Age-dependent seasonality in the incidence of stroke: A 21-year population-based study

INTRODUCTION

Seasonality in the incidence of stroke has been examined in numerous studies, yet data on whether it differs with age are limited. To fill this gap, we utilized a largescale dataset from Israel.

PATIENTS AND METHODS

We retrieved data of all hospitalizations for ischemic stroke (IS), transient ischemic attack (TIA) and intra cerebral hemorrhage (ICH) from 2000 to 2020. We maintained separate datasets for IS/TIA and ICH, divided into five age groups: 18-49, 50-59, 60-69, 70-79, and 80+. We modeled the monthly incidence using a generalized additive model. The seasonal effect was defined by the rate ratio (RR) of each month compared to the annual mean.

RESULTS

The analysis included 317,586 and 23,789 events of IS/TIA and ICH respectively. We found an interaction between age and seasonality, accounting for a phase shift with age in the seasonal pattern of IS/TIA incidence. For cases under 70 years, the peak was during summertime and the RRs increased with decreasing age, reaching 1.11 (95% CI 1.09-1.13) at the youngest age group. In contrast, among the elderly, a winter peak was observed and the RRs increased with age to 1.07 (95% CI 1.06-1.08) at the oldest age group. For ICH, a winter/autumn peak was identified and the RRs increased with age to 1.20 (95% CI 1.16-1.24).

CONCLUSIONS

Our finding of age-dependent seasonal patterns in the occurrence of stroke, suggests closer monitoring of cardiovascular risk factors during wintertime among elderly individuals. The mechanism governing the seasonal phase shift with age in IS/TIA incidence, requires further investigation.

Impact of the COVID-19 pandemic on total, sex- and age-specific all-cause mortality in 20 countries worldwide during 2020: results from the C-MOR project

BACKGROUND

To understand the impact of the COVID-19 pandemic on mortality, this study investigates overall, sex- and age-specific excess all-cause mortality in 20 countries, during 2020.

METHODS

Total, sex- and age-specific weekly all-cause mortality for 2015-2020 was collected from national vital statistics databases. Excess mortality for 2020 was calculated by comparing weekly 2020 observed mortality against expected mortality, estimated from historical data (2015-2019) accounting for seasonality, long- and short-term trends. Crude and age-standardized rates were analysed for total and sex-specific mortality.

RESULTS

Austria, Brazil, Cyprus, England and Wales, France, Georgia, Israel, Italy, Northern Ireland, Peru, Scotland, Slovenia, Sweden, and the USA displayed substantial excess age-standardized mortality of varying duration during 2020, while Australia, Denmark, Estonia, Mauritius, Norway, and Ukraine did not. In sex-specific analyses, excess mortality was higher in males than females, except for Slovenia (higher in females) and Cyprus (similar in both sexes). Lastly, for most countries substantial excess mortality was only detectable (Austria, Cyprus, Israel, and Slovenia) or was higher (Brazil, England and Wales, France, Georgia, Italy, Northern Ireland, Sweden, Peru and the USA) in the oldest age group investigated. Peru demonstrated substantial excess mortality even in the <45 age group.

CONCLUSIONS

This study highlights that excess all-cause mortality during 2020 is context dependent, with specific countries, sex- and age-groups being most affected. As the pandemic continues, tracking excess mortality is important to accurately estimate the true toll of COVID-19, while at the same time investigating the effects of changing contexts, different variants, testing, quarantine, and vaccination strategies.

Adolescent Hypertension Is Associated With Stroke in Young Adulthood: A Nationwide Cohort of 1.9 Million Adolescents

BACKGROUND

Adult hypertension is a well-established risk factor for stroke in young adults (aged <55 years), and the effects are even more deleterious than at an older age. However, data are limited regarding the association between adolescent hypertension and the risk of stroke in young adulthood.

METHODS

A nationwide, retrospective cohort study of adolescents (aged 16-19 years) who were medically evaluated before compulsory military service in Israel during 1985 to 2013. For each candidate for service, hypertension was designated after constructed screening, and the diagnosis was confirmed through a comprehensive workup process. The primary outcome was ischemic and hemorrhagic stroke incidence as registered at the national stroke registry. Cox proportional-hazards models were used. We conducted sensitivity analyses by excluding people with a diabetes diagnosis at adolescence or a new diabetes diagnosis during the follow-up period, analysis of adolescents with overweight, and adolescents with baseline unimpaired health status.

RESULTS

The final sample included 1 900 384 adolescents (58% men; median age, 17.3 years). In total, 1474 (0.08%) incidences of stroke (1236 [84%] ischemic) were recorded, at a median age of 43 (interquartile range, 38-47) years. Of these, 18 (0.35%) occurred among the 5221 people with a history of adolescent hypertension. The latter population had a hazard ratio of 2.4 (95% CI, 1.5-3.9) for incident stroke after adjustment for body mass index and baseline sociodemographic factors. Further adjustment for diabetes status yielded a hazard ratio of 2.1 (1.3-3.5). We found similar results when the outcome was ischemic stroke with a hazard ratio of 2.0 (1.2-3.5). Sensitivity analyses for overall stroke, and ischemic stroke only, yielded consistent findings.

CONCLUSIONS

Adolescent hypertension is associated with an increased risk of stroke, particularly ischemic stroke, in young adulthood.

Particulate Air Pollution Exposure and Stroke among Adults in Israel

Stroke is the second most common cause of death and disability in the world. Many studies have found fine particulate matter (PM2.5) exposure to be associated with an increased risk of atherosclerotic cardiovascular disease, mostly focusing on ischemic heart disease and acute myocardial infarction. In a national analysis conducted in Israel-an area with unique climate conditions and high air pollution levels, we estimated the association between short-term PM2.5 exposure and ischemic stroke, intracerebral hemorrhage (ICH), or transient ischemic attacks (TIA). Using the Israeli National Stroke Registry, we obtained information on all stroke cases across Israel in 2014-2018. We obtained daily PM2.5 exposures from spatiotemporally resolved exposure models. We restricted the analytical data to days in which PM2.5 levels did not exceed the Israeli 24 h standard (37.5 µg/m3). We repeated the analysis with a stratification by sociodemographic characteristics and comorbidities. For all outcomes, the exposure-response curves were nonlinear. PM2.5 exposure was associated with a higher ischemic stroke risk, with larger effect estimates at higher exposure levels. Although nonsignificant, the exposure-response curve for TIA was similar. The associations with ICH were nonsignificant throughout the PM2.5 exposure distribution. The associations with ischemic stroke/TIA were larger among women, non-Jewish individuals, older adults, and individuals with diabetes, hypertension, and ischemic heart disease. In conclusion, short-term PM2.5 exposure is associated with a higher risk for ischemic stroke and possibly TIA, even when PM2.5 concentrations do not exceed the Israeli air quality guideline threshold. Vulnerability to the air pollution effects differed by age, sex, ethnicity, and comorbidities.

Hospitalizations in older-adults newly diagnosed with dementia: A population-based longitudinal study in Israel

OBJECTIVES

To compare inpatient burden (i.e. likelihood of hospitalization, number of admissions and length of stay) in persons with newly diagnosed dementia to the general population without dementia. Additionally, to evaluate whether inpatient burden is increased during the years prior to and post dementia diagnosis, and to identify factors associated with increased inpatient burden.

METHOD

The Israeli National Dementia Dataset (2016) was cross-linked with the National Hospital Discharge Database of the Israeli Ministry of Health (2014-2018). Dementia definition was based on documented dementia diagnoses and/or the purchase of medications during 2016. Mixed-effects models were applied to identify demographic and health characteristics associated with inpatient burden in the one and 2 years prior to and after dementia diagnosis.

RESULTS

The dataset included 11,625 individuals aged ≥65 years, identified as incident dementia cases. Compared to the general population of older-adults without dementia, those with newly diagnosed dementia had a higher age-standardized proportion of hospitalizations (26.4% vs. 40%). The odds for hospitalization were highest during the year preceding dementia diagnosis (OR = 3.19, 95% CI 2.51-4.06) compared to 2 years prior to diagnosis, and remained high (although slightly decreased) after dementia diagnosis. Older age was associated with inpatient burden after, but not prior to dementia diagnosis.

CONCLUSIONS

Older persons with dementia are a vulnerable population group with increased utilization of inpatient burden compared to those without dementia, particularly in the years surrounding dementia diagnosis. Sociodemographic risk factors may differ with respect to the time surrounding dementia diagnosis.

RF28 | PSUN302 Obesity at Late Adolescence and Incident Type 1 Diabetes in Young Adulthood

Aims

Studies in children reported an association between increased body mass index (BMI) and risk for developing type 1 diabetes (T1D), but evidence in late adolescence is limited. We recently investigated the association between adolescent BMI and type 2 diabetes in young adulthood (Diabetes Care 2020, 43(7): 1487-95) and here we studied on the same cohort the association between late adolescent BMI and incident T1D.

Methods

All Israeli adolescents, ages 16-19, undergoing medical evaluation in preparation for mandatory military conscription between January 1996 and December 2016 were included for analysis unless they had a history of dysglycemia (n=1,462,362; 40% women). Data were linked to information about adult onset of T1D in the Israeli National Diabetes Registry. Weight and height were measured at study entry and BMI was computed and transformed to age- and sex-adjusted BMI percentiles according to US Center for Diseases Control. The definition of T1D was determined based on anti-diabetic drugs and was confirmed for a subpopulation of the cohort to which islet autoantibodies data were available. Cox proportional models were applied, with BMI analyzed both as a categorical and continuous variable.

Results

There were 777 incident cases of T1D during 15,810,751 person-years (mean age at diagnosis 25.2±3.9 years). The median follow-up period was 11.2 years (IQR 5.8-16.3), with follow-up length shorter for individuals with a higher BMI. The crude diabetes rate showed a consistent graded increase across BMI groups from underweight to obesity; 3.6 to 8.4 cases per 100,000 person-years, respectively.

In a multivariable model adjusted for age, sex and socio-demographic variables, the hazard ratios (HRs) for T1D were 1.05 (95% CI 0.87-1.27) for the 50th–74th BMI percentiles, 1.41 (1.11–1.78) for the 75th–84th BMI percentiles, 1.54 (1.23–1.94) for adolescents with overweight (85th–94th percentiles), and 2.05 (1.58–2.66) for adolescents with obesity (BMI≥95th percentile)(reference group, 5th-49th BMI percentile group). One increment in BMI standard deviation was associated with 25% greater risk for incidence of T1D (HR=1.25, 95%CI 1.17-1.32). when the presence of one or multiple (≥2) islet antibodies was added as a criterion for T1D definition, the HRs among those with adolescent obesity were 2.90 (1.80-4.68) and 3.14 (1.68-5.88) respectively. Results were marginally affected by level of adjustment for sociodemographic background, were similar when analysis was stratified by sex, and also persisted when the study population was limited to adolescents with unimpaired health in order to mitigate confounding by coexisting illness.

The fraction of type 1 diabetes attributed to adolescent overweight and obesity (Population attributable risk%; PAR%) was 10.1% (95%CI 6.3%-14.2%).

Conclusions

Adolescent overweight and obesity in apparently healthy adolescents were associated with increased risk for incident type 1 diabetes in early adulthood.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 1:24 p.m. - 1:30 p.m.

Cardiac sympathetic afferent denervation reduces matrix metalloproteinase expression and improves cardiac remodeling in rats post myocardial infarction

 

In a previous study from our laboratory, we demonstrated that chronic and selective cardiac sympathetic afferent (spinal) denervation at the time of myocardial infarction (MI) using epicardial application of resiniferatoxin (RTX), a neuronal toxin capable of inducing rapid degeneration of transient receptor potential vanilloid 1 (TRPV1)-expressing afferent neurons and fibers, markedly reduced the cardiac remodeling process 9–11 weeks post-MI in rats. This included reduced cardiac hypertrophy, fibrosis and apoptosis. Here, we further investigated the effect of epicardial application of RTX at the time of MI on cardiac extracellular matrix (ECM) and remodeling post-MI. Echocardiographic and morphologic data demonstrated that, compared to MI+vehicle, MI+RTX exhibited a significantly slower LV chamber dilation (6-week echocardiographic data: left ventricular end-diastolic diameter, 10.7±0.2 vs. 9.6±0.3 mm; left ventricular end-systolic diameter: 8.8±0.2 vs. 7.8±0.3 mm; MI+vehicle vs. MI+RTX, n=18, p&lt;0.05; mean±SE). Scanning electron microscopy showed that RTX reduced collagen deposition in the peri-infarct area in post-MI rats. Western blot and zymography were used to further evaluate the effect of RTX application on matrix metalloproteinase (MMP) expression and activity, which is responsible for degrading ECM and contributing to cardiac dilation post MI. Our data suggest time-dependent increases in MMP expression in infarcted hearts post MI. RTX application largely prevented the increase in MMP9 but not MMP2, 4 weeks post-MI. RTX prevented both increased MMP2 and MMP9 activities in the peri-infarct myocardium at 8–10 weeks post-MI. We further investigated the effect of RTX application on MI-induced cardiac inflammation, which has been reported as an upstream mechanism triggering MMP activation post-MI. The data show that RTX largely abolished MI-induced plasma extravasation and reduced macrophage infiltration and cardiac cytokine content in the peri-infarct or remote myocardium of post-MI rats. These data suggest that cardiac sympathetic afferent denervation at the time of MI exerts a local anti-inflammatory effect and reduces ECM remodeling by preventing excessive MMP activation in post-MI rats.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health Grant HL126796

Obesity in late adolescence and incident type 1 diabetes in young adulthood

AIMS/HYPOTHESIS

Studies in children have reported an association between increased BMI and risk for developing type 1 diabetes, but evidence in late adolescence is limited. We studied the association between BMI in late adolescence and incident type 1 diabetes in young adulthood.

METHODS

All Israeli adolescents, ages 16-19 years, undergoing medical evaluation in preparation for mandatory military conscription between January 1996 and December 2016 were included for analysis unless they had a history of dysglycaemia. Data were linked with information about adult onset of type 1 diabetes in the Israeli National Diabetes Registry. Weight and height were measured at study entry. Cox proportional models were applied, with BMI being analysed both as a categorical and as a continuous variable.

RESULTS

There were 777 incident cases of type 1 diabetes during 15,819,750 person-years (mean age at diagnosis 25.2±3.9 years). BMI was associated with incident type 1 diabetes. In a multivariable model adjusted for age, sex and sociodemographic variables, the HRs for type 1 diabetes were 1.05 (95% CI 0.87, 1.27) for the 50th-74th BMI percentiles, 1.41 (95% CI 1.11, 1.78) for the 75th-84th BMI percentiles, 1.54 (95% CI 1.23, 1.94) for adolescents who were overweight (85th-94th percentiles), and 2.05 (95% CI 1.58, 2.66) for adolescents with obesity (≥95th percentile) (reference group: 5th-49th BMI percentiles). One increment in BMI SD was associated with a 25% greater risk for incidence of type 1 diabetes (HR 1.25, 95% CI 1.17, 1.32).

CONCLUSIONS

Excessively high BMI in otherwise healthy adolescents is associated with increased risk for incident type 1 diabetes in early adulthood.

Myopia and Early-Onset Type 2 Diabetes: A Nationwide Cohort Study

CONTEXT

A correlation between myopia and insulin resistance has been suggested.

OBJECTIVE

We investigated the association between myopia in adolescence and type 2 diabetes (T2D) incidence in young adulthood.

METHODS

This population-based, retrospective, cohort study comprised 1 329 705 adolescents (579 543 women, 43.6%) aged 16 to 19 years, who were medically examined before mandatory military service during 1993 to 2012, and whose data were linked to the Israel National Diabetes Registry. Myopia was defined based on right-eye refractive data. Cox proportional models were applied, separately for women and men, to estimate hazard ratios (HRs) for T2D incidence per person-years of follow-up.

RESULTS

There was an interaction between myopia and sex with T2D (P < .001). For women, T2D incidence rates (per 100 000 person-years) were 16.6, 19.2, and 25.1 for those without myopia, and with mild-to-moderate and high myopia, respectively. These corresponded to HRs of 1.29 (95% CI, 1.14-1.45) and 1.63 (1.21-2.18) for women with mild-to-moderate and high myopia, respectively, compared to those without myopia, after adjustment for age at study entry, birth year, adolescent body mass index, cognitive performance, socioeconomic status, and immigration status. Results persisted in extensive sensitivity and subgroup analyses. When managed as a continuous variable, every 1-diopter lower spherical equivalent yielded a 6.5% higher adjusted HR for T2D incidence (P = .003). There was no significant association among men.

CONCLUSION

For women, myopia in adolescence was associated with a significantly increased risk for incident T2D in young adulthood, in a severity-dependent manner. This finding may support the role of insulin resistance in myopia pathogenesis.

Premature mortality attributable to COVID-19: potential years of life lost in 17 countries around the world, January-August 2020

BACKGROUND

Understanding the impact of the burden of COVID-19 is key to successfully navigating the COVID-19 pandemic. As part of a larger investigation on COVID-19 mortality impact, this study aims to estimate the Potential Years of Life Lost (PYLL) in 17 countries and territories across the world (Australia, Brazil, Cape Verde, Colombia, Cyprus, France, Georgia, Israel, Kazakhstan, Peru, Norway, England & Wales, Scotland, Slovenia, Sweden, Ukraine, and the United States [USA]).

METHODS

Age- and sex-specific COVID-19 death numbers from primary national sources were collected by an international research consortium. The study period was established based on the availability of data from the inception of the pandemic to the end of August 2020. The PYLL for each country were computed using 80 years as the maximum life expectancy.

RESULTS

As of August 2020, 442,677 (range: 18-185,083) deaths attributed to COVID-19 were recorded in 17 countries which translated to 4,210,654 (range: 112-1,554,225) PYLL. The average PYLL per death was 8.7 years, with substantial variation ranging from 2.7 years in Australia to 19.3 PYLL in Ukraine. North and South American countries as well as England & Wales, Scotland and Sweden experienced the highest PYLL per 100,000 population; whereas Australia, Slovenia and Georgia experienced the lowest. Overall, males experienced higher PYLL rate and higher PYLL per death than females. In most countries, most of the PYLL were observed for people aged over 60 or 65 years, irrespective of sex. Yet, Brazil, Cape Verde, Colombia, Israel, Peru, Scotland, Ukraine, and the USA concentrated most PYLL in younger age groups.

CONCLUSIONS

Our results highlight the role of PYLL as a tool to understand the impact of COVID-19 on demographic groups within and across countries, guiding preventive measures to protect these groups under the ongoing pandemic. Continuous monitoring of PYLL is therefore needed to better understand the burden of COVID-19 in terms of premature mortality.

Prevalence and Incidence Rates of Dementia: A Nationwide Population-Based Study of Electronic Health Records in Israel1

BACKGROUND

Data on the rate of dementia is essential for planning and developing appropriate services at the national level.

OBJECTIVE

We report the prevalence and incidence of dementia, based on electronic health records available for the whole population.

METHODS

This national dementia dataset was established as a part of the National Program to Address Alzheimer's and Other Types of Dementia. Data from medical health records for all persons aged 45+ in Israel, for 2016, were extracted from the databases of the four health maintenance organizations. Dementia cases were identified based on either recorded dementia diagnosis, through International Classification of Diseases (ICD-9 and ICD-10) or dispensation of anti-dementia drugs. The date of first diagnosis was determined by the earliest recording.

RESULTS

A total of 65,951 persons with dementia, aged 45+, were identified from electronic health data. Based on both ICD codes and anti-dementia drugs, the prevalence rates of dementia among individuals aged 45+ and 65+ in 2016 were 2.5%and 6.4%, respectively, and the incidence rates were 0.49%and 1.3%, respectively. Based on ICD codes alone, the prevalence rates of dementia among individuals aged 45+ and 65+ in 2016 were 2.1%and 5.4%respectively, and the incidence rates were 0.36%and 0.96%respectively. The rates were higher among females compared to males and paradoxically lower in lower socioeconomic status compared to higher statuses.

CONCLUSION

This data collection reflects the present access of dementia patients to medical care resources and provides the basis for service planning and future dementia policies.

Adolescent body mass index and changes in pre-pregnancy body mass index in relation to risk of gestational diabetes

BACKGROUND

Pregestational excessive body mass index (BMI) is linked to an increased risk for gestational diabetes mellitus (GDM), but less is known on the effect of adolescent BMI on GDM occurrence. The study aimed to investigate possible associations of adolescent BMI and changes in BMI experienced before first pregnancy, with gestational diabetes risk.

METHODS

This retrospective study was based on linkage of a military screening database of adolescent health status (Israel Defence Forces) including measured height and weight, with medical records (Maccabi Healthcare Services, MHS) of a state-mandated health provider. The latter covers about 25% of the Israeli population; about 90% of pregnant women undergo screening by the two-step Carpenter-Coustan method. Adolescent BMI was categorized according to Center of Disease Control and Prevention percentiles. Only first documented pregnanies were analyzed and GDM was the outcome.

FINDINGS

Of 190,905 nulliparous women, 10,265 (5.4%) developed GDM. Incidence proportions of GDM were 5.1%, 6.1%, 7.3%, and 8.9% among women with adolescent normal BMI, underweight, overweight, and obesity (p<0.001), respectively. In models that accounted for age at pregnancy, birth year, and sociodemographic variables, the adjusted odd ratios (aORs) for developing GDM were: 1.2 (95%CI, 1.1-1.3), 1.5 (1.4-1.6), and 1.9 (1.7-2.1) for adolescent underweight, overweight, and obesity (reference group, normal BMI). Adolescent BMI tracked with BMI notes in the pre-pregnancy period (r=63%). Resuming normal pre-pregnancy BMI from overweight or obesity in adolescence diminished GDM risk, but this diminished risk was not observed among those who returned to a normal per-pre-pregnancy BMI from being underweight in adolescence. Sustained overweight or obesity conferred an aOR for developing GDM of 2.5 (2.2-2.7); weight gain from adolescent underweight and normal BMI to pre-pregnancy excessive BMI conferred aORs of 3.1 (1.6-6.2) and 2.6 (2.2-2.7), respectively.

INTERPRETATION

Change in BMI status from adolescence to pre-pregnancy may contribute to GDM risk. Identifying at-risk populations is important for early preventive interventions.

FUNDING

None.

Asthma in Youth and Early-onset Type 2 Diabetes: A Nationwide Study of 1.72 Million Israeli Adolescents

BACKGROUND

The prevalence of both asthma and early-onset diabetes is on the rise; however, the association between them remains unclear. We examined a possible association of asthma at adolescence with type 2 diabetes in young adulthood.

METHODS

This is a nationwide, population-based study of 1 718 541 Israeli adolescents (57% males; mean age 17.3 years; range 16-19 years), examined before compulsory military service between 1992 and 2016, with data linked to the Israeli National Diabetes Registry. Asthma diagnosis and severity were determined by a board-certified pulmonologist and based on spirometry tests.

RESULTS

Type 2 diabetes developed in 58/9090 (0.64%), 507/97 059 (0.52%), 114/23 332 (0.49%), and 7095/1 589 060 (0.44%) persons with moderate-to-severe, mild, inactive, and no history of asthma, respectively, during a mean follow-up >13 years. The respective odds ratios (ORs) were 1.33 (95% CI, 1.02-1.74), 1.17 (1.06-1.28), and 1.09 (0.9-1.31), considering those without asthma history as the reference, in a model adjusted for birth year, sex, body mass index, and other sociodemographic variables. The association persisted when the analysis accounted for coexisting morbidities, and when persons without asthma, individually matched by age, sex, birth year, and body mass index were the reference. Both mild and moderate-to-severe asthma were associated with type 2 diabetes before age 35 years: ORs 1.18 (1.05-1.34) and 1.44 (1.05-2.00), respectively. The strength of the association was accentuated over time. The effect was unchanged when adjusted for oral and inhaled glucocorticoid use.

CONCLUSION

Adolescents with active asthma have higher risk to develop type 2 diabetes. This seems related to disease severity, independent of adolescent obesity status, apparent before age 35 years, and more pronounced in recent years.

Adolescent cognitive function and incident early-onset type 2 diabetes

BACKGROUND

Cognitive function among apparently healthy adolescents has been associated with cardiovascular morbidity and mortality. We examined the relationship between global and subdomain cognitive scores in adolescence and early-onset type 2 diabetes (T2D) in men and women.

METHODS

A nationwide, population-based study of 971,677 Israeli born adolescents (56% men; mean age 17.4 years) who were medically examined and their cognitive performance was assessed before compulsory military service during 1992-2010. Data included global and subdomain cognitive Z-scores (problem-solving, verbal abstraction and categorization, verbal comprehension, and mathematical abilities). Data were linked to the Israeli National Diabetes Registry. The relations between global and subdomain scores and incident T2D was determined using Cox proportional hazard models and logistic regression models. Analyses were conducted separately for men and women.

FINDINGS

During 16,095,122 person-years, 3,570 individuals developed T2D. After adjustment, those in the low compared to the high quintile of global cognitive Z-score had the highest risk for T2D; HR 2.46, (95% CI 2.10-2.88) for men and 2.33 (95% CI 1.88-2.89) for women. A one-unit lower global cognitive Z-score was associated with 1.41 (95% CI 1.34-1.48) and 1.46 (95% CI 1.36-1.56) increased risks for men and women, respectively. The relationship was noted for the cognitive subdomains scores as well as for the global cognitive score, with no heterogeneity across cognitive subdomains.

INTERPRETATION

This large nationally representative cohort suggests relationship between global, as well as subdomain cognitive scores in late adolescence, and incident early onset T2D in both sexes, which was independent of socioeconomic status.

Making Use of Comparable Health Data to Improve Quality of Care and Outcomes in Diabetes: The EUBIROD Review of Diabetes Registries and Data Sources in Europe

Background

Registries and data sources contain information that can be used on an ongoing basis to improve quality of care and outcomes of people with diabetes. As a specific task of the EU Bridge Health project, we carried out a survey of diabetes-related data sources in Europe.

Objectives

We aimed to report on the organization of different sources of diabetes information, including their governance, information infrastructure and dissemination strategies for quality control, service planning, public health, policy and research.

Methods

Survey using a structured questionnaire to collect targeted data from a network of collaborating institutions managing registries and data sources in 17 countries in the year 2017.

Results

The 18 data sources participating in the study were most frequently academic centres (44.4%), national (72.2%), targeting all types of diabetes (61.1%) covering no more than 10% of the target population (44.4%). Although population-based in over a quarter of cases (27.8%), sources relied predominantly on provider-based datasets (38.5%), fewer using administrative data (16.6%). Data collection was continuous in the majority of cases (61.1%), but 50% could not perform data linkage. Public reports were more frequent (72.2%) as well as quality reports (77.8%), but one third did not provide feedback to policy and only half published ten or more peer reviewed papers during the last 5 years.

Conclusions

The heterogeneous implementation of diabetes registries and data sources hampers the comparability of quality and outcomes across Europe. Best practices exist but need to be shared more effectively to accelerate progress and deliver equitable results for people with diabetes.

Diabetes associated risk for mortality increases with time among first stroke survivors - Findings from the Israeli National Stroke Registry

BACKGROUND

Diabetes is a major risk factor for ischemic stroke and may affect post-stroke survival. Previous large scale studies of long-term post-stroke survival are limited and most of them excluded older patients from the study population.

OBJECTIVES

To compare the risk factors and sociodemographic characteristics between first ischemic stroke cases with and without diabetes and to assess the mortality risk associated with diabetes.

METHODS

Using population-based National Stroke Registry in Israel, all patients hospitalized for a first event of ischemic stroke between the years 2014-2018 were followed for all-cause mortality. Chi-square analysis was used to compare the differences in risk factors, sociodemographic profile and cumulative mortality between patients with and without diabetes. Cox proportional hazards models were used to estimate the hazard ratio for mortality in selected timeframes.

RESULTS

Among 41,639 patients with a first event of ischemic stroke, 44.5% were previously diagnosed with diabetes. Diabetic patients were more likely to be males, members of the Arab ethnic group, with lower socioeconomic status and a higher prevalence of cardiovascular comorbidities, anemia, leukocytosis and abnormal kidney function. Diabetes was associated with a higher mortality risk in the first year and long term, but not in the first month following stroke. Diabetes-associated mortality risk interacted with time and age, was higher in younger age and increased with time.

CONCLUSIONS

Our findings suggest that diabetes is associated with a higher prevalence of comorbidities among patients with first ischemic stroke and with a higher risk for mortality in the mid and long term, which is more profound in younger age.

[DIABETIC FOOT IN ISRAEL - CURRENT STATUS AND FUTURE PERSPECTIVES]

Diabetic foot ulcers and amputations are the most dreaded diabetes complications. The annual incidence of diabetic foot ulcers in Israel is estimated at 1.8% of all patients with diabetes. The number of patients with diabetes undergoing major amputation in the recent decade has been relatively stable in Israel, and in 2018, 887 patients with diabetes had undergone a major amputation. The proportion of patients undergoing a vascular intervention in the year prior to a major amputation has remained steady over the recent decade, and ranges between 20-40% depending on the patient's age. Aiming to reduce amputation rate, efforts should be made at three levels: 1) Primary care - increasing awareness of patients and health care teams to diabetic foot complications, the means to avoid them, and the delivery of preliminary care. Efforts to further increase awareness should be undertaken. Identification of the foot at-risk and incorporation of professional teams in the care of these patients, as well as provision of appropriate preventive offloading footwear should be sought. 2) Secondary clinics - these multidisciplinary clinics tend to all complications which cannot be adequately addressed in primary care. The professional standard of these clinics should be determined, and the access to these clinics improved. Adequate equipment in these clinics is mandatory as well. 3) Tertiary hospitals - care for the patients who require hospitalization. A national standard for inpatient diabetic foot care should be implemented and multi-disciplinary departments incorporating internists, orthopedists and vascular surgeons should be established aiming to address the medical and surgical complexity of these patients. Qualified nursing staff as well as additional health care professionals including physiotherapists, dieticians, clinical pharmacists, social workers, occupational therapists and others should also be included. Documentation of diabetic foot ulcers is lacking, both in the community and in hospitals. Use of uniform diagnostic codes should be implemented to enable close monitoring of disease trends.

Adolescent Thyroid Disorders and Risk for Type 2 Diabetes in Young Adulthood

CONTEXT

Thyroid hormones play a key role in systemic metabolism, yet the relationship between thyroid dysfunction and risk for type 2 diabetes is unclear.

OBJECTIVE

To assess type 2 diabetes risk in adulthood among adolescents with thyroid disorders.

DESIGN AND SETTING

A nationwide, population-based study of Israeli adolescents who were examined before military recruitment during 1988 to 2007 and were followed until December 31, 2016.

PARTICIPANTS

1 382 560 adolescents (mean age 17.3 years).

INTERVENTIONS

The diagnosis of thyroid disorders was based on recent thyroid function tests. Data were linked to the Israeli National Diabetes Registry. Cox proportional hazard models were applied.

MAIN OUTCOME MEASURES

Type 2 diabetes incidence.

RESULTS

During a mean follow-up of 18.5 years, 1.12% (69 of 6,152) of adolescents with thyroid disorders were diagnosed with type 2 diabetes vs 0.77% of adolescents without thyroid disorders. The hazard ratio (HR) for type 2 diabetes was 2.3 (95% CI, 1.8-2.9) among those with thyroid disorders, after adjustment for sex, birth-year, body mass index, and sociodemographic confounders. The increased diabetes risk was observed in both men and women, with the presence or absence of obesity, and in the absence of other health conditions and was associated with different types of thyroid disorders. It was also similar when the outcome was defined as type 2 diabetes diagnosed at or before the age of 30 years (HR 2.3, 95% CI, 1.5-3.5).

CONCLUSIONS

Thyroid disorders diagnosed in adolescence are a risk factor for early-onset type 2 diabetes in both men and women.

Excess all-cause mortality and COVID-19-related mortality: a temporal analysis in 22 countries, from January until August 2020

Background

This study aimed to investigate overall and sex-specific excess all-cause mortality since the inception of the COVID-19 pandemic until August 2020 among 22 countries.

Methods

Countries reported weekly or monthly all-cause mortality from January 2015 until the end of June or August 2020. Weekly or monthly COVID-19 deaths were reported for 2020. Excess mortality for 2020 was calculated by comparing weekly or monthly 2020 mortality (observed deaths) against a baseline mortality obtained from 2015–2019 data for the same week or month using two methods: (i) difference in observed mortality rates between 2020 and the 2015–2019 average and (ii) difference between observed and expected 2020 deaths.

Results

Brazil, France, Italy, Spain, Sweden, the UK (England, Wales, Northern Ireland and Scotland) and the USA demonstrated excess all-cause mortality, whereas Australia, Denmark and Georgia experienced a decrease in all-cause mortality. Israel, Ukraine and Ireland demonstrated sex-specific changes in all-cause mortality.

Conclusions

All-cause mortality up to August 2020 was higher than in previous years in some, but not all, participating countries. Geographical location and seasonality of each country, as well as the prompt application of high-stringency control measures, may explain the observed variability in mortality changes.

Reduction in Acute Stroke Admissions during the COVID-19 Pandemic: Data from a National Stroke Registry

Introduction

The COVID-19 pandemic overwhelmed health-care systems worldwide, and medical care for other acute diseases was negatively impacted. We aimed to investigate the effect of the COVID-19 outbreak on admission rates and in-hospital care for acute stroke and transient ischemic attack (TIA) in Israel, shortly after the start of the pandemic.

Methods

We conducted a retrospective observational study, based on data reported to the Israeli National Stroke Registry from 7 tertiary hospitals. All hospital admissions for acute stroke or TIA that occurred between January 1 and April 30, 2020 were included. Data were stratified into 2 periods according to the timing of COVID-19 restrictions as follows: (1) “pre-pandemic” − January 1 to March 7, 2020 and (2) “pandemic” − March 8 to April 30, 2020. We compared the weekly counts of hospitalizations between the 2 periods. We further investigated changes in demographic characteristics and in some key parameters of stroke care, including the percentage of reperfusion therapies performed, time from hospital arrival to brain imaging and to thrombolysis, length of hospital stay, and in-hospital mortality.

Results

2,260 cases were included: 1,469 in the pre-COVID-19 period and 791 in the COVID-19 period. Hospital admissions significantly declined between the 2 periods, by 48% for TIA (rate ratio [RR] = 0.52; 95% CI 0.43–0.64) and by 29% for stroke (RR = 0.71; 95% CI 0.64–0.78). No significant changes were detected in demographic characteristics and in most parameters of stroke management. While the percentage of reperfusion therapies performed remained unchanged, the absolute number of patients treated with reperfusion therapies seemed to decrease. Higher in-hospital mortality was observed only for hemorrhagic stroke.

Conclusion

The marked decrease in admissions for acute stroke and TIA, occurring at a time of a relatively low burden of COVID-19, is of great concern. Public awareness campaigns are needed as patients reluctant to seek urgent stroke care are deprived of lifesaving procedures and secondary prevention treatments.

Body Mass Index in 1.9 Million Adolescents and Stroke in Young Adulthood

[Figure: see text].

Stuttering and Incident Type 2 Diabetes: A Population-Based Study of 2.2 Million Adolescents

PURPOSE

To investigate the association between stuttering in adolescence and incident type 2 diabetes in young adulthood.

METHODS

This nationwide population-based study included 2 193 855 adolescents of age 16 to 20 years who were assessed for military service between 1980 and 2013. Diagnoses of stuttering in adolescence were confirmed by a speech-language pathologist. Diabetes status for each individual as of December 31, 2016, was determined by linkage to the Israeli National Diabetes Registry. Relationships were analyzed using regression models adjusted for socioeconomic variables, cognitive performance, coexisting morbidities, and adolescent body mass index.

RESULTS

Analysis was stratified by sex (Pinteraction = 0.035). Of the 4443 (0.4%) adolescent men with stuttering, 162 (3.7%) developed type 2 diabetes, compared with 25 678 (2.1%) men without stuttering (adjusted odds ratio [OR] 1.3; 95% CI, 1.1-1.6). This relationship persisted when unaffected brothers of men with stuttering were used as the reference group (adjusted OR = 1.5; 95% CI, 1.01-2.2), or when the analysis included only adolescents with unimpaired health at baseline (adjusted OR = 1.4; 95% CI, 1.1-1.7). The association was stronger in later birth cohorts, with an adjusted OR of 2.4 (1.4-4.1) for cases of type 2 diabetes before age 40. Of the 503 (0.1%) adolescent women with stuttering 7 (1.4%) developed type 2 diabetes, compared with 10 139 (1.1%) women without stuttering (OR = 2.03; 95% CI, 0.48-2.20).

CONCLUSIONS

Adolescent stuttering is associated with an increased risk for early-onset type 2 diabetes among men.

Adolescent Nonalcoholic Fatty Liver Disease and Type 2 Diabetes in Young Adulthood

CONTEXT

The long-term risk of type 2 diabetes in adolescents with nonalcoholic fatty liver disease (NAFLD) is unclear.

OBJECTIVE

To assess type 2 diabetes risk among adolescents with NAFLD.

DESIGN AND SETTING

A nationwide, population-based study of Israeli adolescents who were examined before military service during 1997-2011 and were followed until December 31, 2016.

PARTICIPANTS

A total of 1 025 796 normoglycemic adolescents were included.

INTERVENTIONS

Biopsy or radiographic tests were prerequisite for NAFLD diagnosis. Data were linked to the Israeli National Diabetes Registry.

MAIN OUTCOME MEASURES

Type 2 diabetes incidence.

RESULTS

During a mean follow-up of 13.3 years, 12 of 633 adolescents with NAFLD (1.9%; all with high body mass index [BMI] at baseline) were diagnosed with type 2 diabetes compared with 2917 (0.3%) adolescents without NAFLD. The hazard ratio (HR) for type 2 diabetes was 2.59 (95% confidence interval [CI], 1.47-4.58) for the NAFLD vs. the non-NAFLD group after adjustment for BMI and sociodemographic confounders. The elevated risk persisted in several sensitivity analyses. These included an analysis of persons without other metabolic comorbidities (adjusted HR, 2.75 [95% CI, 1.48-5.14]) and of persons with high BMI; and an analysis whose outcome was type 2 diabetes by age 30 years (adjusted HR, 2.14 [95% CI, 1.02-4.52]). The results remained significant when a sex-, birth year-, and BMI-matched control group was the reference (adjusted HR, 2.98 [95% CI, 1.54-5.74]).

CONCLUSIONS

Among normoglycemic adolescents, NAFLD was associated with an increased adjusted risk for type 2 diabetes, which may be apparent before age 30 years.

Adolescent BMI and early-onset type 2 diabetes among Ethiopian immigrants and their descendants: a nationwide study

Background

We assessed in a nationwide cohort the association between adolescent BMI and early-onset (< 40 years) type 2 diabetes among Israelis of Ethiopian origin.

Methods

Normoglycemic adolescents (range 16–20 years old), including 93,806 native Israelis (≥ 3rd generation in Israel) and 27,684 Israelis of Ethiopian origin, were medically assessed for military service between 1996 and 2011. Weight and height were measured. Data were linked to the Israeli National Diabetes Registry. Incident type 2 diabetes by December 31, 2016 was the outcome. Cox regression models stratified by sex and BMI categories were applied.

Results

226 (0.29%) men and 79 (0.18%) women developed diabetes during 992,980 and 530,814 person-years follow-up, respectively, at a mean age of 30.4 and 27.4 years, respectively. Among native Israeli men with normal and high (overweight and obese) BMI, diabetes incidence was 9.5 and 62.0 (per 10⁵ person-years), respectively. The respective incidences were 46.9 and 112.3 among men of Ethiopian origin. After adjustment for sociodemographic confounders, the hazard ratios for type 2 diabetes among Ethiopian men with normal and high BMI were 3.4 (2.3–5.1) and 15.8 (8.3–30.3) respectively, compared to third-generation Israelis with normal BMI. When this analysis was limited to Israeli-born Ethiopian men, the hazard ratios were 4.4 (1.7–11.4) and 29.1 (12.9–70.6), respectively. Results persisted when immigrants of other white Caucasian origin were the reference; and among women with normal, but not high, BMI.

Conclusions

Ethiopian origin is a risk factor for early-onset type 2 diabetes among young men at any BMI, and may require selective interventions.

High ambient temperature in summer and risk of stroke or transient ischemic attack: A national study in Israel

OBJECTIVE

To examine whether high ambient temperature and diurnal temperature range during the summer are associated with risk of stroke/transient ischemic attack (TIA).

METHODS

A time-stratified case-crossover study design was conducted. The study sample comprised all individuals aged ≥50 years who had a stroke/TIA reported to the Israeli National Stroke Registry between 2014 and 2016 during the summer season. Daily temperature data were retrieved from the Israel Meteorological Service. Conditional logistic regression models were used with relative humidity and air pollution as covariates.

RESULTS

The sample included 15,123 individuals who had a stroke/TIA during the summer season (mean age 73 ± 12 years; 54% males). High ambient temperature was associated with stroke/TIA risk starting from the day before the stroke event, and increasing in strength over a six-day lag (OR = 1.10 95%CI 1.09-1.12). Moreover, a larger diurnal temperature range prior to stroke/TIA occurrence was associated with decreased stroke/TIA risk (OR = 0.96 95%CI 0.95-0.97 for a six-day lag).

CONCLUSIONS

High ambient temperature may be linked to increased risk of cerebrovascular events in subsequent days. However, relief from the heat during the night may attenuate this risk.

Adolescent Obesity and Early-Onset Type 2 Diabetes

OBJECTIVE

Type 2 diabetes (T2D) is increasingly diagnosed at younger ages. We investigated the association of adolescent obesity with incident T2D at early adulthood.

RESEARCH DESIGN AND METHODS

A nationwide, population-based study evaluated 1,462,362 adolescents (59% men, mean age 17.4 years) during 1996-2016. Data were linked to the Israeli National Diabetes Registry. Weight and height were measured at study entry. Cox proportional models were applied.

RESULTS

During 15,810,751 person-years, 2,177 people (69% men) developed T2D (mean age at diagnosis 27 years). There was an interaction among BMI, sex, and incident T2D (P _interaction = 0.023). In a model adjusted for sociodemographic variables, the hazard ratios for diabetes diagnosis were 1.7 (95% CI 1.4-2.0), 2.8 (2.3-3.5), 5.8 (4.9-6.9), 13.4 (11.5-15.7), and 25.8 (21.0-31.6) among men in the 50th-74th percentile, 75th-84th percentile, overweight, mild obesity, and severe obesity groups, respectively, and 2.2 (1.6-2.9), 3.4 (2.5-4.6), 10.6 (8.3-13.6), 21.1 (16.0-27.8), and 44.7 (32.4-61.5), respectively, in women. An inverse graded relationship was observed between baseline BMI and mean age of T2D diagnosis: 27.8 and 25.9 years among men and women with severe obesity, respectively, and 29.5 and 28.5 years among low-normal BMI (5th-49th percentile; reference), respectively. The projected fractions of adult-onset T2D that were attributed to high BMI (≥85th percentile) at adolescence were 56.9% (53.8-59.9%) and 61.1% (56.8-65.2%) in men and women, respectively.

CONCLUSIONS

Severe obesity significantly increases the risk for incidence of T2D in early adulthood in both sexes. The rise in adolescent severe obesity is likely to increase diabetes incidence in young adults in coming decades.

Childhood Pancreatitis and Risk for Incident Diabetes in Adulthood

OBJECTIVE

The relationship between acute pancreatitis and incident diabetes is unclear. We assessed whether a resolved single event of acute pancreatitis in childhood was associated with incident diabetes in adulthood.

RESEARCH DESIGN AND METHODS

A nationwide, population-based study of 1,802,110 Israeli adolescents (mean age 17.4 years [range 16-20]) who were examined before compulsory military service between 1979 and 2008 and whose data were linked to the Israeli National Diabetes Registry (INDR). Resolved pancreatitis was defined as a history of a single event of acute pancreatitis with normal pancreatic function at enrollment. Logistic regression analysis was applied.

RESULTS

Incident diabetes developed in 4.6% of subjects with resolved pancreatitis (13 of 281; none of these cases were identified as type 1 diabetes) and 2.5% among the unexposed group (44,463 of 1,801,716). Resolved acute pancreatitis was associated with incident diabetes with an odds ratio (OR) of 2.23 (95% CI 1.25-3.98) with adjustment for age, sex, and birth year. Findings persisted after further adjustments for baseline BMI and sociodemographic confounders (OR 2.10 [95% CI 1.15-3.84]). Childhood pancreatitis was associated with a diagnosis of diabetes at a younger age, with 92% of diabetes case subjects diagnosed before 40 years of age compared with 47% in the unexposed group (P = 0.002). The association accentuated when the study sample was limited to individuals of unimpaired health or normal BMI at baseline.

CONCLUSIONS

A history of acute pancreatitis in childhood with normal pancreatic function in late adolescence is a risk factor for incident type 2 diabetes, especially at young adulthood.

Prevalence of diabetes among children treated with growth hormone in Israel

AIMS

To determine the long-term risk of diabetes in a cohort of children treated with recombinant human growth hormone in Israel, using data from the Israeli National Diabetes Register.

METHODS

Between 1988 and 2009, 2513 children were approved for growth hormone treatment. They were assigned to one of two groups. The first group included children treated for isolated growth hormone deficiency and who were small for gestational age and the second included those treated for multiple pituitary hormone deficiency, chronic renal failure, Turner syndrome or Prader-Willi syndrome. The cohort was cross-linked with the Israeli National Diabetes Register for 2014 (mean follow-up duration 12.1±5.3 years), and prevalent cases of diabetes were identified. Standardized prevalence ratios for diabetes were calculated for people aged 10-29 years.

RESULTS

In 2014, a total of 23 individuals were identified with diabetes (four with pre-existing diabetes, seven developed diabetes before age 17 years and 12 developed it at a later age). In the isolated growth hormone deficiency and small-for-gestational-age group there was no difference in the prevalence of diabetes compared with the general population (standardized prevalence ratio 2.05, 95% CI 0.94-3.89). In the group that included people with multiple pituitary hormone deficiency, chronic renal failure, Turner syndrome and Prader-Willi syndrome there was a significantly higher diabetes prevalence (standardized prevalence ratio 11.94, 95% CI 6.53-20.00) compared with the general population.

CONCLUSIONS

No difference in diabetes prevalence was found in the isolated growth hormone deficiency and small-for-gestational-age group, compared with the general population. Children treated with growth hormone with pre-existing risk factors had an increased prevalence of diabetes. It is advisable to monitor blood glucose levels closely during and after growth hormone treatment, especially in such children.

The number of acute cerebrovascular events in Israel: a forecast until 2040

BACKGROUND

Acute cerebrovascular event is one of the leading causes of death in Israel and is the primary cause of neurological disability in adults. Although some evidence indicates that the incidence rate of acute cerebrovascular events in developed countries is stable or has been decreasing over the past decades, the number of events is expected to increase in these countries due to projected changes in size and composition of the population. The purpose of this study was to provide a forecast of the number of acute cerebrovascular events in Israel for the coming decades.

METHODS

We used data from the National Stroke Registry at the Israel Center for Disease Control and data from the long-term population forecasts of the Israeli Central Bureau of Statistics. We generated forecasts of the annual number of acute cerebrovascular events based on the mean annual incidence rates during 2014-2016 within population subgroups defined by gender, age, and ethnicity, and on the projected population size of these subgroups for 2015-2040. The forecasts were generated for various assumptions as to trends in the incidence rate and for alternatives as to the projected population growth.

RESULTS

Based on the intermediate population growth alternative, the annual number of acute cerebrovascular events is expected to increase from 18,400 to 38,500, 34,800 or 26,400 events, assuming constant annual incidence rates, decreasing annual incidence rates at a rate of 2% every 5 years, or decreasing annual incidence rates at a rate of 7.25% every 5 years, respectively. Whereas, presently, events affecting Arab patients account for 15% of acute cerebrovascular events and events affecting patients over 80 account for 33% of acute cerebrovascular events, by 2040 events affecting Arab patients will account for more than 21% of the events and events affecting patients over 80 will account for 42% of the events.

CONCLUSIONS

In view of the expected increase in the number of acute cerebrovascular events and the changes in the demographic composition of adults suffering from such events, and in order to allow for optimal care and equity, it is imperative to evaluate the preparedness of care provision and the geographical deployment of treatment services in the short and long term.

[THE ISRAELI NATIONAL STROKE REGISTRY - A TOOL FOR MONITORING MORBIDITY AND ACUTE STROKE CARE IN ISRAEL]

BACKGROUND

Stroke is a leading cause of death and disability worldwide. Due to the high burden caused by stroke, the Israeli Ministry of Health initiated a national program for the treatment and prevention of stroke, including the establishment of an Israeli National Stroke Registry (INSR). In this article we will demonstrate the use of the INSR as a tool for monitoring the treatment of acute cerebrovascular events (stroke or transient ischemic attack).

OBJECTIVES

1. Assessing incidence rates of acute cerebrovascular events in Israel for the total population and by gender and ethnic group separately. 2. Presenting trends in a number of key indicators related to acute stroke care.

METHODS

The INSR is based on data retrieval from hospital electronic medical records of all adult cases discharged with acute cerebrovascular diagnosis from January 1, 2014 on. Included in the current analysis were all cases reported to the INSR until June 31, 2017.

RESULTS

The average annual incidence rate of cerebrovascular events in Israel was 3.2 cases per 1,000 people. Age-adjusted rates were significantly higher among Arabs, compared with the Jewish population. From 2014 to 2017 there was a moderate increase in the percentage of arrival by ambulance: from 43.2% to 49.0% and a significant increase in the percentage of head and neck vascular imaging performed: from 50.0% to 72.5%. Between 2014 and 2016 there was a significant increase in the percentage of t-PA administration, and in 2016-2017 the rates stabilized at 9.2%. The proportion of patients hospitalized in neurological wards was 38.0% - a slight increase from 35.0% in 2014.

CONCLUSIONS

The INSR is an effective tool for monitoring morbidity and acute stroke care in Israel. Actions should be taken in order to raise public awareness of stroke warning signs and the establishment of stroke units with skilled multidisciplinary teams should become a priority.

DISCUSSION

Compared with other western countries, rates of t-PA administration and arrival by ambulance in Israel are slightly low, rates of hospitalization in the neurological ward are significantly lower, and the lack of stroke units is most prominent.

Incidence and Risk Factors for Blindness in Adults With Diabetes: The Israeli National Diabetes Registry (INDR)

PURPOSE

To estimate the 3-year incidence of blindness among diabetes patients aged ≥18 years; to compare blindness incidence rates of persons with and without diabetes; and to investigate risk factors associated with diabetic retinopathy (DR), age-related macular degeneration (ARMD), glaucoma, and cataract-related blindness.

DESIGN

Cohort study.

METHODS

The Israeli National Diabetes Registry for 2012 was cross-linked with the database of blindness certifications obtained from the National Registry of the Blind. Blindness was defined as the receipt of an official certificate of blindness (a visual acuity of 3/60 or worse, or a visual field loss of <20 degrees in the better eye.) Incidence rates of blindness, overall and by main cause of blindness, were calculated for the years 2013-2015. Standardized morbidity ratios (SMRs) for 2013 were calculated, using the nondiabetic population as a reference. A multinomial logistic model was used to identify covariates associated with the incidence of blindness by main cause of blindness.

RESULTS

The 3-year incidence rates were 31.0 and 8.4 per 10 000 for overall and DR-related blindness, respectively. The SMR for overall blindness in people with diabetes was significantly higher than in the general nondiabetic population (1.39; 95% confidence interval: 1.27-1.53); however, the SMRs for ARMD, glaucoma, and cataract were not statistically significant. Poor metabolic control, insulin treatment, long diabetes duration, and chronic kidney disease were associated with DR-related blindness. Low socioeconomic status (SES) was associated with both cataract and DR-related blindness.

CONCLUSIONS

Optimum metabolic control of diabetes is important for prevention of DR-related blindness. SES-related disparities in blindness risk should be explored and reduced by directing efforts to provide appropriate treatment for all diabetic patients in order to prevent unnecessary blindness.

Validity of diagnostic codes and estimation of prevalence of diabetic foot ulcers using a large electronic medical record database

AIMS

To assess the validity of the diagnostic codes relating to diabetic foot ulcer (DFU) in the electronic medical records of a large integrated care provider and to assess the prevalence of DFU among its members.

MATERIALS AND METHODS

Data were obtained from the diabetes registry of Maccabi Healthcare Services (MHS), a 2.1-million-member sick-fund in Israel, which included 125 665 patients in 2015. We randomly selected and reviewed ~400 patient files from each of the following categories during study period: (1) had a diagnostic code of DFU; (2) had a diagnostic code, or clinical condition suggestive of DFU including: leg-ulcer, amputation, DFU in quartiles proximate to 2015 or abnormality reported by nurse; (3) patients at high risk for DFU (age > 35 and one of the following: peripheral artery disease, neuropathy, DFU during 2011-2014, eGFR<30 mL/min/m² or foot deformity). The patients' charts were reviewed by study physicians, and DFU was validated or refuted.

RESULTS

Relying upon diagnostic codes entered by physicians, the positive predictive value (PPV) was 73.1% (95% CI 67.6-78.2), and the sensitivity was 48.2% (95% CI 45.8-50.7%). The PPV of the diagnostic codes listed by podiatrists were significantly lower, while that of codes listed by nurses was higher but with lower sensitivity. The estimated annual prevalence of DFU in the diabetes registry of MHS was 1.2% (95%CI 1.0-1.5%).

CONCLUSIONS

Diagnostic codes alone cannot be used reliably to create a DFU registry. Nevertheless, the data collected provide an estimate of the prevalence of DFU among patients included in the MHS diabetes registry.

Global, regional, and national age-sex-specific mortality and life expectancy, 1950-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Assessments of age-specific mortality and life expectancy have been done by the UN Population Division, Department of Economics and Social Affairs (UNPOP), the United States Census Bureau, WHO, and as part of previous iterations of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD). Previous iterations of the GBD used population estimates from UNPOP, which were not derived in a way that was internally consistent with the estimates of the numbers of deaths in the GBD. The present iteration of the GBD, GBD 2017, improves on previous assessments and provides timely estimates of the mortality experience of populations globally.

METHODS

The GBD uses all available data to produce estimates of mortality rates between 1950 and 2017 for 23 age groups, both sexes, and 918 locations, including 195 countries and territories and subnational locations for 16 countries. Data used include vital registration systems, sample registration systems, household surveys (complete birth histories, summary birth histories, sibling histories), censuses (summary birth histories, household deaths), and Demographic Surveillance Sites. In total, this analysis used 8259 data sources. Estimates of the probability of death between birth and the age of 5 years and between ages 15 and 60 years are generated and then input into a model life table system to produce complete life tables for all locations and years. Fatal discontinuities and mortality due to HIV/AIDS are analysed separately and then incorporated into the estimation. We analyse the relationship between age-specific mortality and development status using the Socio-demographic Index, a composite measure based on fertility under the age of 25 years, education, and income. There are four main methodological improvements in GBD 2017 compared with GBD 2016: 622 additional data sources have been incorporated; new estimates of population, generated by the GBD study, are used; statistical methods used in different components of the analysis have been further standardised and improved; and the analysis has been extended backwards in time by two decades to start in 1950.

FINDINGS

Globally, 18·7% (95% uncertainty interval 18·4-19·0) of deaths were registered in 1950 and that proportion has been steadily increasing since, with 58·8% (58·2-59·3) of all deaths being registered in 2015. At the global level, between 1950 and 2017, life expectancy increased from 48·1 years (46·5-49·6) to 70·5 years (70·1-70·8) for men and from 52·9 years (51·7-54·0) to 75·6 years (75·3-75·9) for women. Despite this overall progress, there remains substantial variation in life expectancy at birth in 2017, which ranges from 49·1 years (46·5-51·7) for men in the Central African Republic to 87·6 years (86·9-88·1) among women in Singapore. The greatest progress across age groups was for children younger than 5 years; under-5 mortality dropped from 216·0 deaths (196·3-238·1) per 1000 livebirths in 1950 to 38·9 deaths (35·6-42·83) per 1000 livebirths in 2017, with huge reductions across countries. Nevertheless, there were still 5·4 million (5·2-5·6) deaths among children younger than 5 years in the world in 2017. Progress has been less pronounced and more variable for adults, especially for adult males, who had stagnant or increasing mortality rates in several countries. The gap between male and female life expectancy between 1950 and 2017, while relatively stable at the global level, shows distinctive patterns across super-regions and has consistently been the largest in central Europe, eastern Europe, and central Asia, and smallest in south Asia. Performance was also variable across countries and time in observed mortality rates compared with those expected on the basis of development.

INTERPRETATION

This analysis of age-sex-specific mortality shows that there are remarkably complex patterns in population mortality across countries. The findings of this study highlight global successes, such as the large decline in under-5 mortality, which reflects significant local, national, and global commitment and investment over several decades. However, they also bring attention to mortality patterns that are a cause for concern, particularly among adult men and, to a lesser extent, women, whose mortality rates have stagnated in many countries over the time period of this study, and in some cases are increasing.

FUNDING

Bill & Melinda Gates Foundation.

Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Efforts to establish the 2015 baseline and monitor early implementation of the UN Sustainable Development Goals (SDGs) highlight both great potential for and threats to improving health by 2030. To fully deliver on the SDG aim of "leaving no one behind", it is increasingly important to examine the health-related SDGs beyond national-level estimates. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), we measured progress on 41 of 52 health-related SDG indicators and estimated the health-related SDG index for 195 countries and territories for the period 1990-2017, projected indicators to 2030, and analysed global attainment.

METHODS

We measured progress on 41 health-related SDG indicators from 1990 to 2017, an increase of four indicators since GBD 2016 (new indicators were health worker density, sexual violence by non-intimate partners, population census status, and prevalence of physical and sexual violence [reported separately]). We also improved the measurement of several previously reported indicators. We constructed national-level estimates and, for a subset of health-related SDGs, examined indicator-level differences by sex and Socio-demographic Index (SDI) quintile. We also did subnational assessments of performance for selected countries. To construct the health-related SDG index, we transformed the value for each indicator on a scale of 0-100, with 0 as the 2·5th percentile and 100 as the 97·5th percentile of 1000 draws calculated from 1990 to 2030, and took the geometric mean of the scaled indicators by target. To generate projections through 2030, we used a forecasting framework that drew estimates from the broader GBD study and used weighted averages of indicator-specific and country-specific annualised rates of change from 1990 to 2017 to inform future estimates. We assessed attainment of indicators with defined targets in two ways: first, using mean values projected for 2030, and then using the probability of attainment in 2030 calculated from 1000 draws. We also did a global attainment analysis of the feasibility of attaining SDG targets on the basis of past trends. Using 2015 global averages of indicators with defined SDG targets, we calculated the global annualised rates of change required from 2015 to 2030 to meet these targets, and then identified in what percentiles the required global annualised rates of change fell in the distribution of country-level rates of change from 1990 to 2015. We took the mean of these global percentile values across indicators and applied the past rate of change at this mean global percentile to all health-related SDG indicators, irrespective of target definition, to estimate the equivalent 2030 global average value and percentage change from 2015 to 2030 for each indicator.

FINDINGS

The global median health-related SDG index in 2017 was 59·4 (IQR 35·4-67·3), ranging from a low of 11·6 (95% uncertainty interval 9·6-14·0) to a high of 84·9 (83·1-86·7). SDG index values in countries assessed at the subnational level varied substantially, particularly in China and India, although scores in Japan and the UK were more homogeneous. Indicators also varied by SDI quintile and sex, with males having worse outcomes than females for non-communicable disease (NCD) mortality, alcohol use, and smoking, among others. Most countries were projected to have a higher health-related SDG index in 2030 than in 2017, while country-level probabilities of attainment by 2030 varied widely by indicator. Under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria indicators had the most countries with at least 95% probability of target attainment. Other indicators, including NCD mortality and suicide mortality, had no countries projected to meet corresponding SDG targets on the basis of projected mean values for 2030 but showed some probability of attainment by 2030. For some indicators, including child malnutrition, several infectious diseases, and most violence measures, the annualised rates of change required to meet SDG targets far exceeded the pace of progress achieved by any country in the recent past. We found that applying the mean global annualised rate of change to indicators without defined targets would equate to about 19% and 22% reductions in global smoking and alcohol consumption, respectively; a 47% decline in adolescent birth rates; and a more than 85% increase in health worker density per 1000 population by 2030.

INTERPRETATION

The GBD study offers a unique, robust platform for monitoring the health-related SDGs across demographic and geographic dimensions. Our findings underscore the importance of increased collection and analysis of disaggregated data and highlight where more deliberate design or targeting of interventions could accelerate progress in attaining the SDGs. Current projections show that many health-related SDG indicators, NCDs, NCD-related risks, and violence-related indicators will require a concerted shift away from what might have driven past gains-curative interventions in the case of NCDs-towards multisectoral, prevention-oriented policy action and investments to achieve SDG aims. Notably, several targets, if they are to be met by 2030, demand a pace of progress that no country has achieved in the recent past. The future is fundamentally uncertain, and no model can fully predict what breakthroughs or events might alter the course of the SDGs. What is clear is that our actions-or inaction-today will ultimately dictate how close the world, collectively, can get to leaving no one behind by 2030.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data.

METHODS

We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting.

FINDINGS

Globally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1-4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0-8·4) while the total sum of global YLDs increased from 562 million (421-723) to 853 million (642-1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6-9·2) for males and 6·5% (5·4-7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782-3252] per 100 000 in males vs s1400 [1279-1524] per 100 000 in females), transport injuries (3322 [3082-3583] vs 2336 [2154-2535]), and self-harm and interpersonal violence (3265 [2943-3630] vs 5643 [5057-6302]).

INTERPRETATION

Global all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury.

FUNDING

Bill & Melinda Gates Foundation.

Self-Reported Type 2 Diabetes and Diabetes-Related Eye Disease in Jews and Arabs in Israel

Prevalence rates of diabetes and its complications may be higher in minorities. We assessed these rates in Jews and Arabs living in Israel. Data were pooled from the first and second Israeli national health interview surveys. 9625 Jews and 2401 Arabs participated in the analysis. The age adjusted rate of self-reported diabetes was 10.7 % among Arabs and 5.7 % among Jews [odds ratio (OR) 2.14, 95 % confidence interval 1.77-2.60]. After adjustment for risk factors the OR decreased to 1.28 (95 % CI 1.04-1.59). The rate of self-reported diabetes-related eye disease was 37.6 % among Arabs with diabetes and 18.3 % among Jews (OR 2.69, 95 % CI 1.84-3.93). After adjustment the odds among Arabs were still double that of Jews (OR 2.26, 95 % CI 1.44-3.56). Self-reported type 2 diabetes and diabetes-related eye disease were higher among Arabs. Multi-disciplinary and cultural sensitive approach is required in order to improve diabetes care among the Arab population.

Characteristics and Outcomes of Young Patients with First-Ever Ischemic Stroke Compared to Older Patients: The National Acute Stroke ISraeli Registry

Background

Nationwide data on the clinical profile and outcomes of ischemic stroke in younger adults are still scarce. Our aim was to analyze clinical characteristics and outcomes of young patients with first-ever ischemic stroke compared to older patients.

Methods

The National Acute Stroke ISraeli registry is a nationwide prospective hospital-based study performed triennially. Younger adults, aged 50 years and younger, were compared with patients, aged 51–84 years regarding risk factors, clinical presentation, stroke severity, stroke etiology, and outcomes. A logistic model for stroke outcome was fitted for each age group.

Results

336 first-ever ischemic strokes were identified among patients aged 50 years and younger and 3,243 among patients 51–84 years. Younger adults had lower rates of traditional vascular risk factors, but 82.7% had at least one of these risk factors. Younger adults were more likely to be male (62.8%), current smokers (47.3%), and to have a family history of stroke (7.4%). They tended to have less common stroke presentation such as sensory disturbances or headache and were more likely to arrive at the hospital independently by car. The majority of young adults (70%) had a favorable outcome (modified Ranking Scale; mRS ≤ 1) at discharge, but 11.7% had poor outcome (mRS > 3) and 18.2% had an in-hospital complication. According to a multivariable regression model, in young adults, only baseline stroke severity (National Institute of Health Stroke Scale > 5) was associated with poor outcome at discharge (p < 0.001), whereas in older adults, stroke severity (p < 0.001), female gender (OR = 1.35, CI 95% 1.03–1.76), older age (OR = 1.08, CI 95% 1.01–1.16), atrial fibrillation (OR = 1.62, CI 95% 1.16–2.26), and anterior circulation territory (OR = 2.10, CI 95% 1.50–2.94) were all significantly associated with poor outcome.

Conclusion

Our findings, in this nationwide registry, demonstrate the relatively high rate of smoking and family history of stroke, and the lower rate of hospital arrival by ambulance among young adults. This calls for increasing awareness to the possibility of stroke among young adults and for better prevention, especially smoking cessation.

New onset diabetes in adulthood is associated with a substantial risk for mortality at all ages: a population based historical cohort study with a decade-long follow-up

BACKGROUND

Diabetes has been reported to be associated with an increased relative risk for mortality, with estimates ranging from 1.1 to 2.1. Findings are inconsistent regarding modification of the risk by gender and by age. The aim of this study was to estimate the mortality risk associated with new-onset diabetes in adulthood, by age group and gender.

METHODS

From the database of a large health care provider, we identified 31,987 individuals diagnosed with diabetes during 2003-2005; and 162,656 individuals without diabetes, group-matched by age. We used Cox regression to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for overall mortality adjusted for age, gender, socioeconomic (SE) level, obesity, smoking and comorbidities at baseline.

RESULTS

During a median follow-up of 9.5 years, 4464 (14%) of persons with diabetes and 13,327 (8.2%) of those without died. Among persons with incident diabetes, the proportion of men, smokers, obese and patients of low SE level was higher, as was the prevalence of cardiovascular disease and renal impairment at baseline. Incident diabetes was associated with an adjusted HR for mortality of 1.38 (95% CI 1.32-1.43). Mortality HR for DM was comparable with hypertension (1.42; 1.37-1.46), smoking (1.65; 1.58-1.71) and atherosclerosis (1.40; 1.35-1.46). Diabetes associated mortality HR was somewhat higher among women 1.78 (95% CI 1.58-2.08) as compared with men 1.51 (95% CI 1.41-1.62).

CONCLUSIONS

Incident diabetes in adults is associated with a substantial risk for mortality, especially in younger adults. Further efforts should be allocated to diabetes primary prevention.

Variations in death certification practices distort international comparisons of mortality from diabetes

Background

Israel is ranked second among OECD countries in diabetes mortality despite good performance on diabetes care measures. This study assessed whether variations in death certification practices could explain differences in diabetes mortality rates between countries, using a comparison between the USA and Israel as an example.

Methods

Multiple cause mortality data for Israel and the USA were analyzed. The proportions of cases with diabetes coded as the underlying cause of death (UCOD), of all certificates with diabetes listed as one of the multiple causes of death (MCOD), were calculated by age-group, and compared between the USA and Israel, with emphasis on cases in which cardiovascular events were reported in part I of the certificate.

Results

The diabetes UCOD/MCOD ratio was higher in Israel for all age groups. The differences in proportions were larger when cardiovascular events were reported in part I. Diabetes mortality rate ratio between the countries would be 49% lower if the UCOD/MCOD ratios in US data were applied to the Israeli data.

Conclusions

Half of the difference in the reported diabetes mortality rate between the USA and Israel is explained by different coding practices. International comparisons could be improved by using multiple cause data or by clarifying guidelines regarding certification of diabetes deaths.

The accuracy of suicide statistics: are true suicide deaths misclassified?

PURPOSE

Official suicide statistics often produce an inaccurate view of suicide populations, since some deaths endorsed as being of uncertain manner are in fact suicides; it is common, therefore, in suicide research, to account for these deaths. We aimed to test the hypothesis that non-suicide death categories contain a large potential reservoir of misclassified suicides.

METHODS

Data on undetermined intent and ill-defined death causes, and official suicide deaths recorded in the district of Tel Aviv for the years 2005 and 2008 were extracted. Based on supplementary data, cases regarded as probable suicides ("suicide probable") were then compared with official suicides ("suicide verdicts") on a number of socio-demographic variables, and also in relation to the mechanism of death.

RESULTS

Suicide rates were 42 % higher than those officially reported after accounting for 75 probable suicides (erroneously certified under other cause-of-death categories). Both death classifications ("suicide probable" and "suicide verdicts") had many similarities, significantly differing only with respect to method used. Logistic regression confirmed that the most powerful discriminator was whether the mechanism of death was considered "less active" or "more active" (p < 0.001). Indeed, deaths among the less active group were 4.9 times as likely to be classified as "suicide probable" than were deaths among the more active group.

CONCLUSIONS

Caution is needed when interpreting local area data on suicide rates, and undetermined and ill-defined deaths should be included in suicide research after excluding cases unlikely to be suicides. Improving suicide case ascertainment, using multiple sources of information, and uniform reporting practices, is advised.

A hybrid process of biofiltration of secondary effluent followed by ozonation and short soil aquifer treatment for water reuse

The Shafdan reclamation project facility (Tel Aviv, Israel) practices soil aquifer treatment (SAT) of secondary effluent with hydraulic retention times (HRTs) of a few months to a year for unrestricted agricultural irrigation. During the SAT, the high oxygen demand (>40 mg L(-1)) of the infiltrated effluent causes anoxic conditions and mobilization of dissolved manganese from the soil. An additional emerging problem is the occurrence of persistent trace organic compounds (TrOCs) in reclaimed water that should be removed prior to reuse. An innovative hybrid process based on biofiltration, ozonation and short SAT with ∼22 d HRT is proposed for treatment of the Shafdan secondary effluent to overcome limitations of the existing system and to reduce the SAT's physical footprint. Besides efficient removal of particulate matter to minimize clogging, coagulation/flocculation and filtration (5-6 m h(-1)) operated with the addition of hydrogen peroxide as an oxygen source efficiently removed dissolved organic carbon (DOC, to 17-22%), ammonium and nitrite. This resulted in reduced effluent oxygen demand during infiltration and oxidant (ozone) demand during ozonation by 23 mg L(-1) and 1.5 mg L(-1), respectively. Ozonation (1.0-1.2 mg O3 mg DOC(-1)) efficiently reduced concentrations of persistent TrOCs and supplied sufficient dissolved oxygen (>30 mg L(-1)) for fully oxic operation of the short SAT with negligible Mn(2+) mobilization (<50 μg L(-1)). Overall, the examined hybrid process provided DOC reduction of 88% to a value of 1.2 mg L(-1), similar to conventional SAT, while improving the removal of TrOCs and efficiently preventing manganese dissolution.

Characteristics of suicide completers with a psychiatric diagnosis before death: a postmortem study of 98 cases

The objective of this research was to classify the deaths of 98 victims of suicide in Tel Aviv, Israel between the years 2007 and 2010. This was done by examining background features and clinical characteristics among suicide completers with histories of a prior psychiatric hospitalization using logistic regression modeling. 34% of the sample (33/98) was given at least one psychiatric diagnosis upon discharge from a prior psychiatric hospitalization. Throughout their lifetime, those with psychiatric diagnoses were significantly more likely to have histories of mental health treatment (psychotherapy and psychotropic medication), psychopathology and suicidality among family members, prior suicide attempts and familial or emotional crisis as compared with those without a psychiatric diagnosis. During their last life phase, those with prior psychiatric diagnoses were also significantly more likely to have received psychotherapeutic treatment, expressed a lack of desire to live and presented with affective symptoms (e.g. depression, anxiety, adaptation difficulty and nervousness) as compared with those without such histories. Thus, focusing on high risk populations, such as those with psychiatric illnesses and deciphering the role of mental health treatment, familial predisposition, prior suicide attempt and sub-clinical symptoms in relation to suicide can inform future prevention practices.

Significant cross reactive antibodies to influenza virus in adults and children during a period of marked antigenic drift

Background

Little is known about the development of cross-reactive antibodies following natural exposure to pathogens. Such knowledge is critical in the development of new universal influenza vaccines.

Methods

To study the possibility of the presence of cross-reactive antibodies to influenza viruses which underwent a major antigenic drift between the years 1999 and 2007 sera from samples of 80 children and 400 adults were selected at random from the Israeli national serum bank. The sera was obtained in 2002 and in 2007, two time points that followed a major drift in the infectious H3N2 influenza virus strain (A/Panama/2007/99 to A/Wisconsin/67/2005).

Results

In the summer of 2002, 13% of the children had Hemagglutination Inhibition (HI) antibody titers of at least 40 and these antibodies recognized both A/Panama/2007/99 and A/Wisconsin/67/2005, where the latter strain only began to circulate in Israel in 2006. In 2007, 29% of the children had HI antibody titers of at least 40 directed against both A/Wisconsin/67/2005 and A/Panama/2007/99, even though they had never been exposed to the latter virus. Anti-A/Panama/2007/99 antibodies were detected in 58% and 68% of the 2002 and 2007 adult samples, respectively, while 8% and 39% had antibodies against A/Wisconsin/67/2005, respectively.

Conclusions

The presence of naturally occurring cross-reactive influenza virus antibodies in a significant percentage of children has important implications for the development of a universal influenza vaccine.

Regional gaps in the provision of inpatient rehabilitation services for the elderly in Israel: Results of a national survey

BACKGROUND

Medical events, such as stroke, limb fractures, joint replacements and spinal injuries, can lead to acute functional disability at all ages and to chronic disability, especially among the elderly. Rehabilitation is, therefore, essential for the prevention of permanent disability among older individuals. There are international practice guidelines for stroke and hip fracture management, including recommendations that rehabilitation services be an integral part of the provision of treatment in either an inpatient setting or in the community. There are no organized data on provision of rehabilitation services in Israel or on the distribution of these services throughout the country. Such information would be of great assistance in designing these services where they are needed and in making changes in the existing ones where necessary.

METHODS

Patients aged 65 years or older with stroke or hip fracture were identified through one-day surveys conducted in 2009-2010 in all 26 acute care hospitals in Israel. Data on inpatient and ambulatory rehabilitation services were collected from discharge medical summaries, telephone interviews with the patients or their relatives and reports from the healthcare provider. The extent of rehabilitation services was described and the association between receipt of inpatient rehabilitation and the geographic district based on the patients' listed address was examined in a multivariate analysis.

RESULTS

A total of 570 patients with stroke and 768 patients with hip fracture were identified and interviews were conducted in regards to 421 and 672 respectively. Out of the stroke patients 238(56.5%) received inpatient rehabilitation, 46(10.9%) received ambulatory rehabilitation treatment without inpatient phase and 137 (32.5%) received no rehabilitation. In fracture these rates were 494(73.5%), 96(14.3%) and 82(12.2%) respectively. Patients living in districts with lower availability of rehabilitation beds were less likely to receive inpatient rehabilitation after controlling for patient characteristics.

CONCLUSIONS

Regional disparities in the provision of inpatient rehabilitation care for elderly after an acute episode of stroke or hip fracture were identified and could be partially attributed to the distribution of rehabilitation beds. These findings highlight the need to plan the rehabilitation resources based on the population needs and to routinely monitor the provision of these services.

Adherence to treatment with selective serotonin reuptake inhibitors and the risk for fractures and bone loss: a population-based cohort study

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are suspected of increasing the risk of bone loss and osteoporotic fractures.

OBJECTIVE

The aim of this study was to investigate the association between adherence to SSRI treatment and the risk of bone loss-related events.

METHODS

The data used in this retrospective cohort study are part of the ongoing medical documentation routinely collected in a large health maintenance organization in Israel. Specifically, we used the information collected between January 2004 and April 2010. The study cohort included 10 621 women who were new users of SSRIs. Bone loss-related events were defined as fractures or initiation of bisphosphonate treatment. Adherence level was assessed by calculating the proportion of days covered (PDC) with an SSRI from the date of first dispensed SSRI (index date) to the end of follow-up and was categorized as low (PDC ≤20%), intermediate (PDC 21-79%) and high (PDC ≥80%). To validate the study model, we conducted a similar analysis on patients using antiepileptic drugs, which are known to be positively associated with an increased risk of osteoporotic fractures.

RESULTS

Higher adherence to SSRI treatment was significantly associated with an increased risk of bone loss-related events in a dose-response manner. The adjusted hazard ratio for bone loss-related events adjusted for age, physician visits and body mass index in patients who were covered with an SSRI for 21-79% of the time and 80% or more of the time was 1.15 (95% CI 0.97, 1.37) and 1.40 (95% CI 1.14, 1.73) compared with patients who were covered for less than 21% of the follow-up period.

CONCLUSION

Exposure to SSRI treatment is associated with an increased risk of bone loss-related events. Further studies are required to determine the causality of the association and its relevance to the clinical use of SSRIs.

Diabetes, gestational diabetes and the risk of cancer in women: epidemiologic evidence and possible biologic mechanisms

At present, more than 10% of adult American women are diagnosed with diabetes mellitus (DM). As the prevalence of the disease increases, there is greater interest in the relationship between DM and other major health issues, such as cancer - one of the leading causes of death in the western world. This paper reviews the literature on the relationship between Type 2 DM and different types of cancer among women. We discuss the possible biological mechanisms that may link diabetes and cancer, important confounders, shared risk factors and a short review of the epidemiologic literature on the association between Type 2 DM and cancer of specific organs (pancreas, liver, colorectal, bladder, endometrial, non-Hodgkin's lymphoma and breast). We also examine the association between gestational diabetes, a closely related risk factor for DM in women, and subsequent risk of cancer. Cancer survival of diabetic women is also briefly discussed. The paper concludes with an agenda for future research targeting the relationship between diabetes and cancer.