, 3] with most evidence coming from studies in North American and European cities, where anthropogenic sources are predominant in generating air pollution. Natural particulate matter linked to hospitalisation for pneumonia, particularly in older or cardiac patients http://ow.ly/ct4T303L4QP

The impact of PCR on Clostridium difficile detection and clinical outcomes.

PCR has increasingly replaced toxin A and B enzyme immunoassay (EIA) for the testing of Clostridium difficile infection (CDI). This study evaluated the clinical outcomes of CDI and disease epidemiology since the introduction of PCR. Clinical data and outcomes for patients admitted to a tertiary care centre during 2003 to 2012 were extracted using electronic medical records. Outcomes and incidence of disease were compared between types of CDI testing. In total, 15.6% of 108,092 patients admitted were tested for CDI. Among patients tested, 6.1% had positive results. The mean number of tests performed per 1000 admissions by EIA and PCR was 257.4 and 162.6, respectively. A total of 8.2% of PCR tests were positive compared to 5.0% of EIA tests (P < 0.001). The number of tests performed has decreased and the proportion of positive tests increased since PCR introduction. CDI incidence has remained constant. Only albumin (3.09 vs 3.24 g dl(-1), P 0.002) and inflammatory bowel disease (2.6 vs 7.0%, P < 0.001) status differed between the EIA and PCR groups. While hospital mortality did not differ, patients diagnosed by PCR had a shorter median length of stay (10 vs 8 days, P 0.004). Since PCR testing began, less CDI tests have been performed, but the proportion of positive results has increased. The incidence of CDI has remained constant, suggesting no change in disease epidemiology. The length of stay was shorter in the PCR group, reflective of either earlier detection and quicker onset of therapy or detection of less severe disease. Mortality did not change since the introduction of PCR.

Prognostic Value of Myocardial Ischemic Electrocardiographic Response in Patients With Normal Stress Echocardiographic Study

The prognostic value of ST-segment depression on exercise electrocardiogram (eECG) in the setting of a normal wall motion response in a stress echocardiographic study is not well defined. The aim of the study was to compare outcomes among patients with normal wall motion during stress echocardiography with and without ischemic exercise electrocardiographic changes. A total of 4,233 patients underwent stress echocardiography from 2007 to 2010. The primary outcomes were a composite of all-cause mortality and myocardial infarction. Coronary revascularization was a secondary outcome. A Cox regression model was used for the primary analysis. Ischemic exercise electrocardiographic changes were defined as ST-segment depression of at least 1 mm, on at least 3 consecutive beats, and in at least 2 contiguous leads. A normal stress echocardiogram was present in 2,975 patients; of them, 2,228 (74%) had a normal eECG and 747 (26%) had ischemic changes on eECG. Patients with and without ischemic changes during exercise electrocardiography were similar in age and gender. At 4-years follow-up, 36 patients (2.8%) with a normal eECG experienced a primary end point versus 12 patients (1.9%) in the group with an ischemic exercise electrocardiographic response (p = 0.56). The rate of coronary revascularization was similar between the groups (7.0% and 5.7%, respectively, p = 0.2). There were no differences in the primary outcomes of patients with and without exercise electrocardiographic changes and normal stress echocardiogram (hazard ratio 1.33, 95% confidence interval 0.69 to 2.58). In conclusion, a normal wall motion response even in the setting of an ischemic exercise electrocardiographic response portends a benign prognosis in patients undergoing stress echocardiography.

Performance of risk stratification criteria in the management of febrile young infants younger than three months of age

We evaluated the diagnosis, risk stratification and management of febrile infants under three months of age who presented to an Israeli paediatric emergency room (ER).

The Combined Effect of High Ambient Temperature and Antihypertensive Treatment on Renal Function in Hospitalized Elderly Patients

Background The aging kidney manifests structural, functional as well as pharmacological changes, rendering elderly patients more susceptible to adverse environmental influences on their health, dehydration in particular. Hypothesis Higher temperature is associated with renal function impairment in patients 65 years and older who routinely take thiazide and/or ACE-inhibitors/ARBs. Methods We obtained health data of patients older than 65 who were admitted to a large tertiary center during the years 2006–2011, with a previous diagnosis of hypertension, and treated with thiazide, ACE-inhibitors/ARBs or both. We collected environmental data of daily temperature, available from collaborative public and governmental institutions. In order to estimate the effect of daily temperature on renal function we performed linear mixed models, separately for each treatment group and creatinine change during hospital admission. Results We identified 26,286 admissions for 14, 268 patients with a mean age of 75.6 (±6.9) years, of whom 53.6% were men. Increment in daily temperature on admission of 5°C had significant effect on creatinine increase in the no treatment (baseline creatinine adjusted 0.824 mg/dL, % change 1.212, % change 95% C.I 0.082–2.354) and dual treatment groups (baseline creatinine adjusted 1.032mg/dL, % change 3.440, % change 95% C.I 1.227–5.700). Sub-analysis stratified by advanced age, chronic kidney disease and primary diagnosis on hospital admission, revealed a significant association within patients admitted due to acute infection and treated with dual therapy. Conclusion Whereas previous studies analyzed sporadic climate effects during heat waves and/or excluded older population taking anti-hypertensive medications, the present study is novel by showing a durable association of temperature and decreased renal function specifically in elderly patients taking anti-hypertensive medications.

Pediatric chronic kidney disease rates in Southern Israel are higher than reported

Background: The incidence and prevalence of pediatric chronic kidney disease (p-CKD) in developed countries has previously been estimated to be 12 and 75 cases/10 6 population respectively, much lower than reports in young adults (age 20-40) (40,000/10 6). Thus, the extent of p-CKD may be underestimated. Methods: Being the only Pediatric Nephrology center in Southern Israel, we reviewed all detected cases of p-CKD (stages 1-5) between 1994-2008. We then prospectively summarized the incidence and prevalence of CKD between 2009-2010. Results: We retrospectively identified 192 children (53.9% of Bedouin origin, 53.4% males, median diagnosis age: 1 year) with CKD. The prevalence in December 2008 was 795 cases/10 6 for all CKD stages and 331/10 6 for CKD stage >2. Calculated incidence for the study period (1994-2008) was 46/10 6/year. The main CKD etiologies were: hypodysplasia: 35%; obstructive uropathy: 13%; genetic renal diseases: 28% and glomerulonephritis: 15%. The proportions of children in each CKD stage were as follows: stage 1: 50%; stages 2-4: 30%; stage 5: 20%. During a subsequent two-year study period we identified 26 new CKD cases (incidence: 54 cases/10 6/year). Conclusions: p-CKD rates in our area are higher than reported and maybe even higher if asymptomatic populations are screened. Fifty percent of detected cases have CKD stage 1. This may contribute significantly to CKD beyond the pediatric age.

Ethnicity and sepsis characteristics and outcomes. Population based study

BACKGROUND Two distinct ethnic groups live in Southern Israel: urban Jews and rural Bedouin Arabs. These groups differ in their socioeconomic status, culture and living environment, and are treated in a single regional tertiary care hospital. We hypothesized that these two ethnic groups have different patterns of sepsis-related intensive care admissions. METHODS The study included all adult patients admitted to the Soroka University Medical Center Intensive Care Units between January 2002 and December 2008, with a diagnosis of sepsis. Demographic data, medical history, and hospitalization and outcomes data were obtained. Primary outcome was all-cause mortality. RESULTS Jewish patients admitted to the ICU (1343, 87%) were on average 17 years older than Bedouin Arabs (199, 13%). For the population <65 years, Bedouin Arabs had slightly higher age-adjusted prevalence of ICU sepsis admissions than Jewish patients (39.5 vs. 43.0, p=0.25), while for the population >65 years there was a reverse trend (21.8 vs. 19.8 p=0.49). There were no differences in the type of organ failure, sepsis severity or length of hospitalization between the two groups. Twenty eight days/in-hospital mortality was 33.9% in Bedouin Arabs vs. 45.5% in Jews, p=0.004. Following adjustment for comorbidities, age and severity of the disease, survival was unrelated to ethnicity, both at 28 days (odds ratio for Bedouin Arabs 0.86, 95% CI 0.66-1.24) and following hospital discharge (hazard ratio 0.86, 95% 0.67-1.09). CONCLUSIONS Sepsis-related ICU admissions are more prevalent among Bedouin Arabs at younger age compared with the Jewish population. Adjusted for confounders, ethnicity does not influence prognosis.