Changing practice to increase rates of spinal anaesthesia for total joint replacement.

BACKGROUND: Neuraxial anaesthesia for lower extremity total joint replacement surgery has several advantages over general anaesthesia; however, we encountered resistance to routine use of spinal anaesthesia and standardised analgesic regimens at our large, tertiary hospital. Our Perioperative Surgical Home led to multidisciplinary education and enhanced communication to change practice, with the purpose of increasing rates of neuraxial anaesthetics for these surgeries. METHODS: Team members from anaesthesia, nursing and surgery participated in the development and adoption of the care pathway. After implementation, we performed a retrospective analysis to examine the impact of the pathway on primary anaesthetic choice. Data were analysed using Student's t-test and interrupted time series analysis. RESULTS: The rate of neuraxial anaesthetics increased following implementation of the total joint pathway. CONCLUSION: With multidisciplinary collaboration, we were able to change practice towards spinal anaesthesia, despite a large and diverse group of practitioners.

Sick of news? Television news exposure, collective stressful events and headache related emergency department visits.

Stress is a well-known trigger for primary headache yet its impact is difficult to demonstrate in large epidemiological studies. Israeli national TV news is often referred to as the "tribal fire", as many Israelis watch national news coverage following terror attacks or military operations. We examined the association between exposure to television news and their content with headache related Emergency Department visits. This retrospective cohort study included data on daily Emergency Department visits with a chief complaint of headache in Soroka University Medical Center, during 2002-2012. Data on daily television news viewership ratings were obtained from the Israeli Audience Research Board and its content from Channel 2 headlines, the highest rated TV news program. To estimate the short-term effects of news rating during the evening news on the number of daily headache visits, we applied generalized linear mixed models. 16,693 Emergency Department visits were included in the analysis. An increase in five units of daily rating percentages was associated with increase in Emergency Department visits the following day, relative risk (RR) = 1.032, (95% CI 1.014-1.050). This association increased with the age of the patients; RR = 1.119, (95% CI 1.075-1.65) for older than 60-year-old, RR = 1.044 (95% CI 1.010-1.078) for ages 40-60 and RR = 1.000 (95% CI 0.977-1.023) for younger than 40-year-old. We did not find a specific content associated with ED visit for headache. Higher television news ratings were associated with increased incidence of Emergency Department headache related visits. We assume that especially among older persons, news viewership ratings provide an indirect estimate of collective stress, which acts as a headache trigger for susceptible subjects.

Global mortality from outdoor fine particle pollution generated by fossil fuel combustion: Results from GEOS-Chem.

The burning of fossil fuels - especially coal, petrol, and diesel - is a major source of airborne fine particulate matter (PM2.5), and a key contributor to the global burden of mortality and disease. Previous risk assessments have examined the health response to total PM2.5, not just PM2.5 from fossil fuel combustion, and have used a concentration-response function with limited support from the literature and data at both high and low concentrations. This assessment examines mortality associated with PM2.5 from only fossil fuel combustion, making use of a recent meta-analysis of newer studies with a wider range of exposure. We also estimated mortality due to lower respiratory infections (LRI) among children under the age of five in the Americas and Europe, regions for which we have reliable data on the relative risk of this health outcome from PM2.5 exposure. We used the chemical transport model GEOS-Chem to estimate global exposure levels to fossil-fuel related PM2.5 in 2012. Relative risks of mortality were modeled using functions that link long-term exposure to PM2.5 and mortality, incorporating nonlinearity in the concentration response. We estimate a global total of 10.2 (95% CI: -47.1 to 17.0) million premature deaths annually attributable to the fossil-fuel component of PM2.5. The greatest mortality impact is estimated over regions with substantial fossil fuel related PM2.5, notably China (3.9 million), India (2.5 million) and parts of eastern US, Europe and Southeast Asia. The estimate for China predates substantial decline in fossil fuel emissions and decreases to 2.4 million premature deaths due to 43.7% reduction in fossil fuel PM2.5 from 2012 to 2018 bringing the global total to 8.7 (95% CI: -1.8 to 14.0) million premature deaths. We also estimated excess annual deaths due to LRI in children (0-4 years old) of 876 in North America, 747 in South America, and 605 in Europe. This study demonstrates that the fossil fuel component of PM2.5 contributes a large mortality burden. The steeper concentration-response function slope at lower concentrations leads to larger estimates than previously found in Europe and North America, and the slower drop-off in slope at higher concentrations results in larger estimates in Asia. Fossil fuel combustion can be more readily controlled than other sources and precursors of PM2.5 such as dust or wildfire smoke, so this is a clear message to policymakers and stakeholders to further incentivize a shift to clean sources of energy.

Estimation of excess mortality due to long-term exposure to PM2.5 in continental United States using a high-spatiotemporal resolution model.

BACKGROUND: Exposure to fine particulate matter (<2.5 mm in aerodynamic diameter, PM2.5) pollution, even at low concentrations is associated with increased mortality. Estimates of the magnitude of the effect of particulate air pollution on mortality are generally done on a coarse spatial scale, such as 0.5°, and may fail to capture small spatial differences in exposure and baseline rates, which can bias results and impede the ability to consider environmental justice. We estimated the burden of mortality attributable to long-term exposure to ambient PM2.5 among adults in the Continental United States on a 1 km scale, in order to provide information for decision makers setting health priorities. METHODS: We conducted a health impact assessment for 2015 using a model predicting U.S. PM2.5 concentrations at a spatial resolution of 1 km cells. We applied a concentration-response curve from a recently published meta-analysis of long-term PM2.5 mortality association which incorporates new findings at high and low PM2.5 concentrations. We computed the change in deaths in each grid cell, based on its grid cell population, Zip code level baseline mortality rates, and exposure under two scenarios; a decrease of PM2.5 exposure levels by 40% and a decrease of PM2.5 exposure levels to the county minimum PM2.5 concentrations. RESULTS: We estimated the deaths would fall by 104,786 (95% CI 57,016-135,726) and 112,040 (95% CI 63,261-159,116) attributable to 40% reduction and reduction to the county minimum PM2.5 concentrations, respectively. The greatest mortality impact due to 40% reduction in PM2.5 was observed in California with; 11,621 (95% CI; 7156-15,989) and Texas with; 9616 (95% CI; 5798-13,352) excess deaths attributable to annual mean PM2.5 concentrations of 9.54 and 9.12 µg m-3, respectively. Within city analyses showed substantial heterogeneity in risk. The estimated Attributable fraction (AF %) in locations with high PM2.5 levels was 8.6% (95% CI 5.4-11.7) compared to the overall AF% of 4.9% (95% CI; 2.9-6.8). In comparison, results using county average PM2.5 were smaller than the estimates from the 1 km PM2.5 datasets. Similarly, estimates using county-level mortality rates were smaller than estimates based on Zip-code level mortality rates. CONCLUSIONS: Our study provides evidence of major health benefits expected from reducing PM2.5 exposure, even in regions with relatively low PM2.5 concentrations. Spatial characteristics of exposure and baseline mortality (e.g., accuracy, scales, and variations) in disease burden studies can significantly impact the results.

Suicide behavior and meteorological characteristics in hot and arid climate.

BACKGROUND: Suicidal behavior is determined by the consequence of an interaction between biological, psychological and sociological factors, as well as between individual and environmental effects. Fluctuations in meteorological factors can modify human behavior and affect suicidal rates. We hypothesize that high temperatures can be associated with an increase rate of suicidal attempts. METHODS: We included all the patients admitted to Soroka University Medical Center (SUMC) due to suicide attempts between the years 2002-2017 and were residents of Southern Israel. We computed two sets of regression models: first, a time stratified case-crossover design to control for seasonality and individual differences. Results are presented as odds ratio (OR) with confidence interval (CI); and then, time-series analyses to calculate the incidence rate ratio (IRR) and the cumulative effect of temperature on the daily incidences of emergency department (ED) admissions after suicide attempts. We stratified the analyses by demographic variables to identify significant individual differences. RESULTS: We identified 3100 attempts, by 2338 patients who lived in Be'er Sheva between 16 and 90 years of age; 421 patients made 2+ attempts. Suicide attempts were associated with a 5 °C increase during the summer season (OR 1.59, 95% CI 1.22-2.08) and a 5 °C increase in all seasons was associated with those who have made multiple attempts (OR 1.18, 95% CI 1.0005-1.38). The cumulative effect of 5 °C increment is associated with more suicide attempts over 2 days (IRR 1.10, 95% CI 0.98; 1.24) and 5 days (IRR 1.04, 95% CI 1.00; 1.08). The associations were greater for patients with psychiatric diagnosis and patients with multiple attempts. In a stratified analysis by individual characteristics we didn't find significant association. CONCLUSION: High temperatures and low amount of precipitations are evidently of great impact on people's susceptibility to suicidal behavior, especially for individuals who have had a prior suicide attempt. Our findings indicate the need for public health attention in the summer when temperature increases precipitously over days, especially for those who have made a prior suicide attempt.

Air Quality and Health Impact of Future Fossil Fuel Use for Electricity Generation and Transport in Africa.

Africa has ambitious plans to address energy deficits and sustain economic growth with fossil fueled power plants. The continent is also experiencing faster population growth than anywhere else in the world that will lead to proliferation of vehicles. Here, we estimate air pollutant emissions in Africa from future (2030) electricity generation and transport. We find that annual emissions of two precursors of fine particles (PM2.5) hazardous to health, sulfur dioxide (SO2) and nitrogen oxides (NOx), approximately double by 2030 relative to 2012, increasing from 2.5 to 5.5 Tg SO2 and 1.5 to 2.8 Tg NOx. We embed these emissions in the GEOS-Chem model nested over the African continent to simulate ambient concentrations of PM2.5 and determine the burden of disease (excess deaths) attributable to exposure to future fossil fuel use. We calculate 48000 avoidable deaths in 2030 (95% confidence interval: 6000-88000), mostly in South Africa (10400), Nigeria (7500), and Malawi (2400), with 3-times higher mortality rates from power plants than transport. Sensitivity of the burden of disease to either population growth or air quality varies regionally and suggests that emission mitigation strategies would be most effective in Southern Africa, whereas population growth is the main driver everywhere else.

[PREMEDICATION WITH CORTICOSTEROIDS PRIOR TO IV INFLIXIMAB - A COMPARISON BETWEEN INFLAMMATORY BOWEL DISEASE (IBD) AND RHEUMATIC PATIENTS].

INTRODUCTION: Infliximab is a protein with an anti TNF-α activity which is given in an intra-venous manner to treat inflammatory bowel disease and inflammatory joint disease. This treatment may cause infusion reaction events, but this may be prevented using treatment with pre-medication. OBJECTIVES: To assess the incidence of infusion reaction in patients with inflammatory bowel disease and patients with rheumatic disease who are treated with Infliximab, with or without corticosteroid premedication respectively. To determine whether premedication with corticosteroids decreases the incidence of infusion reactions. METHODS: We conducted a retrospective cohort study at the Soroka Medical Center that includes records from 92 patients treated with Infliximab: Group A includes 70 inflammatory joint disease patients who were not treated with hydrocortisone premedication and, group B includes 22 inflammatory bowel disease patients who were treated with hydrocortisone premedication. Incidence and severity of infusion reaction were assessed. RESULTS: The incidence of infusion reactions in the group which did not receive premedication was 26.1% (18/69), while in the group receiving premedication the incidence was 13.6% (3/22). Results are not statistically significant but reflect a trend. Most reactions occurred in the second treatment and most were of medium severity. CONCLUSIONS: The results seem to reflect a positive trend favoring the use of premedication with hydrocortisone before Infliximab infusion, especially given the minor side-effects of this treatment.

Pain sensitivity and athletic performance.

BACKGROUND: The objective of the study is to determine whether higher pain thresholds are associated with better performance in long-distance runners. METHODS: Seventy participants, divided into groups of fast and non-fast runners according to peak results in a 10km run. Main Outcome Measures, Cold pressor test. RESULTS: Of the 70 participants, 28 were in the fastest group (less than 39 minutes in a 10km run) and 42 in the non-fast group. The faster group was characterized with older age (34.0±8.5 vs. 29.5±5.7, P=0.01), greater mean weekly running time (5.5 [0-17]) vs. 2 [0-10], P<0.001), and more years of running (10 [1.5-34.0] vs. 7 [0-20, P=0.05]). In a multivariable analysis longer cold pressor time was associated with faster 10Km run (OR 1.01, 95% CI 1.00-1.01). CONCLUSIONS: It seems that higher pain thresholds play an important role in the superior ability of long distance runners.

The concentration-response between long-term PM2.5 exposure and mortality; A meta-regression approach.

BACKGROUND: Long-term exposure to ambient fine particulate matter (≤ 2.5 µg/m3 in aerodynamic diameter; PM2.5) is significantly associated with increased risk of premature mortality. Our goal was to provide an updated meta-analysis of all-cause and cause-specific mortality associated with exposure to PM2.5 and to better estimate the risk of death as a function of air pollution levels. METHODS: We systematically searched all published cohort studies examining the association between long term exposure to PM2.5 and mortality. We applied multivariate linear random effects meta-analysis with random effects for cohort, and study within cohort. Meta-regression techniques were used to test whether study population or analytic characteristics modify the PM2.5 -mortality association and to estimate the shape of the concentration-response curve. RESULTS: A total of 53 studies that provided 135 estimates of the quantitative association between the risk of mortality and exposure to PM2.5 were included in the meta-analysis. There were 39 studies from North America, 8 from Europe, and 6 from Asia. Since 2015, 17 studies of long-term air pollution exposure have been published, covering, wider geographic areas with a wider range of mean exposures (e.g. <12 or > 20 µg/m3). A penalized spline showed the slope decreased at higher concentrations but appeared to level off. We found that the inverse transform of average PM2.5 well approximated that spline and provided a parametric estimate that fit better than a linear or logarithmic term for average PM2.5. In addition, we found that studies using space time exposure models or fixed monitors at Zip-code scale (as compared to land use regression method), or additionally controlling for area level socio-economic status, or with mean exposure less than 10 µg/m3 were associated with higher mortality effect estimates. CONCLUSIONS: This meta-analysis provides strong evidence for the adverse effect of PM2.5 on mortality, that studies with poorer exposure have lower effect size estimates, that more control for SES increases effect size estimates, and that significant effects are seen below 10 µg/m3. The concentration -response function produced here can be further applied in the global health risk assessment of air particulate matter.

Predictors of post-colonoscopy emergency department use.

BACKGROUND AND AIMS: Unplanned hospital visits within 7 days of colonoscopy were recently proposed as a quality measure. It is unknown whether patient, procedure, or endoscopist characteristics predict post-colonoscopy emergency department (ED) visits. Our aim was to determine the incidence and relatedness of ED visits within 7 days of colonoscopy and to identify predictors of post-colonoscopy ED use. METHODS: In this retrospective, single-center, cohort study, we evaluated outpatient colonoscopies performed at a tertiary academic medical center or affiliated facility between January 2008 and September 2013. We determined the incidence of ED visits within 7 days of colonoscopy and the relatedness of the ED visit to the procedure. We assessed for independent factors associated with ED use within 7 days using logistic regression analysis. RESULTS: We reviewed 50,319 colonoscopies performed on 44,082 individuals (47% male, median age 59 years) by 40 endoscopists. There were 382 (0.76%) ED visits after colonoscopy, of which 68% were related to the procedure. On multivariate analysis, recent ED visit (odds ratio [OR], 16.60; 95% confidence interval [CI], 12.83-21.48; P < .001), EMR (OR, 4.69; 95% CI, 2.82-7.79; P < .001), number of medication classes (OR, 1.18; 95% CI, 1.11-1.26; P < .001), endoscopist adenoma detection rate (ADR) (OR, 1.14; 95% CI, 1.01-1.29; P = .029), and white race (OR, 0.77; 95% CI, 0.62-0.97; P = .028) were identified as independent variables associated with ED visits after colonoscopy. CONCLUSIONS: Increased patient complexity, higher endoscopist ADR, and EMR were associated with increased ED use after colonoscopy. Patients at high risk for an unplanned hospital visit within 7 days should be targeted for quality improvement efforts to reduce adverse events and cost.

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

AIM: We evaluated the diagnosis, risk stratification and management of febrile infants under three months of age who presented to an Israeli paediatric emergency room (ER). METHODS: This retrospective study enrolled all febrile infants examined in the paediatric ER of Soroka Medical Center during 2010-2013. The patients were classified into low-risk and high-risk subgroups and compared by age and ethnicity. RESULTS: Overall, 2251 febrile infants (60.5% of Bedouin and 34.4% of Jewish ethnicity) were enrolled. Hospitalisation rates were higher among Bedouin vs. Jewish infants (55 vs. 39.8%, p < 0.001). Fever without localising signs was diagnosed in 1028 (45.6%) infants and 499 (48.5%) were hospitalised; 26% were stratified as high-risk and 74% as low-risk. Bedouin infants rates were more likely to be at high-risk (p = 0.001) and hospitalised (p < 0.001) than Jewish infants. With regard to low-risk infants, the incidence rates were higher before two months than two to three months of age (73.3 vs. 59%, p < 0.001), as were the hospitalisation rates (46.3 vs. 20.1%, p < 0.001). No differences were recorded for the hospitalisation rates of Bedouin and Jewish infants between the three daily shifts. CONCLUSION: Major differences were recorded in hospitalisation rates, risk stratification and management of Bedouin and Jewish infants with fever without localising signs.

Do Gender and Season Modify the Triggering Effect of Ambient Temperature on Ischemic Stroke?

BACKGROUND: Ischemic stroke (IS) is a multifactorial disorder, a leading cause of long-term disability, and the second most common cause of death. Previous studies have examined the association between stroke and weather conditions with conflicting results. In this study we aimed to investigate the association between changes in ambient temperature and risk of IS onset. METHODS: We used a time-stratified case-crossover study design including all patients admitted to Soroka University Medical Center in southern Israel between 2012 and 2014 for IS. Exposure windows of 6, 12, 24, 48, 72, and 96 hours were examined. All patients were assessed and classified by a neurologist. Temperature (°C), and relative humidity (%) were obtained from monitoring stations located in Beer-Sheva. RESULTS: A total of 1,174 patients visited Soroka University Medical Center for admission for an IS during the study period. Among them, 56% were male, on average 69.8 ± 13.1 years old. IS incidence was associated with increase in temperature during the summer and autumn season over the 96 hours preceding symptoms onset; the odds ratio (OR) for an increase of 5°C was 3.10 (95% CI, 1.45-6.61) during the summer and 1.86 (95% CI, 1.15-2.99) in autumn. The association between temperature and stroke onset during the winter was negative (OR, 0.68; 95% CI, 0.48-0.97) for 96-hour moving average temperature exposure. Men were more sensitive to 96-hour exposure window temperature fluctuations (OR, 1.35; 95% CI, 1.01-1.80) than women (OR, 0.96; 95% CI, 0.68-1.36). We did not find any associations between IS onset and differences between the maximum and minimum measurements of temperature. CONCLUSIONS: Our findings showed that short-term exposure to high temperatures is associated with a higher risk of IS in men but not in women. Further study is needed to validate this observation and to understand its pathophysiology.

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

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

Does preparation of children before MRI reduce the need for anesthesia? Prospective randomized control trial.

BACKGROUND: Magnetic resonance imaging has been recognized for years as the safest and most precise imaging method, particularly for children. The accuracy of MRI depends on avoidance of patient movement during the study. This may be difficult for children and may require anesthesia. OBJECTIVE: We evaluated an introductory instruction program as an assistive tool in performing MRI without anesthesia. MATERIALS AND METHODS: In one institution, 121 children were randomized to undergo full interactive pre-MRI instruction (n=64), which included an instructional booklet, movie and simulator practice, or partial instruction (n=57), comprised of the booklet only. All researchers and health care professionals involved, except for the one who instructed the families, were masked to the group allocation. Parents' anxiety, according to the Spielberger state anxiety inventory, was measured. RESULTS: Median age was 7.4 years (range: 5 years-16 years). Anesthesia was required for fewer children who received full compared to partial instruction: 17 (27%) vs. 27 (47%), P≤0.02. The median anxiety level prior to instruction was higher than the median level after instruction, for both the partial and full instruction groups. CONCLUSION: Instruction including simulator practice was associated with a decreased need for anesthesia among children undergoing MRI scans.

Risk of Venous Thromboembolism After Receiving Prothrombin Complex Concentrate for Warfarin-associated Intracranial Hemorrhage.

BACKGROUND: Prothrombin complex concentrates (PCCs) are commonly used to rapidly reverse warfarin-associated coagulopathy; however, venous thromboembolism (VTE) is an established adverse event. OBJECTIVE: To determine risk factors for VTE AFTER administration of a three-factor prothrombin complex concentrate (3F-PCC) for warfarin-associated intracranial hemorrhage (ICH). METHODS: Retrospective chart review of all patients with a warfarin-associated ICH who received a 3F-PCC at a single tertiary care hospital between 2008 and 2013. Outcomes were VTE events (defined as deep vein thrombosis [DVT], pulmonary embolism [PE], limb ischemia, transient ischemic attack, cerebrovascular accident, non-ST-segment elevation myocardial infarction, ST-segment elevation myocardial infarction, and unexplained sudden death) occurring within 30 days of 3F-PCC administration. Risk factors in subjects with and without VTE complications were compared via Fisher's exact test, Student's t-test, Mann-Whitney U test, and univariate logistic regression as appropriate. RESULTS: Two hundred nine subjects received 3F-PCC for warfarin-associated ICH. There were 22 VTE events in 19 subjects (9.1%). Baseline characteristics of subjects with and without VTE were similar. There was a significant increase in VTE events in 29 subjects who were taking warfarin for a previous PE or DVT (36.8% vs. 11.6%, p = 0.007; logistic regression odds ratio 4.455, p = 0.005). CONCLUSIONS: Patients with a prior history of PE or DVT who were given 3F-PCC for warfarin-associated ICH were 4.5 times more likely to sustain a VTE within 30 days. A careful analysis of risks and benefits of rapidly reversing anticoagulation must be made prior to the administration of 3F-PCC in this patient population.

A New Cutoff for Abnormal Proteinuria in Diabetes Mellitus Patients: Relationship to Albuminuria.

BACKGROUND: Proteinuria and albuminuria are markers of kidney injury and function, serving as a screening test as well as a means of assessing the degree of kidney injury and risk for cardiovascular disease and death in both the diabetic and the non-diabetic general population. OBJECTIVES: To evaluate the association between proteinuria below 300 mg/24 hours and albuminuria, as well as a possible association with kidney function in patients with diabetes mellitus (DM). METHODS: The medical files of patients with type 1 and type 2 DM with proteinuria below 300 mg/24 hours at three different visits to the Diabetic Nephropathy Clinic were screened. This involved 245 patient files and 723 visits. The data collected included demographics; protein, albumin and creatinine levels in urine collections; blood biochemistry; and clinical and treatment data. RESULTS: The association between proteinuria and albuminuria is non-linear. However, proteinuria in the range of 162-300 mg/24 hours was found to be linearly and significantly correlated to albuminuria (P < 0.001, r = 0.58). Proteinuria cutoff, based on albuminuria cutoff of 30 mg/24 hours, was found to be 160.5 mg/24 hr. Body mass index (BMI) was the sole independent predictor of proteinuria above 160.5 mg/24 hr. Changes in albuminuria, but not proteinuria, were associated with changes in creatinine clearance. CONCLUSIONS: A new cutoff value of 160.5 mg/hr was set empirically, for the first time, for abnormal proteinuria in diabetic patients. It appears that proteinuria below 300 mg/24 hr is not sufficient as a sole prognostic factor for kidney failure.

Individual Effect Modifiers of Dust Exposure Effect on Cardiovascular Morbidity.

BACKGROUND: High concentrations of particulate matter (PM) air pollution have been associated with death and hospital admissions due to cardiovascular morbidity. However, it is not clear a) whether high levels of non-anthropogenic PM from dust storms constitute a health risk; and b) whether these health risks are exacerbated in a particular demographic. METHODS: This study comprised all patients above 18 years old admitted to Soroka University Medical Center (1000 bed tertiary hospital, Be'er-Sheva, Israel, 2001-2010) with a primary diagnosis of acute coronary syndrome (ACS). Data on meteorological parameters and PM10 (particulate matter <10 µm in aerodiameter) were obtained from monitoring stations in the city of Be'er-Sheva. Data were analyzed using a case crossover analysis to examine the effect of dust exposure on hospitalization due to ACS and the interaction with co-morbidities and demographic factors. RESULTS: There were 16,734 hospitalizations due to ACS during the study period. The estimated odds of hospitalization due to ACS was significantly associated with PM10 during non dust storm days at the same day of the exposure (lag0); OR = 1.014 (95%CI 1.001-1.027) for a 10 µg/m3 increase, while a delayed response (lag1) was found during the dust storm days; OR = 1.007 (95%CI 1.002-1.012). The effect size for the dust exposure association was larger for older (above the age of 65), female or Bedouin patients. CONCLUSIONS: Exposure to non-anthropogenic PM is associated with cardiovascular morbidity. Health risk associated dust exposure is gender and age specific with older women and Bedouin patients being the most vulnerable groups.

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

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

Ambient air pollution, weather and daily emergency department visits for headache.

BACKGROUND: Headache is a common condition, and a common complaint leading patients to emergency departments (ED). There have been a number of studies of the effect of environmental factors on headache, such as weather and air pollutants. METHODS: This retrospective cohort study included data on daily ED visits with a chief complaint of headache in Soroka University Medical Center (SUMC) during 2002-2012. Data on weather and air pollutants were obtained from monitor station in Be'er-Sheva. To estimate the short-term effects of air pollution and temperature on number of daily headache ED visits, we applied generalized linear mixed models (GLMM). RESULTS: A total of 22,021 ED visits were included in the analysis. An increase in 5℃ in temperature was associated with an increase in ED visits, relative risk (RR) = 1.042, (95% CI 1.009; 1.076). RR for headache was associated with an increase in 10 units of nitrogen dioxide (NO2), RR = 1.110 (95% CI 1.057; 1.167), with a higher effect for older patients. DISCUSSION: The current findings give evidence of an association between air pollution, weather and ED visits for headache, especially for NO2. Short-term increases in air pollution exposure may trigger headache by increasing pulmonary and systemic inflammation, increasing blood coagulability or altering endothelial function.