Dissemination of Kingella kingae in the community and long-term persistence of invasive clones.

BACKGROUND: Although Kingella kingae is being increasingly recognized as an important pediatric pathogen, our current understanding of the transmission of the organism is limited. The dissemination of K. kingae in the community was studied in 2 ethnic groups living side-by-side in Southern Israel. METHODS: Organisms recovered from oropharyngeal cultures, obtained from healthy young Jewish and Bedouin children during a 12-month period, were typed by pulsed-field gel electrophoresis and compared. RESULTS: Isolates from Bedouin children usually differed from those derived from Jews, confirming the relative social isolation of the 2 populations and the importance of close mingling in the spread of K. kingae. Significant clustering of genotypic clones in households and Bedouin neighborhoods was observed, indicating person-to-person transmission through intimate contact. Organisms detected in the study were identical to historical isolates recovered over the last 15 years from respiratory carriers and patients with bacteremia or skeletal infections. CONCLUSIONS: The present study demonstrates that children may be asymptomatically colonized in the respiratory tract by virulent K. kingae clones. The organism is transmitted from child-to-child through intimate contact. Some strains exhibit increased fitness and are maintained in the population for prolonged periods.

Ethnic ancestry and increased paternal age are risk factors for breast cancer before the age of 40 years.

To study the risk factors associated with breast cancer in women younger than 40 years, a cohort study (The Jerusalem Perinatal Study) of 42 822 female offspring born in hospitals in West Jerusalem during 1964-1976 was carried out. Hazard ratios of potential parental and perinatal risk factors for early breast cancer were measured. The overall incidence of breast cancer was 5.2/100 000 person-years. The highest incidence was found among Jewish women of West Asian ancestry (8.6/100 000 person-years), specifically those whose maternal grandfathers were born in Iraq, Iran or Afghanistan (9.5/100 000 person-years). Using Cox models we found independent risk factors for early breast cancer to be paternal age (relative risk/year=1.06, 95% confidence interval=1.02-1.10, P=0.005), and ancestry from Iraq/Iran/Afghanistan (relative risk=3.1, 95% confidence interval=1.50-6.52, P=0.002). The study confirms a previously observed effect of advanced paternal age on the occurrence of early breast cancer and identifies a novel population group at increased risk for the disease. The excess risk of early breast cancer associated with ancestry from Iraq, Iran and Afghanistan suggests involvement of genetic determinants, environmental exposures and/or lifestyle factors and mandates further investigation.

Survival of critically ill patients hospitalized in and out of intensive care.

OBJECTIVE: A lack of intensive care units beds in Israel results in critically ill patients being treated outside of the intensive care unit. The survival of such patients is largely unknown. The present study's objective was to screen entire hospitals for newly deteriorated patients and compare their survival in and out of the intensive care unit. DESIGN: A priori developed intensive care unit admission criteria were used to screen, during 2 wks, the patient population for eligible incident patients. A screening team visited every hospital ward of five acute care hospitals daily. Eligible patients were identified among new admissions in the emergency department and among hospitalized patients who acutely deteriorated. Patients were followed for 30 days for mortality regardless of discharge. SETTING: Five acute care hospitals. PATIENTS: A total of 749 newly deteriorated patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Crude survival of patients in and out of the intensive care unit was compared by Kaplan-Meier curves, and Cox models were constructed to adjust the survival comparisons for residual case-mix differences. A total of 749 newly deteriorated patients were identified among 44,000 patients screened (1.7%). Of these, 13% were admitted to intensive care unit, 32% to special care units, and 55% to regular departments. Intensive care unit patients had better early survival (0-3 days) relative to regular departments (p=.0001) in a Cox multivariate model. Early advantage of intensive care was most pronounced among patients who acutely deteriorated while on hospital wards rather than among newly admitted patients. CONCLUSIONS: Only a small proportion of eligible patients reach the intensive care unit, and early admission is imperative for their survival advantage. As intensive care unit benefit was most pronounced among those deteriorating on hospital wards, intensive care unit triage decisions should be targeted at maximizing intensive care unit benefit by early admitting patients deteriorating on hospital wards.

Graft survival and its determinants: a 3 year national experience with liver transplantation in Israel.

BACKGROUND: There is a dearth of organs for liver transplantation in Israel. Enhancing our understanding of factors affecting graft survival in this country could help optimize the results of the transplant operation. OBJECTIVES: To report 3 years national experience with orthotopic liver transplantation, and to evaluate patient and perioperative risk factors that could affect 1 year graft survival. METHODS: The study related to all 124 isolated adult liver transplantations performed in Israel between October 1997 and October 2000. Data were abstracted from the medical records. One-year graft survival was described using the Kaplan-Meier survival curve and three multivariate logistic regression models were performed: one with preoperative case-mix factors alone, and the other two with the addition of donor and operative factors respectively. RESULTS: Of the 124 liver transplantations performed, 32 failed (25.8%). The 1 year survival was lower than rates reported from both the United States and Europe but the difference was not significant. Of the preoperative risk factors, recipient age > 60 years, critical condition prior to surgery, high serum bilirubin and serum hemoglobin < or = 10 g/dl were independently associated with graft failure, adjusting for all the other factors that entered the logistic regression equation. Extending the model to include donor and operative factors raised the C-statistic from 0.79 to 0.87. Donor age > or = 40, cold ischemic time > 10 hours and a prolonged operation (> 10 hours) were the additional predictors for graft survival. A MELD score of over 18 was associated with a sixfold increased risk for graft failure (odds ratio = 6.5, P = 0.001). CONCLUSIONS: Graft survival in Israel is slightly lower than that reported from the U.S. and Europe. Adding donor and operative factors to recipient characteristics significantly increased our understanding of 1 year survival of liver grafts.

Negative impact of 'old-to-old' donations on success of cadaveric renal transplants.

The effect of 'old-to-old' cadaveric renal transplants on operative complications and graft survival was assessed in all 325 patients undergoing solitary cadaveric renal transplantations in Israel during a 3-yr period. Preoperative information and hospital course data were abstracted from the charts. Results were analyzed using Kaplan-Meyer survival curves, univariate and multivariate Cox models. Overall, 62 (19.1%) grafts failed within a year. Failure rate was 46.2% for 'old-to-old' transplants compared with 15.5% for all other donor/recipient age combinations (p < 0.0001). 'Old-to-old' transplants remained independently associated with graft failure in a multivariate Cox model after controlling the effect of other risk factors. 'Old-to-old' transplants were also associated with increased operative complications relative to other age combinations. The decision to use 'old-to-old' transplants, even when donors are scarce, is problematic and should be reconsidered.

Factors associated with primary and secondary graft failure following cadaveric kidney transplant.

The risk profile for primary renal graft failure is largely unknown because of its inclusion with secondary failures or its exclusion from analysis. This study compares characteristics of the cadaveric transplant recipients who experienced primary failure, secondary failures or survived with a functioning graft for at least 6 months. Medical records of all cadaveric kidney-transplant patients performed in Israel over a 3-yr period 1997-2000 were reviewed. Fisher's exact test and multinomial regression models were used to assess the association of demographic, pre-operative and operative risk factors with the two types of failure outcomes. Of 325 grafts, 54 (16.6%) failed of which half were primary failures. Univariate analysis demonstrated a significant trend of increasing proportion of patients with specific risk factors from the functioning grafts group to the secondary and to the primary graft failure groups. Independent risk factors for primary graft failure included 'surgical complications', 'donor's age > or =60 yr', 'waiting for transplant > or =6 yr', and 'human leukocyte antigen-DR (HLA-DR) mismatch', based on the multivariate model. These factors may reflect the scarcity of organ donations in Israel, which leads to a prolonged waiting time, higher tolerance for HLA-DR mismatches, and utilization of kidneys from elderly donors.