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A series of elongated folds known as the Syrian arc fold belt developed throughout the Levant region alongside the Tethys closure. This compressional belt followed a preexisting extensional belt that had formed 100-200 m.y. earlier alongside the Tethys opening. Here we analyze a series of Syrian arc-type folds deeply buried in the Levant Basin 50-200 km away from the onshore Syrian arc mountain ridge. The continuous stratigraphic section in the Levant Basin provides a complete record of folding, which is incomplete onshore. We show that folding continued 80 m.y. in the same direction regardless of major tectonic processes that occurred in the surrounding areas. During this period, Africa rotated ~20° counterclockwise and started colliding with Eurasia, Arabia broke off Africa, and subduction initiated under Cyprus. But despite all of these surrounding processes, the direction of folding in the Levant remained nearly constant (relative to Africa). We suggest that the main control on folding direction is inherited extensional structures formed along Africa's margin during Tethys opening and that continuously rotate with it. However, the surrounding tectonic processes, which had minor influence on folding direction, did affect folding intensity and its spatial distribution. Folding ceased in the northwest part of the basin in the Oligocene, peaked in the entire basin during the early Miocene coeval with the Red Sea--Gulf of Suez rifting and convergence of Arabia with Eurasia, and has gradually decreased since the late Miocene, concurrently with the major activity along the Dead Sea transform. [ABSTRACT FROM AUTHOR]

Background: In ER + /HER2- early breast cancer (BC), 21-Gene Recurrence Score (RS) > 25 indicates high-risk of distant-recurrence and predicts benefit from adjuvant chemotherapy (aCT) regardless of tumor-size. However, T1a/b (≤ 1 cm) node-negative (N0) tumors, regarded as of low risk of recurrence, were under-represented in the RS trials. We therefore aimed to investigate the benefit of aCT in patients with T1a/bN0 BC, RS > 25, where clinical and genomic risk indicators are discordant., Methods: This retrospective observational cohort study utilized Israel's national Oncotest database to identify Clalit Health Services (CHS) members, diagnosed with T1a/bN0 HR + /HER2- BC, who underwent RS testing between February 2006, and December 2019. Patients with RS > 25 who received aCT were matched 1:1 by propensity-scoring to similar patients receiving no aCT. Invasive disease-free survival (iDFS) and distant recurrence were the study endpoints. Patient demographic and clinical data were obtained from CHS's centralized database. Kaplan--Meier analysis with log-rank testing was used for comparing outcomes., Results: During the study period, high-risk RS result (> 25) was identified in 156/9858 patients of the study cohort. aCT was administered to 74 (47.4%) and median follow-up was 121 months. Within the 148 matched-cases, eighteen iDFS-events occurred, nine (12.1%) in each group (χ 2  = 0.72, p = 0.39). Four (5.4%) of the aCT treated and three (4.0%) of the untreated patients were diagnosed with distant recurrence (χ 2  = 0.22, p = 0.64)., Conclusions: In this study cohort, patients with T1a/bN0 BC, RS > 25 that received aCT, did not have improved outcomes and the 21-Gene RS > 25 was not found to be predictive, possibly due to the low number of events observed., Competing Interests: Declarations. Conflict of interest: All authors declare that they have no conflict of interest., (© 2024. The Author(s).)

Background: Healthcare organizations attempt to address unwarranted fentanyl use, which often leads to increased risk of addiction and overdose., Objective: To assess the impact of a requirement for a specialist's approval on fentanyl initiation for non-oncological pain., Design: A retrospective cohort study based on observational data., Participants: All 4.4 million non-oncological members of Clalit Health Services were included, from July 20, 2021, to July 19, 2023., Main Measures: The rate of fentanyl initiation was assessed before and after the implementation of the requirement for specialist's approval, which was introduced on July 2022, and expanded 6 months later for continued use. A sub-group analysis by age group was performed, and patient characteristics and indications were assessed. We also compared total opioid dispensation in the 6th and 12th months after the implementation with the predicted rate based on pre-implementation rates., Key Results: Fentanyl initiation rate in the year before the requirement was 711 per million capita, which decreased following the requirement by - 81% (95% CI: - 77%; - 85%). The decrease attenuated with age. The prevalence of diagnosis with substance abuse disorders at the time of fentanyl initiation decreased from 6 to 3%. In the 6th and 12th months after the requirement was implemented, the morphine milligram equivalent (MME) from dispensation of total opioids was lower than predicted based on pre-implementation rates by 7% and 26%, respectively., Conclusions: Requiring specialist approval for fentanyl initiation for non-oncological chronic pain was associated with a decrease in fentanyl prescription initiations, especially among non-elderly patients. A decrease also occurred gradually in total opioid dispensations, further decreasing following the extension of the requirement to continuous fentanyl. The requirement for specialist approval upon fentanyl initiation and continuous fentanyl may present an effective tool for limiting the use of fentanyl and total opioids in healthcare systems., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Objective: Patient satisfaction is an imperative factor in integrating telehealth services as a treatment modality in health care systems. Here, we compared patient satisfaction from telehealth versus in-person health care visits in a large heterogeneous population. Methods: We conducted a retrospective cohort study of patients making telehealth or in-person primary care visits between January 2021 and August 2022. Patient satisfaction with both service types was evaluated using a validated survey. Logistic regression models were employed to assess the association between type of visit (in-person/telehealth) and patient satisfaction (satisfied/unsatisfied) while accounting for sociodemographic and clinical characteristics. Results: Of the 247,087 surveys included in the study, 86,580 (35%) were answered following telehealth visits. Telehealth visitors were more satisfied than in-person visitors in aspects related to doctor-patient interactions, such as "courtesy and respect," "attentive listening," and "coherent explanations" (aOR = 1.17, 95% CI: 1.14-1.21; aOR = 1.16, 95% CI: 1.12-1.19; aOR = 1.15, 95% CI: 1.12-1.18, respectively), and less satisfied in aspects related to indirect services, such as adherence to appointment scheduling, effort required on the part of the patient, and staff cooperation (aOR = 0.95, 95% CI: 0.93-0.97; aOR = 0.89, 95% CI: 0.87-0.91; aOR = 0.85, 95% CI: 0.83-0.87, respectively). Importantly, considerably more telehealth visits were delayed (44%) than in-person visits (27%). Adjustment for this factor further strengthened the observed association between telehealth services and patient satisfaction. Conclusions: While telehealth was associated with high levels of satisfaction in doctor-patient interaction, improvements are still needed in indirect services. Addressing issues related to staff cooperation and streamlining processes to reduce delays could improve overall patient satisfaction with telehealth.

Objectives: Previous research reported inconsistent results on the efficacy of molnupiravir in treating COVID-19. Moreover, efficacy was not assessed in the intended-use population (IUP), as defined by the FDA. Therefore, we aimed to evaluate the effectiveness and safety of molnupiravir for the treatment of COVID-19 in the IUP., Methods: We performed a retrospective cohort study on all IUP in Israel's Clalit Health Services from January 16, 2022, to February 16, 2023. The effectiveness outcome was the incidence of hospitalization or death due to COVID-19, and the safety outcome was the incidence of all-cause mortality within 35 days of SARS-CoV-2 infection. Cox-proportional hazard models were used to analyse the data after 1:5 propensity-score matching., Results: A total of 49 515 patients met the eligibility criteria. Of them, 3957 molnupiravir-treated patients were matched to 19 785 untreated patients. In molnupiravir-treated patients, 70 out of 3957 (5.1 per 10 000 person per day) experienced COVID-19-related hospitalization or death, compared with 699 out of 19 785 untreated patients (10.4 per 10 000 person per day); RR: 0.50 (95% CI, 0.39-0.64). All-cause mortality was also lower in the treated group, with 41 out of 3957 (3.0 per 10 000 person per day) experiencing mortality compared with 414 out of 19 785 untreated patients (6.1 per 10 000 person per day); RR: 0.50 (0.36-0.68)., Discussion: In a real-world cohort of IUP, molnupiravir therapy was associated with a significant reduction in hospitalizations or deaths due to COVID-19 and all-cause mortality., (Copyright © 2024 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Comparative evidence for the effects of bariatric metabolic surgery (BMS) and glucagon-like peptide-1 receptor agonists (GLP-1RA) on cardiovascular outcomes is limited. Here, in an observational, retrospective cohort study, we compared the incidence of congestive heart failure (CHF) in adults living with obesity and diabetes without history of CHF (primary CHF) treated with BMS versus GLP-1RA. The population cohort comprised members of Clalit Health Services with no prior history of ischemic heart disease, ischemic stroke or CHF. During the time period of 2008-2021, patients who underwent their first BMS were matched 1:1 with patients who initiated treatment with GLP-1RA, based on clinical characteristics. The study included 2,205 matched pairs of patients (64.5% female), followed for a median of 6.6 years and up to 12 years. Primary incidence of CHF occurred in 26 (1.2%) patients treated with BMS and in 90 patients treated with GLP-1RA (4.1%) (adjusted hazard ratio 0.43, 95% confidence interval 0.27-0.68). Further adjustment for weight reduction did not significantly diminish this association (hazard ratio adjusted for weight reduction 0.48, 95% confidence interval 0.28-0.82), indicating that the differential effect was not mediated through the relative advantage of BMS in maximal weight reduction. In this study, BMS was associated with a stronger reduction in primary incidence of CHF compared with treatment with GLP-1RA. With the increasing use of highly potent next-generation GLP-1RAs, further comparative long-term studies are warranted., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Prior studies found reduced incidences of cardiovascular diagnoses and treatments in the initial phase of the COVID-19 pandemic. However, these studies included a limited number of outcomes and did not consider pre-pandemic trends. This study aimed to describe trends in the incidence of cardiovascular diagnoses and treatments over the years 2012-2021 in Israel and to compare the two years of the COVID-19 period with the preceding 8 years. In this retrospective, population-based study, carried out within Clalit Health Services, the incidence rates of cardiovascular outcomes were calculated for individuals aged ≥ 25 (~2.7 million adults per year) during the first (Y1, 3/2020-2/2021) and second (Y2, 3/2021-2/2022) years of COVID-19 and the 8 years prior (3/2012-2/2020). Declines were observed in Y1 compared to 2019 in all diagnoses and treatments: STEMI (-16.3%; 95% CI: -16.6, -16.1), non-STEMI (-16.4%; -16.6, -16.2), AF (-14.1%; -14.2, -14.0), CHF (-7.8%; -7.9, -7.7), CVA (-5.0%; -5.0, -4.9), catheterization (-64.7%; -65.2, -64.2), CABG (-77.7%; -79.2, -76.2), ablation (-21.2%; -22.0, -20.4), pacemaker implantation (-39.3%; -40.7, -37.9), and defibrillator insertion (-12.5%; -13.1, -12.0). Compared with expected rates based on pre-pandemic trends, observed rates were within expected ranges (CHF, CVA, and ablation), less than expected (STEMI, non-STEMI, AF, catheterization, CABG, and pacemaker insertion), or more than expected (defibrillator insertion). In Y2, STEMI, catheterization, and CABG returned to expected rates; non-STEMI and AF were lower than expected; and CHF, CVA, ablation, and pacemaker and defibrillator implantations were higher than expected. Several cardiovascular diagnoses and treatment trends were interrupted by COVID-19. The long-term consequences of these changes should be considered by health policymakers.

Competing Interests: We declare no competing interests.

Background: The current Mpox outbreak presents unique vaccination challenges in vulnerable populations. Understanding factors associated with vaccine uptake in vulnerable populations is required for a successful vaccination campaign., Methods: This population-based cohort study was conducted in Clalit Health Services and included all individuals eligible for the Modified Vaccinia Ankara vaccine. Cox proportional hazards models were used to assess the characteristics associated with uptake of the first vaccine dose., Results: Attendance to a primary healthcare clinic in the Tel Aviv district, repeated sexually transmitted infection screening, and the recent purchase of HIV-PrEP or PDE5 inhibitors were associated with higher vaccine adherence, whereas previous nonadherence with recommended vaccines, low sociodemographic status, and history of HIV were associated with lower adherence., Conclusions: These findings highlight the need for proactive patient and healthcare provider-oriented educational campaigns to curb vaccine hesitancy, and may help direct resources toward underserved populations, hence increasing equality in vaccine enrollment., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Objectives: The global supply of vaccines against mpox (previously called monkeypox virus infection) was significantly lower than the demand. Therefore, evidence-based vaccine prioritization criteria, based on risk assessment were needed. Our objective was therefore to identify the characteristics of individuals at the highest risk for mpox., Methods: This population-based cohort study included all Clalit Health Services (CHS) subjects assumed to be at risk for mpox. The eligibility criteria for inclusion were determined based on known characteristics of people with infection worldwide and insights of lesbian, gay, bisexual, transgender, queer+ (LGBTQ+) -specialized CHS clinicians. Cox hazards models were used to identify the risk factors for mpox within the study cohort. The study commenced on 6 June 2022, the date of the first known mpox in CHS members, until 31 July 2022, when the mpox vaccination campaign started., Results: A total of 8088 individuals of 4.7 million CHS members (0.18%) were identified according to the study inclusion criteria. Of those, 69 (0.85%) developed infection during the study period. Risk factors for mpox were birth in 1980 or later (hazard ratio, 5.04; 95% CI, 2.11-12.02), history of syphilis (2.62; 1.58-4.35), registration to primary healthcare clinics in the Tel Aviv district (2.82; 1.44-5.54), HIV-pre-exposure prophylaxis medication use (3.96; 2.14-7.31), PDE5 inhibitors use (2.92; 1.77-4.84), and recent sexually transmitted infections (STIs) within the last 18 months (2.27; 1.35-3.82). No infections were observed in individuals with none of the factors. Individuals with three or more risk factors had a 20.30-fold (10.39-39.69) higher risk for mpox compared with those with 0-2, with 85.5% (75.0-92.8%) sensitivity and 77.8% (76.9-78.7%) specificity., Discussion: Weighting individuals' risk levels based on validated risk factors against vaccine availability can assist health systems in the equitable prioritization of vaccine allocation in various future outbreaks, given supply-demand gaps., (Copyright © 2023 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Introduction: Postacute sequelae resulting from SARS-CoV-2 infections (LONG-COVID) have been reported. The resulting added economic burden from the perspective of healthcare organisations is not clear. Therefore, this study aims to evaluate the additive healthcare costs among COVID-19 recoverees, in a large community-dwelling general population, as incurred by an insurer-provider organisation over time., Methods: In this historical cohort study, cost data from Clalit Health Services (CHS) were analysed. The primary endpoint was the direct cost incurred by CHS per month per person. Costs were measured for COVID-19 recoverees and matched controls, from January 2019 to January 2022. Difference in differences (DiDs) were calculated as the difference in mean monthly costs in cases and controls in the post-COVID-19 individual period, deducing their cost difference in a prepandemic 12 months baseline period., Results: Among N=642 868 community-dwelling COVID-19 recoverees, 268 948 (40.8%) were 0-19 years old and 63 051 (9.6%) were 60 years or older. A total of 16 017 (2.5%) of recoverees had been hospitalised during the acute phase of the COVID-19 disease. Costs in cases and controls converged after 16 months from recovery. The mean monthly cost incurred by CHS per COVID-19 recoverees over up to 15 months (mean: 8.25) of post-COVID-19 follow-up was higher by 8.2% (US$8.2) compared with matched controls. The excess cost attributable to post-COVID-19 effects (DID) was 7.6% of the cost in controls (US$7.7 per patient per month). Both net and relative DIDs were substantially higher in patients who required hospitalisation during the acute phase of COVID-19 and in older adults. Excess in hospitalisations, primary care physicians and medical specialists' visits-related costs were observed., Conclusions: Long-term effects of SARS-CoV-2 infections translate into excess healthcare costs, months after recovery, hence requiring adjustments of funds allocation. These excess costs gradually diminish after recoveree, returning to baseline differences 16 months after recoveree., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The recent global outbreak of the monkeypox (mpox) virus in humans was declared a public health emergency by the World Health Organization in July 2022. The smallpox and mpox vaccine (JYNNEOS; Modified Vaccinia Ankara-Bavarian Nordic; MVA-BN), provided as a two-dose regimen, is currently the primary vaccine utilized against mpox. However, the efficacy of MVA-BN against mpox has never been demonstrated in clinical trials to date. Due to the limited supply of vaccines, the World Health Organization has recommended prioritizing the vaccination of high-risk groups. We evaluated the real-world effectiveness of a single, subcutaneous dose of MVA-BN in this observational, retrospective cohort study, which included the analysis of electronic health records of all members of Clalit Health Services eligible for the vaccine on 31 July 2022. We used a Cox proportional hazards regression model with time-dependent covariates to estimate the association between vaccination and mpox while adjusting for sociodemographic and clinical risk factors. In an analysis of 2,054 male individuals who met vaccine eligibility criteria, 1,037 (50%) were vaccinated during the study recruitment period and completed at least 90 d of follow-up. During the study period, 5 and 16 infections were confirmed in vaccinated and unvaccinated individuals, respectively. The adjusted vaccine effectiveness was estimated at 86% (95% confidence interval, 59-95%). Our results suggest that a single dose of subcutaneous MVA-BN in this high-risk cohort is associated with a significantly lower risk of MPXV infection., (© 2023. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Background: The COVID-19 pandemic generated an extraordinary need for telemedicine., Objective: To identify the factors and multi-way interactions associated with telemedicine use in primary healthcare during the COVID-19 pandemic., Methods: This population-based study included all members (2,722,773) aged ≥18 years of the largest healthcare organization in Israel who used primary care clinic services between 1 March 2020 and 31 December 2021. Individuals were classified as telemedicine users (≥1 phone/video visits or asynchronous encounters) or non-telemedicine users (only in-person encounter/s)., Results: Ethnicity was the most discriminative variable associated with telemedicine use, with 85% and 52% users among Jews and Arabs, respectively. Higher odds for telemedicine utilization were observed among women, residents of urban areas, those confined to home, individuals with high level of technology literacy, residents of the central area (in Jews only), young Jews, and older Arabs. Based on decision tree analysis, the segments of the population with the lowest telemedicine use were characterized by lower primary care needs and comorbidities, as well as low technology literacy. The proportion of telemedicine use in these groups was 56% and 27% in Jews and in Arabs, respectively., Conclusion: A proactive intervention program should be applied among populations who are less likely to use telemedicine in the primary care clinics, including Arabs, Jews who live in the distant periphery, and individuals with low technology literacy.

Background: The oral protease inhibitor nirmatrelvir has shown substantial efficacy in high-risk, unvaccinated patients infected with the B.1.617.2 (delta) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Data regarding the effectiveness of nirmatrelvir in preventing severe coronavirus disease 2019 (Covid-19) outcomes from the B.1.1.529 (omicron) variant are limited., Methods: We obtained data for all members of Clalit Health Services who were 40 years of age or older at the start of the study period and were assessed as being eligible to receive nirmatrelvir therapy during the omicron surge. A Cox proportional-hazards regression model with time-dependent covariates was used to estimate the association of nirmatrelvir treatment with hospitalization and death due to Covid-19, with adjustment for sociodemographic factors, coexisting conditions, and previous SARS-CoV-2 immunity status., Results: A total of 109,254 patients met the eligibility criteria, of whom 3902 (4%) received nirmatrelvir during the study period. Among patients 65 years of age or older, the rate of hospitalization due to Covid-19 was 14.7 cases per 100,000 person-days among treated patients as compared with 58.9 cases per 100,000 person-days among untreated patients (adjusted hazard ratio, 0.27; 95% confidence interval [CI], 0.15 to 0.49). The adjusted hazard ratio for death due to Covid-19 was 0.21 (95% CI, 0.05 to 0.82). Among patients 40 to 64 years of age, the rate of hospitalization due to Covid-19 was 15.2 cases per 100,000 person-days among treated patients and 15.8 cases per 100,000 person-days among untreated patients (adjusted hazard ratio, 0.74; 95% CI, 0.35 to 1.58). The adjusted hazard ratio for death due to Covid-19 was 1.32 (95% CI, 0.16 to 10.75)., Conclusions: Among patients 65 years of age or older, the rates of hospitalization and death due to Covid-19 were significantly lower among those who received nirmatrelvir than among those who did not. No evidence of benefit was found in younger adults., (Copyright © 2022 Massachusetts Medical Society.)

Background: The outbreak of the COVID-19 pandemic led to a decrease in primary health care in-person visits and a simultaneous increase in virtual encounters., Objective: To quantify the change in the total volume of primary care visits and mix of visit types during the two years of the pandemic in Israel., Design: Cross-sectional study., Participants: All primary care visits by members of the largest healthcare organization in Israel, during three one-year periods: the pre-COVID-19 year (March 2019-February 2020), the first year of COVID-19 (March 2020-February 2021), and the second year of COVID-19 (March 2021-February 2022)., Main Measures: Total volume of primary care visits and mix of visit types., Results: More than 112 million primary care visits were included in the study. The total visit rate per 1000 members did not change significantly between the pre-COVID year (19) and the first COVID year (19.8), but was 21% higher in the second COVID-19 year (23). The rate of in-person visits per 1000 members decreased from 12.0 in the pre-COVID year to 7.7 in the first COVID year and then increased to 9.6 in the second. The rate of phone visits and asynchronous communication increased from 0.7 and 6.3, respectively, in the pre-COVID year, to 4.1 and 8, respectively, in the first COVID year, and remained unchanged in the second. There was substantial variation across age groups and sectors in the adoption of virtual platforms., Conclusions: The rapid introduction of virtual encounters in primary care tended to displace in-person visits in the first year of the pandemic, but they appear to have been additive in the second. This transition should be monitored, with the goal of ensuring appropriate planning efforts and resource allocation to deal with the potential added burden on medical staff. Efforts should be invested in encouraging the use of virtual platforms in patient groups that currently underutilize it, such as minorities.

Background: A decline in cardiovascular hospitalizations was observed during the initial phases of the COVID-19 pandemic. We examine the continuous effect of the COVID-19 pandemic in reducing cardiovascular hospitalization and associated mortality rates during the first year of the pandemic in Israel., Methods: We conduct a retrospective cohort study using the data of Clalit Health Services, the largest healthcare organization in Israel. We divide the Corona year into six periods (three lockdowns and three post-lockdowns) and compare the incidence rates of cardiovascular hospitalizations and 30-day all-cause mortality during each period to the previous three years., Results: The number of non-STEMI hospitalizations during the first year of the pandemic was 13.7% lower than the average of the previous three years (95% CI 11-17%); STEMI hospitalizations were 15.7% lower (95% CI 13-19%); CHF (Congestive heart failure) hospitalizations were 23.9% lower (95%, CI 21-27%). No significant differences in 30-day all-cause mortality rates were observed among AMI (acute myocardial infarction) patients during most of the periods, whereas the annual 30-day all-cause mortality rate among CHF patients was 23% higher., Conclusions: AMI and CHF hospitalizations were significantly lower during the first year of the pandemic relative to 2017-9. Mortality rates were higher in the case of CHF patients but not in the case of AMI patients, possibly due to a change in the clinical acuity of patients arriving at the hospitals. We conclude that targeted public health messaging should be implemented together with proactive monitoring, in order to identify residual disability in patients who may have received non-optimal treatment during the pandemic.

Objective: This study aimed to assess area-level socioeconomic position (SEP) disparities in nutritional status, to determine whether disparities differed by sex and to assess whether nutritional status and disparities changed over time., Design: We used repeated cross-sectional data from a national programme that evaluates the quality of healthcare in Israel to assess children's nutritional status., Setting: The study included all Israeli residents aged 7 years during 2014-2018 (n=699 255)., Methods: SEP was measured based on the Central Bureau of Statistics' statistical areas, and grouped into categories, ranging from 1 (lowest) to 10 (highest). We used multivariable multinomial regression to assess the association between SEP and nutritional status and between year and nutritional status. We included interactions between year and SEP to assess whether disparities changed over time., Results: Children in SEP 1, comprised entirely of children from the Bedouin population from Southern Israel, had drastically higher odds of thinness compared with those in the highest SEP (Girls: OR 5.02, 99% CI 2.23 to 11.30; Boys: OR 2.03, 99% CI 1.19 to 3.48). Odds of obesity were highest in lower-middle SEPs (OR SEP 5 vs 10 1.84, 99% CI 1.34 to 2.54). Prevalence of overweight and obesity decreased between 2014 and 2018, normal weight increased and thinness did not change. SEP disparities in thinness decreased over time in boys but showed a reverse trend for girls. No substantial improvement was seen in SEP disparities for other weight categories., Conclusions: Our study demonstrates the need to consider initiatives to combat the considerable SEP disparities in both thinness and obesity., Competing Interests: Competing interests: YLW reports grants from Azrieli Foundation, during the conduct of the study., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: We sought to evaluate the extent of overall and second-line systemic antibiotic use in the Israeli community, to compare them to international data and to monitor temporal trends., Background: Antibiotic overuse is prevalent and has grave implications, primarily the emergence of resistant pathogens - an urgent public health concern worldwide., Methods: The Israel National Program for Quality Indicators in Community Healthcare (QICH) obtains data from electronic medical records from the 4 health-plans, covering the entire civilian population. We assessed 2 quality indicators, compatible with those of the OECD: 1. Overall volume of antibiotics for systemic use dispensed. 2. Volume of second-line antibiotics as a proportion of all systemic antibiotics. Analysis was stratified by gender, age and socio-economic position (SEP)., Results: The volume of systemic antibiotics dispensed in 2016 was 20.76 DDD/1000 person/day, with second-line antibiotics comprising 22.0% of the total. These values have been stable since 2014, and are higher compared with the OECD averages (20.61 DDD/1000 person/day, and 17.02% in 2015). Both overall volume and the proportion of second-line antibiotics rose with age and were higher among women especially in the 20-40 years age bracket (overall volume of 23.98 DDD/1000 person/day, proportion of second-line antibiotics of 23.98% VS 17.41 and 19.17% in men). Higher overall use was observed among patients of low SEP., Conclusions: The observed volume of systemic antibiotics and the proportion of second-line antibiotics dispensed in the Israeli community were stable and high. Higher use was observed among older individuals, women and patients of low SEP. Our results call for the implementation of a national-level, community-based antibiotic stewardship program. QICH might serve to monitor such a program.

Past studies examining the effects of the metabolic syndrome (MS) on prognosis in postangiography patients were limited in size or were controversial in results. The aim of the study was to examine the association of the MS and the risk for long-term mortality in a large cohort of patients undergoing coronary angiography for various clinical indications. Medical history, physical examination, and laboratory values were used to diagnose patients with the MS. Cox regression models were used to analyze the effect of MS on long-term all-cause mortality. We prospectively recruited 3,525 consecutive patients with a mean age of 66 ± 22 years (range 24 to 97) and 72% men. Thirty percent of the cohort had MS. Patients with MS were more likely to have advanced coronary artery disease and acute coronary syndrome (p <0.001). Patients with MS had more abnormalities in their metabolic and inflammatory biomarkers regardless of their clinical presentation. A total of 495 deaths occurred during a mean follow-up period of 1,614 ± 709 days (median 1,780, interquartile range 1,030 to 2,178). MS was associated with an increased risk of death in the general cohort (hazard ratio [HR] 1.27, 95% confidence interval [CI] 1.01 to 1.56, p = 0.02). MS had a significant effect on mortality in stable patients (HR 1.55, 95% CI 1.1 to 2.18, p = 0.01), whereas it did not have a significant effect on mortality in patients with acute coronary syndrome (HR 1.11, 95% CI 0.86 to 1.44, p = 0.42). In conclusion, MS is associated with increased mortality in postangiography patients. Its adverse outcome is mainly seen in patients with stable angina., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: POSSUM was developed to predict risk-adjusted mortality and morbidity rates for surgical procedures. We evaluated the impact of serum albumin and serum protein levels on POSSUM scores., Methods: Medical files of 2269 patients operated for proximal femur fractures were reviewed. Preoperative serum albumin levels were available for 387 patients (mean 35.1g/l, range 22-49) and serum protein levels for 279 patients (mean 61.6g/l, range 40-86)., Results: Serum albumin and protein levels were inversely associated with mortality in multivariate models (albumin, OR=0.89, p=0.009; protein, OR=0.92, p=0.009) and in composite outcome models as well (albumin, OR=0.955, p=0.219, protein, OR=0.94, p=0.014). The area under the curve (AUC) for POSSUM prediction of mortality (n=1770) was 0.632 (95% CI: 0.580-0.684, p<0.001). The AUC for a model including serum protein levels was 0.742 (95% CI: 0.649-0.834, p<0.001). Hospitalisation time was longer for patients with lower serum proteins levels (p=0.045), with an inverse correlation (Pearson correlation -0.164, p=0.011)., Conclusions: Lower preoperative serum albumin and serum protein levels were associated with increased risk for mortality, increased hospitalisation time and poorer outcomes in patients operated for proximal femoral fractures. Including those values to POSSUM scores would increase their predictive power., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Accumulating evidence demonstrates that both maternal prepregnancy body mass index (mppBMI) and gestational weight gain (GWG) are associated with adult offspring adiposity. However, whether these maternal attributes are related to other cardiometabolic risk factors in adulthood has not been comprehensively studied., Methods and Results: We used a birth cohort of 1400 young adults born in Jerusalem who had extensive archival data and clinical information at 32 years of age to prospectively examine the associations of mppBMI and GWG with adiposity and related cardiometabolic outcomes. Greater mppBMI, independently of GWG and confounders, was significantly associated with higher offspring BMI, waist circumference, systolic and diastolic blood pressures, insulin, and triglycerides and with lower high-density lipoprotein cholesterol. For example, the effect sizes were translated to nearly 5 kg/m(2) higher mean BMI, 8.4 cm higher waist circumference, 0.13 mmol/L (11.4 mg/dL) higher triglycerides, and 0.10 mmol/L (3.8 mg/dL) lower high-density lipoprotein cholesterol among offspring of mothers within the upper mppBMI quartile (mppBMI >26.4 kg/m(2)) compared with the lower quartile (mppBMI <21.0 kg/m(2)). GWG, independently of mppBMI, was positively associated with offspring adiposity; differences of 1.6 kg/m(2) in BMI and 2.4 cm in waist were observed when offspring of mothers in the upper (GWG >14 kg) and lower (GWG <9 kg) quartiles of GWG were compared. Further adjustment for offspring adiposity attenuated the observed associations to the null., Conclusions: Maternal size both before and during pregnancy is associated with cardiometabolic risk factors in young adult offspring. The associations appear to be driven mainly by offspring adiposity. Future studies that explore mechanisms underlying the intergenerational cycle of obesity are warranted to identify potentially novel targets for cardiometabolic risk-reduction interventions.

Objective: Gestational diabetes mellitus (GDM) influences fetal development and offspring's metabolic risk. We evaluated this association in 17-year-old offspring adjusting for birth weight (BW) and prepregnancy maternal BMI (mBMI)., Study Design: The JPS birth cohort contains extensive data on 92,408 births from 1964 to 1976. Offspring's BMI and blood pressure (BP) were obtained from military records. For a subcohort born between 1974 and 1976, prepregnancy mBMI was available. Offspring were classified as born to mothers with GDM (n = 293) or born to mothers without recorded GDM (n = 59,499)., Results: GDM offspring had higher mean BMI and systolic and diastolic BP compared to no-recorded-GDM offspring. After adjusting for BW, GDM remained significantly associated with offspring BMI and diastolic BP (β = 1.169 and 1.520, resp.). In the subcohort, when prepregnancy mBMI was entered to the models, it markedly attenuated the associations with GDM., Conclusions: Maternal characteristics have long-term effects on cardiometabolic outcomes of their offspring aged 17 years.

Purpose: To explore the association between birth weight in offspring, a marker of the intrauterine environment, and mortality in their mothers, taking into account maternal pre-pregnancy characteristics, including maternal body mass index (BMI), smoking, and socioeconomic status. Distinguishing the effects of offspring's birth weight and pre-pregnancy characteristics on maternal outcome may provide clues regarding mechanisms underlying the association between birth weight and maternal mortality., Methods: We studied long-term total mortality (average follow-up period, 29.1 years) in a population-based cohort of 13,185 mothers, aged 15 to 48 years at their offspring's birth, who delivered in West Jerusalem during 1974 through 1976., Results: Univariate and multivariate Cox-proportional hazard models used to estimate the hazard of overall mortality among mothers indicated a nonlinear relationship with birth weight of offspring when introduced into the models as a continuous variable, and a linear positive association with maternal pre-pregnancy BMI. Inclusion of maternal BMI and other pre-pregnancy characteristics in the model did not alter the association between offspring's birth weight and mothers' all-cause mortality. When birth weight was introduced as a categorical variable, higher mortality was observed among mothers who gave birth to babies with birth weight less than 2500 g (hazard ratio [HR] = 1.90; 95% confidence interval [95%CI], 1.23-2.94) as compared to mothers whose offspring had birth weight between 3000 and 3499 g. The HR for mothers who gave birth to babies with birth weight 4000 g or more was 1.30 (95%CI, 0.88-1.91)., Conclusions: Independent of pre-pregnancy maternal BMI and other characteristics, birth weight of offspring was associated with mortality in their mothers, suggesting that intrauterine metabolic events reflected by birth weight and not explained by maternal obesity, smoking, and socioeconomic status have remote consequences for maternal health. These findings underline the need to explore specific genetic and/or environmental mechanisms that account for these associations.