Yoram Chaiter

Persistent Asymptomatic Isolated Microscopic Hematuria in Israeli Adolescents and Young Adults and Risk for End-Stage Renal Disease

CONTEXT Few data are available on long-term outcomes among adolescents and young adults with persistent asymptomatic isolated microscopic hematuria. OBJECTIVE To evaluate the risk of end-stage renal disease (ESRD) in adolescents and young adults with persistent asymptomatic isolated microscopic hematuria. DESIGN, SETTING, AND PARTICIPANTS Nationwide, population-based, retrospective cohort study using medical data from 1,203,626 persons aged 16 through 25 years (60% male) examined for fitness for military service between 1975 and 1997 were linked to the Israeli treated ESRD registry. Incident cases of treated ESRD from January 1, 1980, to May 31, 2010, were included. Cox proportional hazards models were used to estimate the hazard ratio (HR) of treated ESRD among those diagnosed as having persistent asymptomatic isolated microscopic hematuria. MAIN OUTCOME MEASURES Treated ESRD onset, defined as the date of initiation of dialysis treatment or the date of renal transplantation, whichever came first. RESULTS Persistent asymptomatic isolated microscopic hematuria was diagnosed in 3690 of 1,203,626 eligible individuals (0.3%). During 21.88 (SD, 6.74) years of follow-up, treated ESRD developed in 26 individuals (0.70%) with and 539 (0.045%) without persistent asymptomatic isolated microscopic hematuria, yielding incidence rates of 34.0 and 2.05 per 100,000 person-years, respectively, and a crude HR of 19.5 (95% confidence interval [CI], 13.1-28.9). A multivariate model adjusted for age, sex, paternal country of origin, year of enrollment, body mass index, and blood pressure at baseline did not substantially alter the risk associated with persistent asymptomatic isolated microscopic hematuria (HR, 18.5 [95% CI, 12.4-27.6]). A substantially increased risk for treated ESRD attributed to primary glomerular disease was found for individuals with persistent asymptomatic isolated microscopic hematuria compared with those without the condition (incidence rates, 19.6 vs 0.55 per 100,000 person-years, respectively; HR, 32.4 [95% CI, 18.9-55.7]). The fraction of treated ESRD attributed to microscopic hematuria was 4.3% (95% CI, 2.9%-6.4%). CONCLUSION Presence of persistent asymptomatic isolated microscopic hematuria in persons aged 16 through 25 years was associated with significantly increased risk of treated ESRD for a period of 22 years, although the incidence and absolute risk remain quite low.

Adolescent BMI at Northern Israel: From Trends, to Associated Variables and Comorbidities, and to Medical Signatures.

AbstractThe increasing prevalence of abnormal body mass index (BMI), mainly obesity, is becoming a significant public health problem. This cross-sectional study aimed to provide a comprehensive view of secular trends of BMI, and the associated socio-demographic variables and comorbidities among adolescents with abnormal BMI. Individuals of the study population were born mainly between 1970 and 1993, and were examined at 16 to 19 years of age during the years 1987 to 2010, at 1 conscription center in the northern district of Israel.The study population included 113,694 adolescents. Univariate and multivariable logistic regression models were used to investigate the associations between BMI categories, socio-demographic variables, and medical conditions.A downward trend in the prevalence of normal BMI among both male and female adolescents was obtained, while trends of overweight and obesity (in both genders) and underweight (only among females) rose. Socio-demographic variables such as religion, education, family-related parameters, residential environment, country of birth, and origin were all associated with different risks for abnormal BMI. Obesity was associated with higher risk for hyperlipidemia, endocrine disorders (only in males), knee disorders, and hypertension type I + II (in both genders). Overweight was associated with knee disorders (only in females). Underweight, exclusively in males, was associated with increased risk for endocrine disorders, proteinuria, and cardiac disorders. Hierarchical clustering analysis revealed the intricate relations between gender, BMI, and medical signatures. It brought to light novel clusters of diseases that were abundant among populations having above-normal BMI or underweight males. Furthermore, above-normal BMI was associated with a lower rate of cardiac anomalies and scoliosis/kyphosis, whereas being underweight was associated with a lower risk for hypertension and flat foot.This study provides a reliable and in-depth view of secular trends in height, weight, and BMI of male and female adolescents. It supports previous associations between abnormal BMI and demographic variables and comorbidities, while uncovering novel associations, mainly regarding medical signatures of each gender–BMI group. This might lead to better monitoring, early detection, prevention, and treatment of various conditions associated to abnormal BMI categories and gender groups.

Coordinated computerized systems aimed at management, control, and quality assurance of medical processes and informatics.

PURPOSE As part of the routine work of the medical committees in the Israel Defense Forces, a unique nationwide computerized control system is being implemented to assess and manage medical processes. The purpose of this paper is to report on that implementation. DESIGN/METHODOLOGY/APPROACH The computerized system consists of three main components: a specific status indicating the processes in each file, an appointment system, and an internal computerized system that uses a magnetic card for the regulation of the local waiting lists. FINDINGS The combined computerized system improves the control and management of the medical processes and informatics from the point-of-view of both the patients and system operators. Different parameters of quality control regarding the medical and administrative processes are assessed (such as efficiency), and solutions are sought. Computerized system-based design and re-allocation of human and medical resources were implemented according to the capacities and limitations of the medical system. A reduction in the daily number of invited recruits improved the quality of the medical encounters. Specific combined status codes were introduced for the efficient planning of the medical encounters. Implementation and automation of medical regulations and procedures within the computerized system make the latter play a key role and serve as a control tool during the decision-making process. ORIGINALITY/VALUE The computerized system allows efficient follow-up and management of medical processes and informatics, led to a better utilization of human and medical resources, and becomes a component of the decision making by the system operators and the administrative staff. Such a system could be used with success in clinics, hospitals, and other medical facilities.

From a Quality Assurance and Control System for Medical Processes, Through Epidemiological Trends of Medical Conditions, to a Nationwide Health Project

Yossy Machluf1,2, Amir Navon1, Avi Yona1, Avinoam Pirogovsky1,3, Elio Palma1,4, Orna Tal5, Nachman Ash6, Avi Cohen1 and Yoram Chaiter1 1Quality Assurance and Control Committee, Medical Corps, IDF, 2Weizmann Institute of Science, Rehovot, 3Head of Standards and Regulation Department in the Division of Community Medicine, Ministry of Health, Tel Aviv, 4Head of Department of Occupational Medicine, Clalit Health Services, Afula, 5Israeli Center for Technology Assessment in Health Care; The Gertner Institute for Epidemiology and Health Policy Research, Head of Emerging Technologies Unit, Tel Aviv, 6Chief Medical Officer, Medical Corps, IDF, Israel

Asthma severity and heterogeneity: Insights from prevalence trends and associated demographic variables and anthropometric indices among Israeli adolescents

ABSTRACT Objectives: While asthma presents various clinical forms with different levels of severity, it is unclear whether asthma severities are a consequence of disease management or varied etiologies. We sought to investigate this question. Methods: This paper presents a cross-sectional study of 113,671 Israeli adolescents. Prevalence rates of mild and moderate-to-severe asthma over a 24-year period were calculated and multivariate regression models (outcomes: different asthma severity, reference: subjects without asthma) were performed to analyze associations with anthropometric indices and socio-demographic variables, in males and females separately. Results: The prevalence of mild asthma increased until birth years 1976–1980 and then steadily decreased. In contrast, the prevalence of moderate-to-severe asthma was relatively stable until birth years 1976–1980, then rose steeply until 1986–1990 and subsequently plateaued in the early 1990s. Obesity was positively associated with both mild and moderate-to-severe asthma in males (Odds Ratio (OR) [95%CIs]: 1.61 [1.37–1.89] and 1.63 [1.34–1.98], respectively) and females (1.54 [1.10–2.16] and 1.54 [1.20–1.98], respectively). Family size greater than three siblings was negatively associated with both mild and moderate-to-severe asthma in males (0.62 [0.56–0.68] and 0.59 [0.52–0.68]) and females (0.71 [0.60–0.83] and 0.73 [0.63–0.83]). In contrast, in males, underweight was only associated with mild asthma (1.54 [1.22–1.94]) but not with moderate-to-severe asthma. In females, overweight was only associated with moderate-to-severe asthma (1.21 [1.00–1.46]) and rural residence was only associated with mild asthma (1.26 [1.09–1.47]). Conclusions: The differences between mild and moderate-to-severe asthma enhance asthma phenotype characterization, with respect to secular trends and associated variables, and indicate varied etiologies.

Amblyopia and strabismus: trends in prevalence and risk factors among young adults in Israel

Aims To estimate the prevalence of amblyopia, present strabismus and amblyopia risk factors (ARFs) among young adults in Israel and to analyse trends over time of prevalence rates. Methods We conducted a cross-sectional study including 107 608 pre-enlistees aged 17.4±0.6 years born between 1971 and 1994. Across the birth years, the following trends of prevalence rates among young adults were analysed: prevalence of amblyopia, prevalence of strabismus, severity of amblyopia and prevalence of ARFs (strabismsus, anisometropia and isoametropia). Unilateral amblyopia was defined as best corrected visual acuity (BCVA) of <0.67 (6/9) in either eye or as an interocular difference of two lines or more. Bilateral amblyopia was defined as BCVA of <0.67 (6/9) in both eyes. The severity of amblyopia was classified as mild (BCVA ≥0.5 [6/12]), moderate (BCVA <0.5 [6/12] and ≥0.25 [6/24]) or severe (BCVA <0.25 [6/24]). Results The prevalence of young adulthood amblyopia declined by 33%, from 1.2% to 0.8% (R2=0.87, p<0.001) across 24 birth years. This decline may be due to a drop in unilateral amblyopia from 1% to 0.6% (R2=0.93, p<0.001), while the prevalence of bilateral amblyopia remained stable (0.2%, p=0.12). The decline in amblyopia was apparent in mild and moderate amblyopia, but not in severe amblyopia. Strabismus and anisometropia were detected in 6–12% and 11–20% of subjects with unilateral amblyopia, respectively, without significant trends. Strabismic amblyopia remained constant in the entire population across years. Isoametropia was detected in 46–59% of subjects with bilateral amblyopia without a significant trend across birth years. Prevalence of strabismus in the study population decreased by 50%, from 1.2% to 0.6% (R2=0.75, p<0.001). In subjects with present strabismus, the prevalence of mild unilateral amblyopia increased, while moderate or severe unilateral amblyopia remained relatively stable. Conclusion Among young adults, the prevalence of unilateral amblyopia, as well as the prevalence of present strabismus, decreased significantly over a period of a generation. The prevalence of strabismic, bilateral or severe (both unilateral and bilateral) amblyopia remained stable. The establishment of the national screening programme for children and the improved utility of treatment for amblyopia and strabismus coincide with these trends. Thus, it is possible that these early interventions resulted in modification of the ‘natural history’ of these conditions and their prevalence in adolescence.

Cardiac anomalies and associated comorbidities in a large adolescent population

Abstract Objective: To determine the prevalence, secular trends and associations of heart disease in a large unscreened, otherwise basically healthy, adolescent population. Subjects and methods: Cross-sectional study of the cardiac status of 113,694 adolescents from the northern district of Israel, who completed the profiling process between the ages of 16 and 19, including all essential measures over a 22-year period. Results of imaging were categorized as either isolated valvar or structural abnormalities, and their clinically significant subgroups defined prospectively. The findings were correlated with the socio-demographic and anthropometric data and non-cardiac health conditions. Results: Of those sent for echocardiography, 1257 (0.93% of the total population) had isolated valvar disease and 216 (0.19%) had structural abnormalities, with 20% of both groups considered significant. Females had lower prevalence of heart disease. There was peak prevalence in the second 5-year period. Tall subjects or a past history of rheumatic fever had more valvar abnormalities. Thin subjects or those with skeletal anomalies had more structural abnormalities. Significant valvar and structural anomalies were more common in subjects with learning disorders, endocrine disorders and diabetes mellitus. Fewer valvar abnormalities were diagnosed in obese subjects. Heart disease was more common in those with non-solid tumors. Conclusion: Appreciable numbers of potentially healthy adolescents were found to have heart disease. There appeared to be an association with body size, skeletal abnormalities and relatively common medical disorders, the cause of which remains to be determined in prospective studies that could change the way common adolescent disease should be followed.

Valvular Heart Disease in a Young Israeli Ethiopian Immigrant Population From the Gondar Region With Implications for Rheumatic Heart Disease

Background Rheumatic heart disease (RHD) among Ethiopian school children was recently found to be 1.4%. Immigration of the Jewish population from the Gondar region to Israel created an opportunity for further enquiry. Methods A cross-sectional study of the cardiac status of 113,671 adolescent recruits aged 16–19 years from the northern district of Israel who completed the medical profiling process over a 22-year period. Results 140 recruits had a history of rheumatic fever (0.12%), although none from an Ethiopian origin (n = 1,719). The prevalence of valvular heart disease clinically and confirmed echocardiographically in Ethiopian recruits was not different from the total population (0.81 and 0.93%, respectively). However, the prevalence was higher in those migrating to Israel in their 13th year or older (2.09%), compared to those migrating at a younger age or born in Israel (0.49%). Conclusion The Ethiopian teenage Israeli population from Gondar had a high rate of auscultation positive and echocardiographically confirmed valvular disease that suggested a high rate of RHD (~1.6%), despite no relevant past history. Our findings also suggested that for the younger Ethiopian immigrants or Israeli born subjects of Ethiopian origin, the improved medical care may well reduce the prevalence of valvular heart disease to that of the rest of the local population.

Association between asthma and migraine: A cross-sectional study of over 110 000 adolescents

Epidemiological studies have reported an association between asthma and migraine, mainly in adults.

From Population Databases to Research and Informed Health Decisions and Policy

Background In the era of big data, the medical community is inspired to maximize the utilization and processing of the rapidly expanding medical datasets for clinical-related and policy-driven research. This requires a medical database that can be aggregated, interpreted, and integrated at both the individual and population levels. Policymakers seek data as a lever for wise, evidence-based decision-making and information-driven policy. Yet, bridging the gap between data collection, research, and policymaking, is a major challenge. The model To bridge this gap, we propose a four-step model: (A) creating a conjoined task force of all relevant parties to declare a national program to promote collaborations; (B) promoting a national digital records project, or at least a network of synchronized and integrated databases, in an accessible transparent manner; (C) creating an interoperative national research environment to enable the analysis of the organized and integrated data and to generate evidence; and (D) utilizing the evidence to improve decision-making, to support a wisely chosen national policy. For the latter purpose, we also developed a novel multidimensional set of criteria to illuminate insights and estimate the risk for future morbidity based on current medical conditions. Conclusion Used by policymakers, providers of health plans, caregivers, and health organizations, we presume this model will assist transforming evidence generation to support the design of health policy and programs, as well as improved decision-making about health and health care, at all levels: individual, communal, organizational, and national.