Publications by authors named "Victor Novack"

248 Publications

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

PLoS One 2021 8;16(4):e0249749. Epub 2021 Apr 8.

Neurology Department, Soroka University Medical Center, Beer-Sheva, Israel.

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.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249749PLOS
April 2021

Extreme temperature and out-of-hospital-cardiac-arrest. Nationwide study in a hot climate country.

Environ Health 2021 Apr 5;20(1):38. Epub 2021 Apr 5.

Negev Environmental Health Research Institute, Soroka University Medical Center, 84101, Beer Sheva, Israel.

Background: Out-of-hospital-cardiac arrest (OHCA) is frequently linked to environmental exposures. Climate change and global warming phenomenon have been found related to cardiovascular morbidity, however there is no agreement on their impact on OHCA occurrence. In this nationwide analysis, we aimed to assess the incidence of the OHCA events attended by emergency medical services (EMS), in relation to meteorological conditions: temperature, humidity, heat index and solar radiation.

Methods: We analyzed all adult cases of OHCA in Israel attended by EMS during 2016-2017. In the case-crossover design, we compared ambient exposure within 72 h prior to the OHCA event with exposure prior to the four control times using conditional logistic regression in a lag-distributed non-linear model.

Results: There were 12,401 OHCA cases (68.3% were pronounced dead-on-scene). The patients were on average 75.5 ± 16.2 years old and 55.8% of them were males. Exposure to 90th and 10th percentile of temperature adjusted to humidity were positively associated with the OHCA with borderline significance (Odds Ratio (OR) =1.20, 95%CI 0.97; 1.49 and OR 1.16, 95%CI 0.95; 1.41, respectively). Relative humidity below the 10th percentile was a risk factor for OHCA, independent of temperature, with borderline significance (OR = 1.16, 95%CI 0.96; 1.38). Analysis stratified by seasons revealed an adverse effect of exposure to 90th percentile of temperature when estimated in summer (OR = 3.34, 95%CI 1.90; 3.5.86) and exposure to temperatures below 10th percentile in winter (OR = 1.75, 95%CI 1.23; 2.49). Low temperatures during a warm season and high temperatures during a cold season had a protective effect on OHCA. The heat index followed a similar pattern, where an adverse effect was demonstrated for extreme levels of exposure.

Conclusions: Evolving climate conditions characterized by excessive heat and low humidity represent risk factors for OHCA. As these conditions are easily avoided, by air conditioning and behavioral restrictions, necessary prevention measures are warranted.
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http://dx.doi.org/10.1186/s12940-021-00722-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022396PMC
April 2021

Diabetes and glycemic control in necrotizing otitis externa (NOE).

Eur Arch Otorhinolaryngol 2021 Apr 1. Epub 2021 Apr 1.

Department of Otolaryngology-Head and Neck Surgery, Soroka University Medical Center and the Faculty of Health Sciences, Ben Gurion University, Yitzhak I. Rager Blvd 151, 84101, Beer Sheva, Israel.

Purpose: Although the association between necrotizing otitis externa (NOE) and diabetes mellitus (DM) is well known, there is little knowledge in regards to the effects of DM and glycemic control on the outcome of NOE. The aim of the study was to determine the effects of DM duration and glycemic control, and in-hospital glycemic control on NOE severity.

Methods: A retrospective case series analysis, including all patients hospitalized between 1990 and 2018 due to NOE were included. Data collected included NOE disease characteristics, duration of DM, DM-associated comorbidities, glycated hemoglobin (HbA1c), urine microalbumin and in-hospital blood glucose measurements. Disease severity was defined based on duration of hospitalization (above or below 20 days) and need for surgery.

Results: Eighty-nine patients were included in the study. Eighty-three patients (94.3%) had DM. Preadmission HbA1c was 8.13% (5.8-12.6%). Forty-nine patients (65.5%) had mean blood glucose of ≥ 140 mg/dL and 26 (34.5%) had ≤ 140 mg/dL. DM duration was 157.88 months among NOE patients who required surgery, and 127.6 months among patients who were treated conservatively (p value 0.25). HbA1c in patients hospitalized < 20 days was 7.6%, and 8.7% among NOE hospitalized ≥ 20 days (p value 0.027). Seven patients with mean blood glucose of ≤ 140 mg/dL had Pseudomonas Aeruginosa (PA-NOE) (26.7%), in comparison to 25 (51.0%) with mean blood glucose measurement of ≥ 140 mg/dL (p = 0.045).

Conclusions: HbA1c at admission is associated with longer hospitalization duration among NOE patients. Mean blood glucose during hospitalization was associated with a higher likelihood of PA infection, however, it had no effect on disease outcome.
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http://dx.doi.org/10.1007/s00405-021-06772-yDOI Listing
April 2021

Outcomes prediction in longitudinal data: Study designs evaluation, use case in ICU acquired sepsis.

J Biomed Inform 2021 Mar 9;117:103734. Epub 2021 Mar 9.

Department of Software and Information Systems Engineering, Ben Gurion University of the Negev, Beer-Sheva, Israel. Electronic address:

Outcomes' prediction in Electronic Health Records (EHR) and specifically in Critical Care is increasingly attracting more exploration and research. In this study, we used clinical data from the Intensive Care Unit (ICU), focusing on ICU acquired sepsis. Looking at the current literature, several evaluation approaches are reported, inspired by epidemiological designs, in which some do not always reflect real-life application's conditions. This problem seems relevant generally to outcomes' prediction in longitudinal EHR data, or generally longitudinal data, while in this study we focused on ICU data. Unlike in most previous studies that investigated all sepsis admissions, we focused specifically on ICU-Acquired Sepsis. Due to the sparse nature of the longitudinal data, we employed the use of Temporal Abstraction and Time Interval-Related Patterns discovery, which are further used as classification features. Two experiments were designed using three different outcomes prediction study designs from the literature, implementing various levels of real-life conditions to evaluate the prediction models. The first experiment focused on predicting whether a patient would suffer from ICU-acquired sepsis and when during her admission, given a sliding observation time window, and the comparison of the three study designs behavior. The second experiment focused only on predicting whether the patient will suffer from ICU-acquired sepsis, based on data taken relatively to his admission start time. Our results show that using Temporal Discretization for Classification (TD4C) led to better performance than using the Equal-Width Discretization, Knowledge-Based, or SAX. Also, using two states abstraction was better than three or four. Using the default Binary TIRP representation method performed better than Mean Duration, Horizontal Support, and horizontally normalized horizontal support. Using XGBoost as a classifier performed better than Logistic Regression, Neural Net, or Random Forest. Additionally, it is demonstrated why the use of case-crossover-control is most appropriate for real life application conditions evaluation, unlike other incomplete designs that may even result in "better performance".
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http://dx.doi.org/10.1016/j.jbi.2021.103734DOI Listing
March 2021

Examination of the association of steroids with fluid accumulation in critically ill patients, considering the possibility of biases.

Sci Rep 2021 Mar 10;11(1):5557. Epub 2021 Mar 10.

General Intensive Care Unit, Soroka University Medical Center, and The Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, 84101, Beer-Sheva, Israel.

Glucocorticoids might have significant influence on positive fluid balance, mostly due to their mineralocorticoid effect. We assessed the association between glucocorticoid therapy and fluid balance in septic patients, in the intensive care unit (ICU). We considered two definitions of exposure: daily exposure to glucocorticoids and glucocorticoid treatment at any time. Of 945 patients, 375 were treated with glucocorticoids in the ICU. We applied four regression models. In the first, fluid balance did not differ during days with and without glucocorticoid treatment, among patients treated and not treated with glucocorticoids in the ICU. In our second model, daily fluid balance was increased in patients who were ever treated with glucocorticoids during their ICU stay compared to untreated patients. In the third model, which included only patients treated with glucocorticoids during their ICU stay, glucocorticoid treatment days were not associated with daily fluid balance. In the last model, on "steroid-free days", patients who received glucocorticoid treatment during their ICU stay had a positive fluid balance compared to those who were never treated with steroids. Despite their known mineralocorticoid activity, glucocorticoids themselves appear not to contribute substantially to fluid retention. This work highlights the importance of precise selection of variables to mitigate biases.
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http://dx.doi.org/10.1038/s41598-021-85172-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946917PMC
March 2021

Differences in environmental factors contributing to preterm labor and PPROM - Population based study.

Environ Res 2021 Feb 18;196:110894. Epub 2021 Feb 18.

Negev Environmental Health Research Institute, Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel; Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er-Sheva, Israel.

Background: Previous reports indicate an association between ambient temperature (Ta) and air pollution exposure during pregnancy and preterm birth (PTB). Nevertheless, information regarding the association between environmental factors and specific precursors of spontaneous preterm birth is lacking. We aimed to determine the association between Ta and air pollution during gestation and the precursors of spontaneous preterm parturition, i.e. preterm labor (PTL) and preterm prelabor rupture of membranes (PPROM).

Methods: From 2003 to 2013 there were 84,476 deliveries of singleton gestation that comprised the study cohort. Exposure data during pregnancy included daily measurements of temperature and particulate matter <2.5 μm and <10 μm, PM and PM, respectively. Deliveries were grouped into PPROM, PTL and non-spontaneous preterm and term deliveries. Exposure effect was tested in windows of a week and two days prior to admission for delivery and adjusted to gestational age and socio-economic status. Poisson regression models were used for analyses.

Results: There is an association of environmental exposure with the precursors of spontaneous preterm parturition; PPROM was more sensitive to Ta fluctuations than PTL. This effect was modified by the ethnicity, Bedouin-Arabs were susceptible to elevated Ta, especially within the last day prior to admission with PPROM (Relative Risk (RR) =1.19 [95% CI, 1.03; 1.37]). Jews, on the other hand, were susceptible to ambient pollutants, two (RR=1.025 [1.010; 1.040]) and one (RR= 1.017 [1.002; 1.033]) days prior to spontaneous PTL with intact membranes resulting in preterm birth.

Conclusion: High temperature is an independent risk factor for PPROM among Bedouin-Arabs; ambient pollution is an independent risk factor for spontaneous PTL resulting in preterm birth. Thus, the precursors of spontaneous preterm parturition differ in their association with environmental factors.
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http://dx.doi.org/10.1016/j.envres.2021.110894DOI Listing
February 2021

Atrial Fibrillation and Mortality in the Oldest Old after Surgery for Hip Fractures.

Gerontology 2021 Feb 17:1-7. Epub 2021 Feb 17.

Emergency Medicine Department, Soroka University Medical Center, Beer-Sheva, Israel.

Introduction: One-year mortality following hip fractures increases steeply with age, from 2% in the 60- to 69-year-old population up to 28% in the oldest old (older than 90 years). Of the various factors that contribute to hip fractures, atrial fibrillation (AF) is an independent risk factor at any age.

Objective: The objective of this study was to assess the association of AF with mortality among the oldest old with hip fractures.

Method: This is a retrospective cohort study of 701 persons above age 90 years who underwent orthopedic repair for a hip fracture during 2000-2018. Of them, 218 (31%) had AF at hospital admission. The primary outcome was survival following surgery. We compared patient characteristics and 30-day, 180-day, 1-year, and 3-year survival between patients with and without AF.

Results: The adjusted odds ratio for 30-day postoperative mortality for those with AF versus without AF group was 1.03 (95% confidence interval [CI] 0.63-1.66). Survival estimates were higher among those without AF than with AF at 180 days postoperative: 0.85 (95% CI 0.82-0.89) versus 0.68 (95% CI 0.61-0.74), p < 0.001; at 1 year postoperative: 0.68 (95% CI 0.63-0.72) versus 0.48 (95% CI 0.42-0.55), p < 0.001; and at 3 years postoperative: 0.47 (95% CI 0.42-0.52) versus 0.28 (95% CI 0.27-0.34), p < 0.001.

Conclusions: Among individuals aged >90 years, operated for hip fractures, mortality was similar for those with and without AF at 30 days postoperative. However, the survival curves diverged sharply after 180 days. Our findings suggest that AF is not an immediate surgical risk factor, but rather confers increased long-term risk in this population.
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http://dx.doi.org/10.1159/000513450DOI Listing
February 2021

Computer tomography findings in necrotizing otitis externa based on the offending pathogens.

Eur Arch Otorhinolaryngol 2021 Jan 27. Epub 2021 Jan 27.

Department of Otolaryngology-Head and Neck Surgery, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University in the Negev, Beersheba, Israel.

Purpose: High-resolution temporal bone computer tomography (HRTBCT) is the most common initial radiological modality used for the assessment of necrotizing otitis externa (NOE).

Objectives: (1) To compare the extension of disease, as seen on HRTBCT, in patients with NOE caused by different pathogens and (2) assess whether radiological findings may suggest the offending pathogen in cases of sterile-NOE.

Methods: All NOE patients were hospitalized between 1990 and 2018. All patients underwent HRTBCT at admission. Three groups (fungus-NOE, PA-NOE and sterile-NOE) comprising of ten patients each were randomly selected. HRTBCT was reevaluated by a senior radiologist. Thirteen radiological subsites were selected for reevaluation.

Results: All patients in the fungal-NOE group complained of otalgia, compared to nine in the sterile-NOE and six in the PA-NOE groups (p value = 0.044). External ear canal edema and granulation tissue were the most common findings in all groups. Surgery was performed in five patients in the fungal-NOE and PA-NOE and three in the sterile-NOE group (p value =  > 0.05). Radiological findings indicating severe bone erosion within the EEC was seen in all patients but 3 (p value =  > 0.05). Severe TMJ erosion was seen in one patient within the fungal-NOE and PA-NOE group (p value =  > 0.05). When mild and severe involvement were combined, TMJ bone erosion was seen in four patients in the fungal-NOE and only in one patient in the PA-NOE (p = 0.04).

Conclusions: TMJ involvement may be more common in fungal disease, suggesting a different spreading pathway, as opposed to PA-NOE. Accordingly, TMJ involvement on HRTBCT may justify antifungal treatment in sterile culture-NOE.
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http://dx.doi.org/10.1007/s00405-020-06583-7DOI Listing
January 2021

Cannabis is associated with blood pressure reduction in older adults - A 24-hours ambulatory blood pressure monitoring study.

Eur J Intern Med 2021 Jan 20. Epub 2021 Jan 20.

Cannabis Clinical Research Institute and Clinical Research Center, Soroka University Medical Center, and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel. Electronic address:

Background: Medical cannabis use is increasing rapidly in the past several years, with older adults being the fastest growing group. Nevertheless, the evidence for cardiovascular safety of cannabis use is scarce. The aim of this study was to assess the effect of cannabis on blood pressure, heart rate, and metabolic parameters in older adults with hypertension.

Methods: We conducted a prospective study of patients aged 60 years or more with hypertension and a new prescription of cannabis. We have performed the following assessments: 24-hours ambulatory blood pressure monitoring, ECG, blood tests, and anthropometric measurements prior to the initiation of cannabis therapy and 3 months afterward. The primary outcome was change in mean 24-h blood pressure at 3 months.

Results: Twenty-six patients with a mean age of 70.42 ± 5.37 years, 53.8% females completed the study. At 3 months follow-up, the mean 24-hours systolic and diastolic blood pressures were reduced by 5.0 mmHg and 4.5 mmHg, respectively (p<0.001 for both). The nadir for the blood pressure and heart rate was achieved at 3 hours post-administration. The proportion of normal dippers changed from 27.3% before treatment to 45.5% afterward. No significant changes were seen in the different metabolic parameters assessed by blood tests, anthropometric measurements, or ECG exam.

Conclusion: amongst older adults with hypertension, cannabis treatment for 3 months was associated with a reduction in 24-hours systolic and diastolic blood pressure values with a nadir at 3 hours after cannabis administration.
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http://dx.doi.org/10.1016/j.ejim.2021.01.005DOI Listing
January 2021

Does methylphenidate use affect sperm parameters in patients undergoing infertility investigation? A retrospective analysis of 9769 semen samples.

Arch Gynecol Obstet 2021 Jan 12. Epub 2021 Jan 12.

Fertility and IVF Unit, Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Objectives: Methylphenidate (MPH) is the most widely prescribed therapy for attention deficit hyperactivity disorder. Animal studies have shown a potential adverse effect of MPH exposure on male fertility. We examined the impact of MPH on human male sperm parameters.

Design: Sperm parameters of 9769 samples from patients 18 years of age or older, collected as part of the basic evaluation of couples referred to the Infertility Clinic were analyzed retrospectively. We divided the study population into three groups according to MPH purchasing information: MPH purchased ≤ 90 days prior to sperm analysis-current users (n = 83), MPH purchased > 90 days prior to sperm analysis-past users (n = 293), and MPH-naïve patients (n = 9393).

Methods: All sperm samples were analyzed by the same laboratory technician team for the following routine parameters: semen volume, sperm concentration, percentage of motile sperm, and percentage of normal morphology according to World Health Organization. The analysis of the samples was completed by evaluation of total sperm count, total sperm motility, and percentage of fast and slow motile cells. Sperm morphology was evaluated by a laboratory technician using methodological examination according to the strict Kruger-Tygerberg criteria.

Results: Methylphenidate exposure did not affect sperm morphology but was associated with increased sperm concentration as well as increased total sperm count and total sperm motility among current and past users compared with MPH-naïve patients. In particular, progressive motility and total motile sperm count were significantly increased following MPH use. A multivariate analysis adjusting for age and current smoking was conducted, further supporting a positive correlation between current MPH use and increased values of total sperm count and total sperm motility.

Limitations: Our study has several inherent weaknesses, foremost of which is its retrospective nature. Another notable weakness is that medication purchasing data may not accurately reflect MPH exposure in the study population. Patients may be purchasing MPH and not taking it as prescribed.

Conclusions: In the present study, we could not demonstrate a negative impact of methylphenidate treatment on sperm parameters in adults with ADHD. Hence, we may assume that methylphenidate does not negatively affect male fertility.
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http://dx.doi.org/10.1007/s00404-020-05938-zDOI Listing
January 2021

Medical Practice Variation Among Primary Care Physicians: 1 Decade, 14 Health Services, and 3,238,498 Patient-Years.

Ann Fam Med 2021 Jan-Feb;19(1):30-37

Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel

Purpose: Variation in medical practice is associated with poorer health outcomes, increased costs, disparities in care, and increased burden on the public health system. In the present study, we sought to describe and assess inter- and intra-primary care physician variation, adjusted for patient and clinic characteristics, over a decade of practice and across a broad range of health services.

Methods: We assessed practice patterns of 251 primary care physicians in southern Israel. For each of 14 health services (imaging tests, cardiac tests, laboratory tests, and specialist visits) we described interphysician and intraphysician variation, adjusted for patient case mix and clinic characteristics, using the coefficient of variation. The adjusted rates were assessed by generalized linear negative-binomial mixed models.

Results: The variation between physicians was on average 3-fold greater than the variation of individual physician practice over the years. Services with low utilization were associated with greater inter- and intraphysician variation: r = (-0.58), = .03 and r = (-0.39), = .17, respectively. In addition, physician utilization ranks averaged over all health services were consistent across the 14 health services (intraclass correlation coefficient, 0.94; 95% CI, 0.93-0.95).

Conclusions: Our results show greater variation in practice patterns between physicians than for individual physicians over the years. It appears that the variation remains high even after adjustment for patient and clinic characteristics and that the individual physician utilization patterns are stable across health services. We propose that personal behavioral characteristics of medical practitioners might explain this variation.
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http://dx.doi.org/10.1370/afm.2627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7800753PMC
May 2019

Association Between Intraoperative Hypotension and Postoperative Adverse Outcomes in Patients Undergoing Vascular Surgery - A Retrospective Observational Study.

J Cardiothorac Vasc Anesth 2021 May 5;35(5):1431-1438. Epub 2020 Nov 5.

Center for Anesthesia Research Excellence (CARE), Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Electronic address:

Objective: Intraoperative hypotension (IOH) is associated with adverse outcomes. It could be challenging to define IOH in vascular surgical patients with increased baseline blood pressure (BP). The authors studied the relationship between (1) absolute and relative BP thresholds of IOH, (2) preoperative pulse pressure (PP) and isolated systolic hypertension, and (3) endovascular versus open surgical approach with adverse outcomes in vascular surgical patients.

Design: Retrospective observational study.

Setting: Teaching hospital.

Patients: A total of 566 vascular surgical patients from 2011 to 2018.

Intervention: None.

Measurements And Main Results: BP thresholds were as follows: IOH - absolute mean arterial pressure (MAP) <65 mmHg, relative MAP >20% decrease from baseline, preoperative PP hypertension - PP >40 mmHg, isolated systolic hypertension - baseline systolic BP ≥140 mmHg with diastolic BP <90 mmHg. Thresholds were characterized by (1) total duration and (2) area under the curve. Primary outcome was a composite of postoperative in-hospital complications (acute kidney injury, stroke, myocardial infarction, congestive heart failure, and mortality). Forty-six (8.1%) patients had in-hospital complications. Only IOH duration-MAP <65 mmHg (odds ratio 1.01; 95% confidence interval 1.00-1.02; p = 0.004) was significantly associated with outcome. No associations were found with MAP >20% decrease from baseline and preoperative BP. Significant interaction was observed with the surgical approach and outcome (p = 0.031), which was stronger after 60 minutes of IOH in endovascular approach.

Conclusion: Longer periods of IOH (MAP <65 mmHg for >60 minutes) during endovascular surgery were associated with adverse outcomes. Relative fall in BP from baseline, preoperative isolated systolic, and PP hypertension were not associated with postoperative complications.
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http://dx.doi.org/10.1053/j.jvca.2020.11.005DOI Listing
May 2021

The use of prostate specific antigen density to predict clinically significant prostate cancer.

Sci Rep 2020 11 17;10(1):20015. Epub 2020 Nov 17.

Department of Urology, Soroka University Medical Center, POB 151, 84101, Be'er-Sheva, Israel.

The purpose of this study was to assess the predictive value of prostate specific antigen density (PSAD) for detection of clinically significant prostate cancer in men undergoing systematic transrectal ultrasound (TRUS)-guided prostate biopsy. We retrospectively analyzed data of men who underwent TRUS-guided prostate biopsy because of elevated PSA (≤ 20 ng/ml) or abnormal digital rectal examination. Receiver operating characteristic curve analysis to compare PSA and PSAD performance and chi-square automatic interaction detector methodologies were used to identify predictors of clinically significant cancer (Gleason score ≥ 7 or international society of urological pathology grade group ≥ 2). Nine-hundred and ninety-two consecutive men with a median age of 66 years (IQR 61-71) were included in the study. Median PSAD was 0.10 ng/ml (IQR 0.10-0.22). Prostate adenocarcinoma was diagnosed in 338 men (34%). Clinically significant prostate adenocarcinoma was diagnosed in 167 patients (50% of all cancers and 17% of the whole cohort). The AUC to predict clinically significant prostate cancer was 0.64 for PSA and 0.78 for PSAD (P < 0.001). The highest Youden's index for PSAD was at 0.20 ng/ml with 70% sensitivity and 79% specificity for the diagnosis of clinically significant cancer. Men with PSAD < 0.09 ng/ml had only 4% chance of having clinically significant disease. The detection rate of clinically significant prostate cancer in patients with PSAD between 0.09 and 0.19 ng/ml was significantly higher when prostate volume was less than 33 ml. In conclusion, PSAD was a better predictor than PSA alone of clinically significant prostate cancer in patients undergoing TRUS-guided biopsy. Patients with PSAD below 0.09 ng/ml were unlikely to harbor clinically significant prostate cancer. Combining PSAD in the gray zone (0.09-0.19) with prostate volume below 33 ml adds diagnostic value of clinically significant prostate cancer.
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http://dx.doi.org/10.1038/s41598-020-76786-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672084PMC
November 2020

Comparison between three protocols of corneal collagen crosslinking in adults with progressive keratoconus: Standard versus accelerated CXL for keratoconus.

Eur J Ophthalmol 2020 11 13:1120672120972632. Epub 2020 Nov 13.

Department of Ophthalmology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Objective: The study aimed to compare eye outcomes between the standard and accelerated corneal cross-linking (CXL) protocols over a 1-year follow-up, and assess whether the accelerated protocols are non-inferior to the standard.

Methods: A retrospective cohort study including patients older than 18 years diagnosed with progressive keratoconus who underwent a CXL procedure. The primary outcome was defined as an increase of more than 1.5 diopter (D) in Kmax. The analysis included intra- and inter-group comparisons assessing differences in eye characteristics before and 12 months after the procedure. Furthermore, we assessed whether the accelerated procedures were non-inferior to the standard regarding Kmax change after 12 months.

Results: Eighty-four patients included in the study of which 23, 37 and 23 underwent the standard CXL (group I), 10-min. (group II) and the 3-min. (group III) accelerated procedures, respectively. Intra-group comparison before and after 12 months of mean Ksteep and anterior corneal astigmatism showed significant improvement only for group I (-0.3D decrease for both). Inter-group comparison showed better results after 12 months for group I (-0.9 ± 1.2) compared to group III (0.1 ± 0.8) in Ksteep, Kmean (-0.5+1. vs 0.1+0.7, respectively) and anterior astigmatism (-0.5 + 0.9 vs 0.3+1.1, respectively). We could not declare that the accelerated CXLs are non-inferior to the standard (-value = 0.11 and 0.15).

Conclusion: The standard CXL showed better results for keratometry and astigmatism in comparison with the accelerated. Therefore, the wide use of the accelerated CXL should be considered and reviewed for longer follow-up time and larger sample size in focus on the visual acuity parameters.
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http://dx.doi.org/10.1177/1120672120972632DOI Listing
November 2020

Inpatient patient safety events in vulnerable populations: a retrospective cohort study.

BMJ Qual Saf 2020 Oct 26. Epub 2020 Oct 26.

Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Background: Widespread attention to structural racism has heightened interest in disparities in the quality of care delivered to racial/ethnic minorities and other vulnerable populations. These groups may also be at increased risk of patient safety events.

Objective: To examine differences in inpatient patient safety events for vulnerable populations defined by race/ethnicity, insurance status and limited English proficiency (LEP).

Design: Retrospective cohort study.

Setting: Single tertiary care academic medical centre.

Participants: Inpatient admissions of those aged ≥18 years from 1 October 2014 to 31 December 2018.

Measurements: Primary exposures of interest were self-identified race/ethnicity, Medicaid insurance/uninsured and LEP. The primary outcome of interest was the total number of patient safety events, defined as any event identified by a modified version of the Institute for Healthcare Improvement global trigger tool that automatically identifies patient safety events ('automated') from the electronic record or by the hospital-wide voluntary provider reporting system ('voluntary'). Negative binomial models were used to adjust for demographic and clinical factors. We also stratified results by automated and voluntary.

Results: We studied 141 877 hospitalisations, of which 13.6% had any patient safety event. In adjusted analyses, Asian race/ethnicity was associated with a lower event rate (incident rate ratio (IRR) 0.89, 95% CI 0.83 to 0.96); LEP patients had a lower risk of any patient safety event and voluntary events (IRR 0.91, 95% CI 0.87 to 0.96; IRR 0.89, 95% CI 0.85 to 0.94). Asian and Latino race/ethnicity were also associated with a lower rate of voluntary events but no difference in risk of automated events. Black race was associated with an increased risk of automated events (IRR 1.11, 95% CI 1.03 to 1.20).

Limitations: This is a single centre study.

Conclusions: A commonly used method for monitoring patient safety problems, namely voluntary incident reporting, may underdetect safety events in vulnerable populations.
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http://dx.doi.org/10.1136/bmjqs-2020-011920DOI Listing
October 2020

Response guided therapy for reducing duration of direct acting antivirals in chronic hepatitis C infected patients: a Pilot study.

Sci Rep 2020 10 20;10(1):17820. Epub 2020 Oct 20.

Department of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.

The advent of direct-acting antivirals (DAAs) has transformed the landscape of hepatitis C virus (HCV) management. We aimed to prospectively (real-time) evaluate the feasibility of using a response-guided therapy approach, based on mathematical modeling of early viral kinetics, to reduce the duration of DAAs therapy. Patients were treated with DAAs according to the physicians' preference. HCV was measured at baseline and at day 2 and weeks 1, 2 and 4 after treatment initiation. The primary endpoint was the proportion of patients with sustained-virological response (SVR) at 12 and/or 24 weeks post-treatment. Twenty-nine patients (mean age 54 ± 16, 44% females, 73% with HCV genotype 1), were enrolled and all completed therapy. Treatment duration was shortened in 11 of the 29 patients (38%). SVR was achieved in 28 of the 29 patients (97%). Relapse occurred post treatment in a single case of a non-cirrhotic male with genotype 3, who was treated with sofosbuvir/velpatasvir for 6 weeks. Virus sequencing did not identify baseline or treatment emergent resistance associated substitutions. Real-time mathematical modeling of early HCV kinetics can be utilized for shortening DAAs duration in approximately 40% of patients without compromising treatment efficacy.Clinical trial registration: ClinicalTrials.gov Identifier: NCT03603327.
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http://dx.doi.org/10.1038/s41598-020-74568-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575564PMC
October 2020

Determinants of Medical Practice Variation Among Primary Care Physicians: Protocol for a Three Phase Study.

JMIR Res Protoc 2020 Oct 20;9(10):e18673. Epub 2020 Oct 20.

Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Background: One of the greatest challenges of modern health systems is the choice and use of resources needed to diagnose and treat patients. Medical practice variation (MPV) is a broad term which entails the differences between health care providers inclusive of both the overuse and underuse. In this paper, we describe a 3-phase research protocol examining MPV in primary care.

Objective: We aim to identify the potential targets for behavioral modification interventions to reduce the variation in practice patterns and thus improve health care, decrease costs, and prevent disparities in care.

Methods: The first phase will delineate the variation in primary care practice over a wide range of services and long follow-up period (2003-2017), the second will examine the 3 determinants of variation (ie, patient, physician, and clinic characteristics), and attempt to derive the unexplained variance. In the third phase, we will assess a novel component that might contribute to the previously unexplained variance - the physicians' personal behavioral characteristics (such as risk aversion, fear of malpractice, stress from uncertainty, empathy, and burnout).

Results: This work was supported by the research grant from Israel National Institute for Health Policy Research (Grant No. 2014/134). Soroka University Medical Center Institutional Ethics Committee has approved the updated version of the study protocol (SOR-14-0063) in February 2019. All relevant data for phases 1 and 2, including patient, physician, and clinic, were collected from the Clalit Health Services data set in 2019 and are currently being analyzed. The evaluation of the individual physician characteristics (eg, risk aversion) by the face-to-face questionnaires was started on 2018 and remains in progress. We intend to publish the results during 2020-2021.

Conclusions: Based on the results of our study, we aim to propose a list of potential targets for focused behavioral intervention. Identifying new targets for such an intervention can potentially lead to a decrease in the unwarranted variation in the medical practice. We suggest that such an intervention will result in optimization of the health system, improvement of health outcomes, reduction of disparities in care and savings in cost.

International Registered Report Identifier (irrid): DERR1-10.2196/18673.
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http://dx.doi.org/10.2196/18673DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7609196PMC
October 2020

Cell-free DNA concentration in patients with clinical or mammographic suspicion of breast cancer.

Sci Rep 2020 09 3;10(1):14601. Epub 2020 Sep 3.

Department of Clinical Biochemistry and Pharmacology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Mammography has a crucial role in the detection of breast cancer (BC), yet it is not limitation-free. We hypothesized that the combination of mammography and cell-free DNA (cfDNA) levels may better discriminate patients with cancer. This prospective study included 259 participants suspected with BC before biopsy. Blood samples were taken before biopsy and from some patients during and at the end of treatment. cfDNA blood levels were measured using our simple fluorescent assay. The primary outcome was the pathologic diagnosis of BC, and the secondary aims were to correlate cfDNA to severity, response to treatments, and outcome. Median cfDNA blood levels were similar in patients with positive and negative biopsy: 577 vs. 564 ng/ml (p = 0.98). A significant decrease in cfDNA blood level was noted after the following treatments: surgery, surgery and radiation, neo-adjuvant chemotherapy and surgery, and at the end of all treatments. To conclude, the cfDNA level could not be used in suspected patients to discriminate BC. Reduction of tumor burden by surgery and chemotherapy is associated with reduction of cfDNA levels. In a minority of patients, an increase in post-treatment cfDNA blood level may indicate the presence of a residual tumor and higher risk. Further outcome assessment for a longer period is suggested.
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http://dx.doi.org/10.1038/s41598-020-71357-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7471679PMC
September 2020

The association between exposure to radiation and the incidence of cataract.

Int Ophthalmol 2021 Jan 27;41(1):237-242. Epub 2020 Aug 27.

Department of Ophthalmology, Hadassah Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel.

Objective: To examine the association between exposure to radiation from computed tomography (CT) studies and the incidence of cataract.

Methods: In a nested case-control study, all cataract cases and their matched controls were sampled from a retrospective cohort of Israeli residents who underwent CT scans or ultrasonic tests in Soroka Medical Center, Beer-Sheva, Israel, between the years 1996 and 2014. The risk of cataract associated with head, neck or the rest of the body CT was assessed using Poisson survival analysis.

Results: The nested matched sample included 3841 cataract cases and their age- and sex-matched controls (n = 228,743). CT radiation exposure was more frequent in the cataract group, with 9.7% head CT, 1.2% neck CT and 6.6% other CT, compared to 5%, 0.7% and 3.7% among person-years without cataract (p < 0.001). In a multivariate analysis, a similar increased risk of cataract associated with head (hazard ratio (HR): 1.24, 95% confidence interval (CI): 1.11; 1.38) and other CT (HR: 1.25, 95% CI: 1.10; 1.43) was found. No association with neck CT (HR: 1.07, 95% CI: 0.80; 1.43) was observed.

Conclusion: In our study population, a similar risk of cataract with head, neck or the rest of the body CT was detected.
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http://dx.doi.org/10.1007/s10792-020-01572-5DOI Listing
January 2021

Reverse Trigger Phenotypes in Acute Respiratory Distress Syndrome.

Am J Respir Crit Care Med 2021 01;203(1):67-77

Department of Anesthesia, Critical Care and Pain Medicine, and.

Reverse triggering is an underexplored form of dyssynchrony with important clinical implications in patients with acute respiratory distress syndrome. This retrospective study identified reverse trigger phenotypes and characterized their impacts on Vt and transpulmonary pressure. Fifty-five patients with acute respiratory distress syndrome on pressure-regulated ventilator modes were included. Four phenotypes of reverse triggering with and without breath stacking and their impact on lung inflation and deflation were investigated. Inflation volumes, respiratory muscle pressure generation, and transpulmonary pressures were determined and phenotypes differentiated using Campbell diagrams of respiratory activity. Reverse triggering was detected in 25 patients, 15 with associated breath stacking, and 13 with stable reverse triggering consistent with respiratory entrainment. Phenotypes were associated with variable levels of inspiratory effort (mean 4-10 cm HO per phenotype). Early reverse triggering with early expiratory relaxation increased Vts (88 [64-113] ml) and inspiratory transpulmonary pressures (3 [2-3] cm HO) compared with passive breaths. Early reverse triggering with delayed expiratory relaxation increased Vts (128 [86-170] ml) and increased inspiratory and mean-expiratory transpulmonary pressure (7 [5-9] cm HO and 5 [4-6] cm HO). Mid-cycle reverse triggering (initiation during inflation and maximal effort during deflation) increased Vt (51 [38-64] ml), increased inspiratory and mean-expiratory transpulmonary pressure (3 [2-4] cm HO and 3 [2-3] cm HO), and caused incomplete exhalation. Late reverse triggering (occurring exclusively during exhalation) increased mean expiratory transpulmonary pressure (2 [1-2] cm HO) and caused incomplete exhalation. Breath stacking resulted in large delivered volumes (176 [155-197] ml). Reverse triggering causes variable physiological effects, depending on the phenotype. Differentiation of phenotype effects may be important to understand the clinical impacts of these events.
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http://dx.doi.org/10.1164/rccm.201907-1427OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781129PMC
January 2021

Ultrasound-Guided Pecto-Intercostal Fascial Block for Postoperative Pain Management in Cardiac Surgery: A Prospective, Randomized, Placebo-Controlled Trial.

J Cardiothorac Vasc Anesth 2021 Mar 24;35(3):896-903. Epub 2020 Jul 24.

Center for Anesthesia and Research Excellence, Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA. Electronic address:

Objective: To explore the effect of pecto-intercostal fascial plane block (PIFB) on postoperative opioid requirements, pain scores, lengths of intensive care unit and hospital stays and incidence of postoperative delirium in cardiac surgical patients.

Design: Single- center, prospective, randomized (1:1), quadruple- blinded, placebo-controlled trial.

Setting: Single center, tertiary- care center.

Participants: The study comprised 80 adult cardiac surgical patients (age >18 y) requiring median sternotomy.

Intervention: Patients were randomly assigned to receive ultrasound-guided PIFB, with either 0.25% bupivacaine or placebo, on postoperative days 0 and 1.

Measurements And Main Results: Of the 80 patients randomized, the mean age was 65.78 ± 8.73 in the bupivacaine group and 65.70 ± 9.86 in the placebo group (p = 0.573). Patients receiving PIFB with 0.25% bupivacaine showed a statistically significant reduction in visual analog scale scores (4.8 ± 2.7 v 5.1 ± 2.6; p < 0.001), but the 48-hour cumulative opioid requirement computed as morphine milligram equivalents was similar (40.8 ± 22.4 mg v 49.1 ± 26.9 mg; p = 0.14). There was no difference in the incidence of postoperative delirium between the groups evaluated using the 3-minute diagnostic Confusion Assessment Method (3/40 [7.5%] v 5/40 [12.5%] placebo; p = 0.45).

Conclusion: Patients who received PIFB with bupivacaine showed a decline in cumulative opioid consumption postoperatively, but this difference between the groups was not statistically significant. Low incidence of complications and improvement in visual analog scale pain scores suggested that the PIFB can be performed safely in this population and warrants additional studies with a larger sample size.
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http://dx.doi.org/10.1053/j.jvca.2020.07.058DOI Listing
March 2021

Increased risk of cardiac arrhythmias with cannabis use - More studies are needed.

Eur J Intern Med 2020 10 6;80:14-15. Epub 2020 Aug 6.

Cannabis Clinical Research Institute and Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel. Electronic address:

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http://dx.doi.org/10.1016/j.ejim.2020.08.008DOI Listing
October 2020

Does the physician in triage strategy improve door-to-balloon time for patients with STEMI?

Emerg Med J 2020 Sep 4;37(9):540-545. Epub 2020 Aug 4.

Emergency Department, Soroka University Medical Center, Beer Sheva, Southern, Israel.

Background: The physician in triage (PIT) strategy was implemented in the emergency department (ED) of the Soroka University Medical Center (SUMC) to improve overcrowding and waiting time. Our objective in the current study was to assess the impact of the PIT strategy on door-to-balloon time for the treatment of acute ST-elevation myocardial infarction (STEMI).

Methods: The PIT programme began on January 2016, working weekdays between 8:00 and 23:00 hours. We included patients who visited the ED and were diagnosed with STEMI, from November 2014 to February 2018. The primary outcome was improvement in door-to-balloon (D2B) time 90 min between the preintervention and postintervention period. The analysis included a comparison between the two time periods using univariate tests, a time trend analysis illustrated by the locally weighted scatterplot smoothing curves and a regression analysis using generalised estimating equation models. To determine the impact of the PIT, as opposed to other changes in the department, we stratified the population arriving after January 2016 to patients arriving during PIT hours versus patients arriving on weekends and at nights (23:00-8:00 hours).

Results: In all, 415 patients met all the inclusion criteria of which 237 (57.1%) visited on weekdays 8:00-23:00 hours. The per cent of patients with D2B 90 min was 13.9% higher for postintervention versus preintervention visits (p=0.006). D2B time was significantly shorter by 9 min for postintervention visits (p=0.001). In the postintervention period, patients arriving between 8:00 and 23:00 hours on weekdays were more likely to have D2B <90 min than those arriving nights and weekends; 90/146 (61.6%) vs 47.2% (51/108), respectively, p=0.02. ORs for D2B 90 min was 2.04 (95% CI 1.06 to 3.91) for weekday visits, and 1.90 (0.88 to 4.12) for weekend and night visits.

Conclusion: The PIT model in SUMC is associated with D2B reduction for patients with STEMI. To achieve further reduction, both targeted interventions should be performed and PIT strategy should be applied for full time, including nights and weekends.
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http://dx.doi.org/10.1136/emermed-2019-209241DOI Listing
September 2020

Risk factors for antepartum death in term pregnancies.

J Matern Fetal Neonatal Med 2020 Jul 26:1-6. Epub 2020 Jul 26.

Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.

Objective: To identify risk factors for antepartum fetal death (APD) in term pregnancies while considering maternal, pregnancy and fetal characteristics.

Materials And Methods: Our study took place between the years 1988-2013. A total of 272,527 singleton births at term were recorded during this time period, including 524 cases of APD (0.2%). Cases of known chromosomal or other fetal abnormalities and cases with poor prenatal care were excluded. In order to identify independent risk factors contributing to antepartum fetal death in term we conducted a multivariate analysis using logistic regression.

Results: The main risk factors found to be significantly associated with APD in term were suspected intrauterine growth restriction (OR = 2.70,  < .001), diabetes (OR = 1.37,  = .05), hypertensive disorders (OR = 1.59,  = .01), advanced maternal age (OR = 1.03,  < .001) and grand-multiparity (OR = 1.79,  < .001). Advanced gestational age was not significantly associated with APD (38.95 vs. 39.44,  < .001).

Conclusions: Most of the risk factors for antepartum fetal death in term pregnancies found in this study coincide with known risk factors for APD as described in previous studies. We believe that in the presence of these risk factors, closer surveillance and careful medical management of the pregnancy are required, in order to reduce the incidence of APD, including induction of labor at advanced gestational age.
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http://dx.doi.org/10.1080/14767058.2020.1797664DOI Listing
July 2020

Soccer heading and subclinical neuropsychiatric symptomatology in professional soccer players.

Neurology 2020 09 10;95(13):e1776-e1783. Epub 2020 Jul 10.

From the Department of Neurology (N.A., Y.Z., I.A.-S., G.I.), Clinical Research Center (T.C., V.N.), and Department of Internal Medicine C (L.Z.), Soroka University Medical Center, Beer-Sheva, Israel.

Objectives: To evaluate the association between postconcussive symptomatology and heading in professional soccer players, overcoming the bias of self-reported exposure, we evaluated several clinical neuropsychiatric symptoms using questionnaires after a thorough objective follow-up of players' heading exposure throughout an entire season.

Methods: We collected heading data for all Israeli Premier League players for an entire season using a web-based platform for performance analysis, which enabled us to quantify the exact number of headers per player. Players filled out questionnaires regarding postconcussion symptoms, depression, anxiety, and sleep disorders. We tested the association between the number of headers and each outcome using a negative binomial regression corrected for the hours played.

Results: A total of 159 players were included, of whom 79 were considered in the high heading exposure group (49%), defined as more than median number of headings (1.34 per game hour). Among players without any past head injury, those with higher heading exposure were less likely to have postconcussion symptoms compared with players with low heading exposure (relative risk [RR] per heading per hour 0.94, 95% confidence interval [CI] 0.912-0.963). Players with high heading exposure had fewer depression symptoms (RR 0.98, 95% CI 0.961-0.997), anxiety (RR 0.98, 95% CI 0.958-0.997), and sleep disorders (RR 0.98, 95% CI 0.961-0.996).

Conclusion: Professional soccer players with high heading rate do not display higher postconcussive symptomatology severity. Symptoms among players with low heading exposure might be explained by low resilience, possibly associated with an inferior heading technique. Alternatively, it can reflect heading-avoidant behavior.
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http://dx.doi.org/10.1212/WNL.0000000000010244DOI Listing
September 2020

Incidence and Clinical Outcomes of Pacing Induced Cardiomyopathy in Patients With Normal Left Ventricular Systolic Function and Atrioventricular Block.

Am J Cardiol 2020 08 18;128:174-180. Epub 2020 May 18.

Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel; Cardiology Department, Soroka University Medical Center, Beer Sheva, Israel. Electronic address:

Patients with preserved left ventricular (LV) ejection function (EF) and atrioventricular block (AVB) who are anticipated for high-burden of right ventricular (RV) pacing possess a risk to develop pacing-induced cardiomyopathy (PIC) and adverse clinical outcomes. Hence, the aim of the study is to evaluate the incidence, predictors, and clinical outcomes of RV PIC in patients with preserved LVEF, AVB, and high-burden of RV pacing. One thousand and thirteen patients with second or third-degree AVB underwent first time pacemaker implantation between January 2002 and August 2016. A total of 203 patients with a newly implanted pacemaker, normal baseline LVEF, and high burden of RV pacing were included in the present study. Follow-up echocardiography was examined for a new decrease in LVEF of 10% or higher. Alternative causes for cardiomyopathy were ruled out. Patient characteristics, echocardiographic measurements, device clinic data, mortality, and hospitalizations for heart failure were collected and compared between the PIC and the non-PIC groups. Fifty-one patients (25%) developed LV dysfunction with 22 patients (11%), showing LVEF < 40%. During a mean follow-up of 49.2 months, the risk of heart failure hospitalization or all-cause mortality was significantly higher in the PIC group versus non-PIC group (35.3% vs 19.1%, p = 0.009). In conclusion the incidence of PIC in patients with normal LVEF and AVB, who are anticipated for high-burden of RV pacing is high. PIC in patients with a previously normal LV function is associated with unfavorable long-term clinical outcomes, including higher rates of heart failure hospitalizations and all-cause mortality.
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http://dx.doi.org/10.1016/j.amjcard.2020.05.017DOI Listing
August 2020

Early Point-of-Care Ultrasound Assessment for Medical Patients Reduces Time to Appropriate Treatment: A Pilot Randomized Controlled Trial.

Ultrasound Med Biol 2020 Aug 16;46(8):1908-1915. Epub 2020 May 16.

Internal Medicine Division, Soroka University Medical Center, Beer-Sheva, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Numerous studies emphasize the diagnostic importance of point-of-care ultrasound (POCUS), but the level of evidence remains low as most data are gathered from observational studies. We conducted a pilot, randomized controlled trial to evaluate the effect of POCUS exam on medical patient's management and clinical outcomes. Patients presenting with chest pain or dyspnea were enrolled and randomly allocated to an early POCUS scan group and a control group. POCUS assessment, within 24 h of internal ward admission, was conducted only for the intervention group. The primary outcome was time to correct diagnosis. Secondary outcomes included time to appropriate treatment, POCUS-related rate of primary diagnosis alteration and new clinically relevant findings and time to hospital discharge. Sixty patients were enrolled. Thirty patients were randomly allocated to each study arm. The POCUS exam revealed clinically relevant findings among 79% of patients and led to alteration of the primary diagnosis among 28% of patients. Time to appropriate treatment was significantly shorter among patients in the POCUS group compared with the control group (median time of 5 h [95% confidence interval: 0.5-9] vs. 24 h [95% CI: 19-29] p = 0.014). The time needed to achieve correct diagnosis by the primary team was shorter in the POCUS group compared with the control group, yet it did not reach statistical significance (median time of 24 h [95% CI: 18-30] vs. 48 h [95% CI: 20-76], p = 0.12). These results indicate that POCUS assessment conducted early among patients with dyspnea or chest pain improves diagnostic accuracy and shortens significantly the time to appropriate treatment.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2020.03.023DOI Listing
August 2020

Causes and Rates of 30-Day Readmissions After Transjugular Intrahepatic Portosystemic Shunts.

AJR Am J Roentgenol 2020 07 6;215(1):235-241. Epub 2020 May 6.

Department of Radiology, Division of Vascular and Interventional Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, 1 Deaconess Rd, WCC 308, Boston, MA 02215.

The purpose of this study was to investigate the causes and rates of 30-day readmission after transjugular intrahepatic portosystemic shunt (TIPS) at a single liver transplant center. We reviewed 165 TIPS procedures performed between 2003 and 2013. After excluding patients who died during the index admission ( = 16), any readmission within 30 days of discharge was identified, and cause of readmission was determined. Causes were categorized as planned or unplanned and interventional radiology (IR)-related or IR-unrelated. Unplanned readmissions were independently categorized as preventable or unpreventable by two interventional radiologists. Discrepant opinions were resolved by consensus. Factors predictive of 30-day readmission were identified by univariate and multivariate analysis. The reviewed TIPS procedures were performed in 165 patients (mean age ± SD, 56 ± 11 years; 69% male, 31% female). TIPS were placed for ascites or hydrothorax in 82 patients (50%) and variceal bleeding in 83 patients (50%). The 30-day readmission rate was 21% (31/149). The most common causes for readmissions were ascites or hydrothorax (23%, 7/31) and hepatic encephalopathy (23%, 7/31). All 30-day readmissions were unplanned; 17 (55%) of them were potentially preventable. Of the 17 potentially preventable readmissions, five (29%) were IR-related and 12 (71%) were IR-unrelated. In IR-related readmissions, all patients presented with a recurrence of symptoms (rebleeding or ascites) and were found to have TIPS stenosis or occlusion. Mortality rates were similar between patients who were and were not readmitted ( = 0.23). On multivariate analysis, spontaneous bacterial peritonitis during the index admission was the only variable associated with 30-day readmission (odds ratio = 4.81, = 0.02). Over half of 30-day readmissions after TIPS could have been prevented by early outpatient follow-up and intraprocedural technique to optimize stent landing zones.
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http://dx.doi.org/10.2214/AJR.19.21732DOI Listing
July 2020

Human biologic monitoring based on blood donations to the National Blood Services.

BMC Public Health 2020 Apr 8;20(1):469. Epub 2020 Apr 8.

Faculty of Health Sciences, Ben-Gurion University of the Negev, Sderot Rager 151, 84101, Beer-Sheva, Israel.

Background: The ambient exposure does not always reflect the internal levels of pollution absorbed in the body. While human biomonitoring (HBM) could provide a valid estimate of exposure extent, it is usually an expensive and a heavily manpowered enterprise. Using samples collected during blood donations for HMB may provide a more efficient platform for a routine biomonitoring.

Methods: The current study is aimed to explore the feasibility of using the national blood banking system for the purposes of HBM, to compare between residents of a suspected polluted area in northern Israel (Haifa Bay) to the rest of the country. Specifically, we will assemble a geographically representative sample of blood donors residing in the study area and of the general population, to test for four industry and traffic-related metals: lead (Pb), cadmium (Cd), arsenic (As) and chromium (Cr). Samples of whole blood from donors will be tested in the Laboratory of Public Health Services managed by the Ministry of Health. The information on donors' biomarkers levels will be further linked with the air pollution and meteorological data assessed at the location of the blood collection sites (short-term exposure) and donors' permanent address (long-term exposure), as recorded by the monitoring stations spread throughout Israel and the satellite-based exposure models. The association between biomarkers and ambient environmental exposures will be assessed. The samples' collection is planned for 2 years of 2020-2021.

Discussion: The information collected in this study could lead to environmental regulations within Haifa Bay area aimed to prevent exposure to high levels of hazardous chemicals.
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http://dx.doi.org/10.1186/s12889-020-08588-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140578PMC
April 2020

Human biologic monitoring based on blood donations to the National Blood Services.

BMC Public Health 2020 Apr 8;20(1):469. Epub 2020 Apr 8.

Faculty of Health Sciences, Ben-Gurion University of the Negev, Sderot Rager 151, 84101, Beer-Sheva, Israel.

Background: The ambient exposure does not always reflect the internal levels of pollution absorbed in the body. While human biomonitoring (HBM) could provide a valid estimate of exposure extent, it is usually an expensive and a heavily manpowered enterprise. Using samples collected during blood donations for HMB may provide a more efficient platform for a routine biomonitoring.

Methods: The current study is aimed to explore the feasibility of using the national blood banking system for the purposes of HBM, to compare between residents of a suspected polluted area in northern Israel (Haifa Bay) to the rest of the country. Specifically, we will assemble a geographically representative sample of blood donors residing in the study area and of the general population, to test for four industry and traffic-related metals: lead (Pb), cadmium (Cd), arsenic (As) and chromium (Cr). Samples of whole blood from donors will be tested in the Laboratory of Public Health Services managed by the Ministry of Health. The information on donors' biomarkers levels will be further linked with the air pollution and meteorological data assessed at the location of the blood collection sites (short-term exposure) and donors' permanent address (long-term exposure), as recorded by the monitoring stations spread throughout Israel and the satellite-based exposure models. The association between biomarkers and ambient environmental exposures will be assessed. The samples' collection is planned for 2 years of 2020-2021.

Discussion: The information collected in this study could lead to environmental regulations within Haifa Bay area aimed to prevent exposure to high levels of hazardous chemicals.
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http://dx.doi.org/10.1186/s12889-020-08588-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140578PMC
April 2020