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Objectives Birthweight is often used as an indicator of fetal health. Categorization of infants as small or large for gestational age has clinical significance. Due to growth differences between countries, it is important to have local reference data. The aim of the study was to describe an Israel population-based reference of birthweight by gestational age stratified for singletons/multiple births and gender. Methods Data on birthweight and gestational age were obtained for the years 2010–2019 from the Ministry of Health Birth Registry. Implausible birthweight and gestational age values were excluded in a two step process. First, overtly implausible values were excluded using visual mapping. Then, infants whose birthweight was below or above the fifth interquartile range for each completed week were excluded. Results During the 10-year period there were 1,761,884 infants delivered in Israel; 1,689,696 were included in the analysis. 4.4% of the live born infants were from multiple births. The mean birthweight of singletons (3251 g) was 947 ± 4 g higher than that of multiples (2304 g). The birthweight of the male multiple births began to differ from that of the singletons at 30 weeks; female multiple births began to deviate at 31 weeks. The increase in birthweight of singletons leveled after 42 weeks and those born after 43 weeks weighed less than infants born earlier. Comparison of the curves for singletons from the present study to those reported for the years 1993–2001 reveal a similar median but significant differences in the distribution of lower and higher percentiles. Conclusions Improved data collection and validation permitted inclusion of 96% of births for analysis. Use of interquartile range distribution to exclude values of birthweight/gestational age that were implausible improved validity. Compared to curves reported previously, changes were found in the distribution of birthweights for the upper and lower percentiles. Periodic updates of growth curve references are important.

Previous studies on psychiatric patients infected with COVID-19 have reported a more severe course of disease and higher rates of mortality compared with the general population. This cohort study linked Israeli national databases including all individuals ever hospitalized for a psychiatric disorder (cases), and COVID-19 testing, infection, hospitalization, mortality, and vaccinations, between March 1

BACKGROUND In December 2010, the pentavalent rotavirus vaccine (RotaTeq) was added to the national immunization program in Israel. The study aim was to examine national reductions in all-cause acute gastroenteritis (AGE) and rotavirus gastroenteritis (RVGE) hospitalizations among children aged 0-59 months following the introduction of universal rotavirus immunization in Israel. METHODS We extracted data from the Israel National Hospital Discharge Database. Hospitalization rates were calculated by dividing the annual number of all-cause AGE and RVGE hospitalizations by the number of children aged 0-59 months residing Israel. To assess rate reductions, we compared the mean hospitalization rate for the pre-vaccine years (2002-2008) with that for the universal vaccination years (2011-2017). Interrupted time-series analyses were undertaken. During 2008-2010 rotavirus vaccines were partially available. RESULTS A total of 131,116 AGE hospitalizations were reported, of which 13,111 (10.0%) were coded as RVGE hospitalizations. The average annual all-cause AGE hospitalization rate during the pre-vaccine period was 147.9 (95% CI 146.7-149.0) per 10,000 children aged 0-59 months, and declined by 38.7-53.0% during the universal vaccination years. The average annual pre-vaccine RVGE hospitalization rate was 16.9 (95% CI 16.5-17.3) per 10,000 children, and declined by 89.1% during 2016-2017. Findings from interrupted time-series analyses showed significant impact of introducing universal rotavirus immunization on the declines of all-cause AGE and RVGE hospitalizations rates. A multivariable Autoregressive Integrated Moving Average model showed that the variable "immunization period" was a significant predictor of RVGE hospitalizations (t = 7.3, p

Background Many studies have shown significant gaps in mortality, and cause specific mortality by educational status. This study investigated these measures in Israel by educational and ethnic status in recent decades. Method A mortality follow-up till 2017 was done of a cohort of Israeli residents aged 25–64 in 2000 who remained in Israel and had available educational data, grouped into under 8, 9–11, 12, 13–15 and 16 and above years of education. Indirect age adjustment was used to calculate Standard Mortality Ratios (SMRs) by sex and educational group, and a Cox regression model to assess relative risk of total and cause specific mortality controlling for age and ethnic group (Jews and Others and Arabs).The analysis was repeated for each ethnic group separately. Results 2,776,422 persons were included of whom 174,792 (6.3%) died till 2017. SMR’s for total mortality of males and females with less than 8 years of education compared to 16 and over were 2.2 and 1.8, respectively. Corresponding HR were 2.13 (95% CI 2.08–2.18) and 1.77 (95% CI 1.72–1.82), respectively. The highest cause specific hazard ratios in males were for homicide, 4.40 (95% CI 3.19–6.07), respiratory diseases, 4.01 (95% CI 3.61–4.44), infectious diseases, 3.55 (95% CI 3.15–3.19) and diabetes 3.41 (95% CI 3.06–3.79) and in females for diabetes, 4.41 (95% CI 3.76–5.16), infectious diseases, 4.16 (95% CI 3.52–4.91), respiratory diseases, 4.13 (95% CI 3.55–4.81), and heart disease, 2.96 (95% CI 2.66–3.29). Education-adjusted risk of all-cause mortality for Arab males was 1.07 (1.05–1.09) times that of Jews and Others and non-significant in females. High mortality risk was found for Arab males and females compared to Jews and Others for homicide, diabetes, heart and cerebrovascular disease and for respiratory disease in males. Lower risk was found for suicide and infectious diseases in both sexes and cancer in females. Conclusion We found significant effect of educational level on all-cause and cause specific mortality, particularly respiratory diseases, infectious diseases, diabetes and homicide. Our results highlight the importance of increasing the educational level of all groups in the population and of encouraging healthy behavior in the lower educated.

Limited population-based data have explored perianal involvement in Crohn's disease (CD) and compared the disease course between severe and non-severe perianal CD (PCD). We aimed to explore the disease course of these phenotypes in a population-based study of CD.Cases were identified from the epi-IIRN cohort and included 2 Israeli health maintenance organizations covering 78% of the population. We validated specific algorithms to identify fistulizing PCD and to differentiate severe from non-severe disease by medication utilization, International Classification of Disease, 9th Revision codes, and perianal procedures.A total of 12,904 CD patients were included in an inception cohort from 2005 (2186 pediatric-onset, 17%) providing 86,119 person-years of follow-up. Fistulizing PCD was diagnosed in 1530 patients (12%) (574 with severe PCD, 4%). The prevalence of PCD was 7.9%, 9.4%, 10.3%, and 11.6% at 1, 3, 5, and 10 years from CD diagnosis, respectively. At 5 years, PCD patients were more likely to be hospitalized (36% in non-PCD vs 64% in PCD; P.001), undergo inflammatory bowel disease-related surgeries (9% vs 38%, respectively; P.001), and develop anorectal cancer (1.2/10,000 person-years for non-PCD vs 4.2/10,000 for PCD; P = .01). Severe PCD was associated with poorer outcomes compared with non-severe PCD, as shown for hospitalizations (61% in non-severe PCD vs 73% in severe; P = .004) and surgeries (35% vs 43%; P = .001).Despite higher utilization of immunomodulators and biologics, PCD is associated with poor disease outcomes, especially in severe PCD.

Background Asthma is a common chronic childhood illness and frequent cause of hospitalization. A decline in hospital admission rates was noted up to the 1990s, however, trends are not as clear since the turn of the century. This study aimed to assess the rates and regional differences of asthma admissions over more than two decades using the national Ministry of Health database, which registers data from all the hospitals. Methods A retrospective cohort study, analysis of all pediatric asthma admissions, for Patients 1-14 years old, between 1996 and 2017 as recorded by the National Hospital Discharge Registry, was performed. Asthma admission rates were calculated per 1000 age adjusted residents, using the number of admission cases as the numerator, and age specific population size as the denominator. Results The annual asthma hospitalization rate decreased in the entire pediatric population from 2.14 in 1996-0.89 in 2017. Children in the 1-4 year age group comprised most of the hospital admissions, and most of the decline was attributable to this age group. Significant differences in hospitalizations were found between different regions as well as differences in the rate of decline in asthma hospitalizations with the lowest admission rate in the Jerusalem district, highest in Haifa, northern and southern Israeli regions and the greatest rate of decline in the Tel-Aviv district. Conclusion This nationwide study, over more than two decades, shows clear regional differences in the rates of asthma admissions as well as regional differences in the rates of decline.

Previous findings regarding European Holocaust survivors' suicide risk are conflicting. North African survivors' suicide risk was not previously studied. In this study, we aimed to determine suicide risk among European and North African Holocaust survivors. The study was based on the Israeli population census from 1972, followed until 2015 for suicide. European survivors were grouped into survivors of severe Nazi persecution (HS) and early HS. North African survivors were grouped into those from Algeria, Libya and Tunisia who were likely to have suffered more severe persecution (group 1) and those from Morocco who apparently suffered less persecution (group 2). Comparison groups were chosen according to similar ethnic origins who were not under Nazi control. Age standardized suicide rates, Standard Mortality Ratios (SMR) were calculated. Cox regression analysis was used to assess suicide risk. The age adjusted suicide rates (per 100,000) among Europeans were: HS 17.8 (95%CI 16.9-18.6), early HS 28.6 (95%CI 24.9-32.2), comparison group 20.3 (95%CI 18.5-22.1). Among North Africans: group 1, 6.9 (95%CI 5.6-8.2), group 2, 4.8 (95%CI 4.0-5.5), comparison group, 8.5 (95% CI 6.4-11.0). The SMRs with European comparisons were 0.88 (95%CI 0.84-0.92) for HS and 1.41 (95%CI 1.20-1.65) for early HS. SMRs with North African comparisons were 0.81 (95%CI 0.67-0.97) for group 1 and 0.57 (95%CI 0.48-0.66) for group 2. Cox regression models showed significantly higher suicide risk for European early HS vs comparisons (Hazard Ratio (HR) = 1.31, 95% CI 1.12-1.52), and lower risk for HS (0.89, 95%CI 0.80-0.98). North African group 2 had significantly lower HR (0.58, 95%CI 0.43-0.79). To conclude, higher resilience was found among European survivors of severe adversity, compared to those who suffered lesser persecution. No elevated risk was found among North African survivors.

BackgroundPrevious studies have demonstrated the association between psychological distress (measured by the 12-item General Health Questionnaire, GHQ-12) and risks of all-cause mortality and deaths from cardiovascular, cancer and other causes. We hypothesised that in the Israeli population permanently exposed to war/terror stressors, this relationship is absent.MethodsWe performed an analysis of data from participants in the Israel National Health Survey conducted in 2003–2004, who died during the follow-up decade. Subjects were assigned to groups based on GHQ-12 score: 0–10 (asymptomatic), 11–14 (subclinically symptomatic), 15–19 (symptomatic) and 20–36 (highly symptomatic). Data were weighted to the total population.ResultsWe analysed data from 4843 individuals, median age 40.5 (IQR 28–54); 473 participants died during the follow-up. We found a significant increase in total mortality, cardiovascular and other causes of mortality (but not cancer deaths) with increase in GHQ-12 score (P for linear trend of ungrouped GHQ scores ConclusionContrary to our hypothesis, psychological distress was associated with all-cause and cardiovascular but not cancer mortality. The absence of reverse causality provides evidence for the direct deleterious effects of psychological distress on mortality outcomes.

Since 2000, the Israeli mental health system has undergone a reduction in hospital beds, initiation of community-based rehabilitation, and transfer of governmental services to health maintenance organizations. This study examined trends, predictors and outcomes of involuntary psychiatric hospitalizations (IPH), in particular for immigrants. All first psychiatric hospitalizations of adults, 2001-2018, in the National Psychiatric Case Registry were used. Involuntary and voluntary hospitalizations were analyzed by demographic and clinical characteristics, and age-adjusted rates calculated over time. Multivariate logistic regression models were used to investigate IPH predictors and first IPH as a risk factor for one-year suicide after last discharge, and a Cox multivariate regression model to examine its risk for all-cause mortality. Among 73,904 persons in the study, age-adjusted rates of IPH were higher between 2011 and 2015 and then decreased slightly until 2018. Ethiopian immigrants had the highest risk for IPH, immigrants from the former Soviet Union a lower risk, and that of Arabs was not significantly different, from non-immigrant Jews. IPH was not significantly associated with one-year suicide or all-cause mortality. These findings demonstrate the vulnerability of Ethiopian immigrants, typical of disadvantaged immigrants having a cultural gap with the host country and highlight the importance of expanding community mental health services.

BACKGROUND Influenza-related morbidity impacts healthcare systems, including hospitals. OBJECTIVE To obtain a quantitative assessment of hospitalization burden in pediatric and internal medicine departments during influenza seasons compared with the summer months in Israel. METHODS Data on pediatric and internal medicine hospitalized patients in general hospitals in Israel during the influenza seasons between 2005 and 2013 were analyzed for rate of hospitalizations, rate of hospitalization days, hospital length of stay (LOS), and bed occupancy and compared with the summer months. Data were analyzed for hospitalizations for all diagnoses, diagnoses of respiratory or cardiovascular disease (ICD9 390-519), and influenza or pneumonia (ICD9480-487), with data stratified by age. The 2009-2010 pandemic influenza season was excluded. RESULTS Rates of monthly hospitalizations and hospitalization days for all diagnoses were 4.8% and 8% higher, respectively, during influenza seasons as compared with the summers. The mean LOS per hospitalization for all diagnoses demonstrated a small increase during influenza seasons as compared with summer seasons. The excess hospitalizations and hospitalization days were especially noticed for the age groups under 1 year, 1-4 years, and 85 years and older. The differences were severalfold higher for patients with a diagnosis of respiratory or cardiovascular disease and influenza or pneumonia. Bed occupancy was higher during influenza seasons compared with the summer, particularly in pediatric departments. CONCLUSIONS Hospital burden in pediatric and internal medicine departments during influenza seasons in Israel was associated with age and diagnosis. These results are important for optimal preparedness for influenza seasons.

Background Perianal disease is a disabling complication of Crohn’s disease (CD). In this study, we aimed to explore the incidence of fistulising perianal CD (PCD) and its association with treatment pattern and disease outcomes, within the validated epiIIRN cohort which includes all IBD patients in Israel (n = 45,074). We also aimed to differentiate simple from complicated PCD. Methods The current analysis was performed on data from the two largest Health Maintenance Organisations (HMOs), covering 75% of the Israeli population. First, we developed and validated algorithms to identify fistulising PCD patients and differentiate simple from complex disease, by establishing two reference cohorts of true positive PCD patients (TP, patients with perianal abscess/fistula) classified into simple or complicated PCD, and true negatives (TN) of CD patients without perianal disease (validated by chart reviews). We then applied the algorithms on the complete epiIIRN IBD cohort. Random charts were reviewed to validate again PCD diagnosis. Results The chosen algorithm included patients with at least one perianal-related diagnosis, procedure or surgery (sensitivity/specificity 75%/96% for identifying PCD, and 70%/79% for differentiating complicated vs. simple PCD). Of the total 26,440 CD patients, 4237 (16%) had fistulising PCD, of whom 1004 (4% of the total) had complicated PCD. Those with complicated PCD were diagnosed with IBD at a younger age than simple PCD and non-PCD (29.2 ± 13.6 vs. 32.2 ± 16 and 32.8 ± 16.7 years, respectively) (p < 0.001). PCD patients were treated more often with biologics (32% in non-PCD compared with 47% in simple PCD and 70% in complicated PCD, p = 0.01), steroids (74%, 78% and 83%, respectively; p < 0.001) and immunomodulators (56%, 64% and 67%, respectively; p < 0.001). Despite this, PCD patients had more hospitalisations (median 0 (IQR 0–2), 5 (2–11) and 13 (7–22) in non PCD, simple PCD and complicated PCD, respectively, p < 0.001), more colon surgery (5%, 18% and 52% in non PCD, respectively, p < 0.001) and higher mortality compared with CD patients without perianal disease (p < 0.001). Conclusion Conclusion: Despite the higher utilisation of immunomodulators and biologics, patients with PCD are at higher risk of hospitalisation and surgical resection, higher need for steroids and higher mortality. PCD is a strong predictor of disease course and thus should prompt early intensified treatment and close monitoring. This study was supported by a grant from the Leona M. and Harry B. Helmsley Charitable Trust.

Respiratory Syncytial Virus (RSV) is a known cause of morbidity among young children, while RSV-related disease in the elderly is not fully recognized. Several RSV candidate vaccines for infants, pregnant women and adults are under development. We aimed to estimate nationwide age-specific hospitalizations and seasonal trends, to help determine the optimal age for vaccination.Hospitalizations with a primary RSV-related diagnoses were retrieved from the National Hospital Database for the years 2000-2017. Data were analyzed by year, month and age group to determine hospitalization rates and seasonal trends.During the analysis period, 39,156 hospitalizations received primary RSV-related ICD-9 diagnostic codes. The highest mean yearly hospitalization rate occurred among infants1 year of life (1,218.4 per 100,000). Within the first year of life, the highest mean yearly hospitalization rate was observed in the second month of life (3,541.5 hospitalizations per 100,000). Hospitalization rates for individuals ≥5 years old increased during the study period, primarily among patients ≥65 years of age, reaching hospitalization rate of 9 per 100,000 in 2017. A clear seasonal pattern was observed.An effective vaccine for infants and pregnant women has the potential to reduce hospitalizations burden. RSV-related hospitalizations burden among adults requires additional research.

Background In 2014 the OECD published a report regarding inter-regional variation of hysterectomies in 13 countries including Israel. Variance in hospital admission rates were also reported. The Israeli Ministry of Health has set as one of its main goals the reduction in differences in health care, particularly between the country’s periphery and central regions. These variations may reflect differences in characteristics, resource allocation, and medical staff employment, expertise and training. The advances in technology in the last decades including laparoscopic and robotic surgeries and the variance in their implementation emphasize the great regional variance. The aim of this study was to examine hysterectomy trends in the past decade with emphasis on regional differences. Methods The study is based on information maintained by the Israeli Ministry of Health and portrays the trend in hysterectomy rates as a factor of indication, surgical approach and length of hospitalization as collected from the years 2007–2016. Results Inter-regional significant differences were found between the 7 regions of Israel, though there was a clear trend toward a national 11–24% decrease in hysterectomy rates. A 2–4 time increase in laparoscopic hysterectomies was observed. There was a clear country-wide trend toward shortening hospital stay from 5 to 4 days in total. Conclusions Hysterectomy rates have declined in the past decade due to the implementation of new technologies allowing earlier diagnosis and minimally invasive surgery on top of offering alternative, non-surgical treatment modalities. Uneven allocation of resources and manpower allowing technology implementation and optimal medical services may have contributed to the findings.

Background To compare the underlying cause of death reported by the Israeli Central Bureau of Statistics (CBS) with diagnoses in the electronic health records (EHR) of a fully integrated payer/provider healthcare system. Methods Underlying cause of death was obtained from the CBS for deaths occurring during 2009–2012 of all Clalit Health Service members in Israel. The final cohort consisted of members who had complete medical records. The frequency of a supportive diagnosis in the EHR was reported for 10 leading causes of death (malignancies, heart disease, cerebrovascular disease, diabetes, kidney disease, septicemia, accidents, chronic lower respiratory disease, dementia and pneumonia and influenza). Results Of the 45 680 members included in the study, the majority of deaths had at least one diagnosis in the EHR that could support the cause of death. The lowest frequency of supportive diagnosis was for septicemia (52.2%) and the highest was for malignancies (94.3%). Sensitivity analysis did not suggest an alternative explanation for the missing documentation. Conclusions The underlying cause of death coded by the CBS is often supported by diagnoses in Clalit’s EHR. Exceptions are septicemia or accidents that cannot be anticipated from a patient’s EHR, and dementia which may be under-reported.

Background Epidemiological studies have demonstrated a relationship between cognitive function in youth and the future risk of death. Less is known regarding the relationship with diabetes related death. This study assessed the relationship between cognitive function in late adolescence and the risk for diabetes, cardiovascular- (CVD) and all-cause mortality in adulthood. Methods This retrospective study linked data from 2,277,188 16–19 year olds who had general intelligence tests (GIT) conducted during pre-military recruitment assessment with cause of death as coded by the Israel Central Bureau of Statistics. The associations between cognitive function and cause-specific mortality were assessed using Cox models. Results There were 31,268 deaths that were recorded during 41,916,603 person-years of follow-up, with a median follow-up of 19.2 (IQR 10.7, 29.5) years. 3068, 1443, 514 and 457 deaths were attributed to CVD, CHD, stroke, and diabetes, respectively. Individuals in the lowest GIT vs. highest GIT quintiles in unadjusted models had the highest risk for all-cause mortality (HR 1.84, 95% CI 1.78, 1.91), total CVD (HR 3.32, 95% CI 2.93, 3.75), CHD (HR 3.49 95% CI 2.92, 4.18), stroke (HR 3.96 95% CI 2.85, 5.5) and diabetes-related (HR 6.96 95% CI 4.68, 10.36) mortality. These HRs were attenuated following adjustment for age, sex, birth year, body-mass index, residential socioeconomic status, education and country of origin for all-cause (HR 1.23, 95% CI 1.17, 1.28), CVD (HR 1.76, 95% CI 1.52, 2.04), CHD (HR 1.7 95% CI 1.37, 2.11), stroke (HR 2.03, 95% CI 1.39, 2.98) and diabetes-related (HR 3.14 95% CI 2.00, 4.94) mortality. Results persisted in a sensitivity analyses limited to participants with unimpaired health at baseline and that accounted competing risk. Conclusions This analysis of over 2 million demonstrates a strong relationship between cognitive function at youth and the risk for diabetes, all-cause and CVD-related mortality independent of adolescent obesity. Electronic supplementary material The online version of this article (10.1186/s12933-018-0798-5) contains supplementary material, which is available to authorized users.

OBJECTIVE The sequelae of increasing childhood obesity are of major concern. We assessed the association of BMI in late adolescence with diabetes mortality in midlife. RESEARCH DESIGN AND METHODS The BMI values of 2,294,139 Israeli adolescents (age 17.4 ± 0.3 years), measured between 1967 and 2010, were grouped by U.S. Centers for Disease Control and Prevention age/sex percentiles and by ordinary BMI values. The outcome, obtained by linkage with official national records, was death attributed to diabetes mellitus (DM) as the underlying cause. Cox proportional hazards models were applied. RESULTS During 42,297,007 person-years of follow-up (median, 18.4 years; range CONCLUSIONS Adolescent BMI, including values within the currently accepted “normal” range, strongly predicts DM mortality up to the seventh decade. The increasing prevalence of childhood and adolescent overweight and obesity points to a substantially increased future adult DM burden.

Background: There have been very few prospective studies of death by suicide in the general population. Rather, studies of suicide have generally used psychological autopsies, a method that has the potential weakness of recall bias. Aims: To examine correlates of death by suicide among a community-based nonclinical sample prospectively assessed years before death by suicide. Method: We analyzed data from an epidemiological study of a 10-year birth cohort (n = 4,914) conducted in Israel in the 1980s, with follow-up mortality data over 25 years. Results: Eight participants died by suicide during follow-up (6/100,000 per year; mean follow-up to suicide = 18.3 ± 2.0 years), the majority of whom were rated as functioning relatively well at baseline. Male sex, psychiatric hospitalizations, major depressive disorder, and previous suicide attempts were associated with later suicide. Conclusion: In this nonclinical sample of persons assessed between ages 25 and 34, several correlates of suicide were identified, but the majority of persons who died by suicide were relatively high functioning at baseline. Major precursors of suicide may be more proximal factors of acute or chronic negative changes in life circumstances.

Background Up to 25% of patients with ulcerative colitis (UC) may undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouchitis may occur in 50–70% of patients, and ~30% may develop chronic pouchitis (CP) or Crohn’s-like disease of the pouch (CLDP). We aimed to identify predictors for the development of CP or CLDP during a long follow-up period. Methods Patients followed prospectively at the pouch clinic at Rabin Medical Center, were cross-referenced with data from the validated epiIIRN cohort which includes all IBD patients in Israel (n = 45 074). All patients had at least one year of follow-up since ileal continuity (i.e., ileostomy closure after pouch formation). CP was defined as an active flare of pouchitis for >4 weeks and being treated with antibiotics or anti-inflammatory therapy, or >4 episodes of acute pouchitis/year. CLDP was defined as having one or more of the following: pouch-related fistula (>1 year after ileostomy closure), inflammation of the afferent limb, or fibrostenotic disease of the pouch. For the analysis, the cohort was further categorised into favourable pouch outcomes (sustained normal pouch, acute pouchitis) vs. unfavourable pouch outcomes (CP, CLDP or pouch failure). Logistic regression included gender, age, previous therapies, disease duration before pouch surgery, surgical technique and number of previous non-IBD related abdominal operations. Results We included 182 patients (55% females; median age at IPAA: 32 years (IQR 23–45); median disease duration until pouch surgery 6 years (3–11); two-staged surgery 69%). The median follow up time was 14 years (IQR 7–22). Before surgery, 37% of patients had been exposed to immunomodulators (either thiopurines or methotrexate), 24% were exposed to anti-TNF therapy and 5% were previously treated with vedolizumab. An unfavourable pouch phenotype was noted in 48% of patients. On multivariate logistic regression, anti-TNF therapy and older age at pouch surgery were associated with decreased odds of an unfavourable pouch outcome (OR 0.3 95% CI 0.11–0.69, p = 0.007 and OR 0.96 95% CI 0.93–0.98, p = 0.005, respectively). Conclusion Therapy of UC with an anti-TNF and older age were associated with a favourable pouch outcome. These may be surrogates for patients with longer follow up as well as indication for IPAA. Such factors should be taken into consideration in clinical decision making.

Background Natural environments may have beneficial impacts on pregnancy outcomes. However, longitudinal evidence is limited and the associations with variance in surrounding greenness is unknown. Our objective was to evaluate these associations among 73 221 live births in Tel Aviv, Israel. Methods Longitudinal exposure to mean of greenness during pregnancy and trimesters were calculated using satellite-based Moderate Resolution Imaging Spectroradiometer (MODIS) Normalised Difference Vegetation Index (NDVI) data. In addition, exposure to mean and variation of NDVI from high-resolution satellite and percentage of tree cover [Vegetation Continuous Fields (VCF)] at 300-m buffer were evaluated in a cross-sectional approach. Generalized linear models were used to estimate the crude and adjusted associations. We explore the possible mediating role of ambient exposures and distance to ‘outdoor gyms’ located in parks. Results Crude beneficial associations between exposure to higher mean NDVI during pregnancy and pregnancy outcomes were observed [for birthweight, 3rd/1st tertile exposure increased the mean by 25.5 g, 95% confidence intervals (CIs): 15.4, 35.5] and decreased the odds of low birthweight, small for gestational age, preterm deliveries (PTD) and very PTD. Adjustment for individual and neighbourhood-level markers of socio-economic status (SES) attenuated all the associations. Strongest associations were observed during the first and second trimesters. Cross-sectional associations for mean greenness were similar with narrower CIs, and associations with NDVI were stronger than with tree cover and stronger for mean compared with variance of greenness. Associations were consistent for term births, different buffer sizes and for further adjustment to maternal education. Stronger associations were observed for lowest SES. Distance to ‘outdoor gyms’ and variance of greenness had the largest estimates of mediation. Conclusion This study adds to the limited information on when exposure to greenness is most beneficial, on the association with variance of greenness and the possible pathways. These observations require confirmation in other populations.

Background Preterm birth at very low birth weight (VLBW, Aims To evaluate the reproductive outcome of VLBW infants who survive to adulthood (next-generation). Study design Retrospective cohort Subjects Infants born at a single tertiary center between the years 1982–1997 who survived to 18 years of age (first-generation). Outcome measures The number and the birth weight of offspring from adults born with VLBW were compared to those of other birth weight groups born in the same epoch: 1500–2499g, 2500–3799g (reference group) and ≥3800g. We calculated the ratio of actual compared to expected number of children in the next-generation for extreme birth weight parents, using the reference group as a control group and adjusting for birth year. Thereafter, we measured whether first-generation VLBW had an increased risk for a VLBW in the next-generation. Results After exclusions, we identified first-generation 67,183 births, including 618 (9.2%) VLBW. There were 193 males and 184 female VLBW infants who survived to adulthood. Both female and male first-generation patients from the VLBW group had half the reproductive rate relative for the normal birth weight group. After adjusting for parental age, male and female VLBW survivors had no significant risk for a VLBW neonate in the next-generation, however, the overall number of are small and may limit any conclusion. Conclusions VLBW children who reach adulthood may be at a significantly lower reproductive capacity.

Trends in birthweight and abnormal fetal growth, namely term low birthweight (LBW), macrosomia, small-for-gestational age (SGA) and large-for-gestational age (LGA), are important indicators of changes in the health of populations. We performed this epidemiological study to evaluate these trends among 2,039,415 singleton live births from Israel over a period of 15 years. Birth certificate data was obtained from the Ministry of Health. Multivariable linear and logistic regression models were used to evaluate crude and adjusted estimates compared to the baseline of 2000 and polynomial trends. During the study period we observed a significant decrease in the rates of infants born SGA and LGA (10.7% to 9.2%, 10.2% to 9.6% respectively). After adjustment, based on the imputed data set, term mean birthweight increased by 6.0 grams (95% CI: 2.9, 9.1), and term LBW odds decreased by 19% in 2014 compared to 2000 (adj ORs: 0.81; 95% CI: 0.77, 0.85). Significant decreases were also observed for adjusted SGA, LGA and macrosomia rates. The decrease in abnormal fetal growth rates were not entirely explained by changes in sociodemographic characteristics or gestational age and may imply real improvement in child intrauterine growth in Israel during the last 15 years, especially in the Jewish population.

Background: The prevalence of asthma has increased in western countries towards the end of the last century, but recently seems to have stabilized. Objective: To evaluate trends in the prevalence and severity of asthma that occurred in Israel over the past decade. Methods: The medical records of 17-year-old boys, eligible for national service, between 1999 and 2008 were reviewed. National annual hospitalization and death rates for asthma were extracted. Results: Three hundred thousand medical records were reviewed. During the study period, lifetime asthma prevalence decreased from 9.7 to 8.1% (p = 0.002). The point prevalence of moderate-to-severe and mild persistent asthma decreased significantly from 0.88 and 3.41% to 0.36 and 2.44%, respectively, during this period. The prevalence of intermittent asthma and asthma in clinical remission for more than 3 years did not change significantly. The annual hospitalization rate for asthma decreased from 13.0 to 7.5 per 10,000 population (p < 0.0001), whilst the annual death rate due to asthma decreased between 1999 and 2008 from 2.1 to 1.4 per 100,000 population (p = 0.003). Conclusions: The prevalence of asthma in Israeli teenage boys decreased significantly over the last decade. In addition, asthma hospitalization and asthma-related death rates in the total population also decreased.

The association between Holocaust experience, suicide, and psychiatric hospitalization has not been unequivocally established. The aim of this study was to determine the risk of suicide among 3 Jewish groups with past or current psychiatric hospitalizations: Holocaust survivors (HS), survivors of pre-Holocaust persecution (early HS), and a comparison group of similar European background who did not experience Holocaust persecution. In a retrospective cohort study based on the Israel National Psychiatric Case Register (NPCR) and the database of causes of death, all suicides in the years 1981-2009 were found for HS (n = 16,406), early HS (n = 1,212) and a comparison group (n = 4,286). Age adjusted suicide rates were calculated for the 3 groups and a logistic regression model was built to assess the suicide risk, controlling for demographic and clinical variables. The number of completed suicides in the study period was: HS-233 (1.4%), early HS-34 (2.8%), and the comparison group-64 (1.5%). Age adjusted rates were 106.7 (95% CI 93.0-120.5) per 100,000 person-years for HS, 231.0 (95% CI 157.0-327.9) for early HS and 150.7 (95% CI 113.2-196.6) for comparisons. The regression models showed significantly higher risk for the early HS versus comparisons (multivariate model adjusted OR = 1.68, 95% CI 1.09-2.60), but not for the HS versus comparisons. These results may indicate higher resilience among the survivors of maximal adversity compared to others who experienced lesser persecution.

OBJECTIVES Orofacial clefts are one of the most common birth malformations and represent a significant public health economic expenditure. The purpose of this investigation was to study the epidemiology of orofacial clefts in newborns from 1993 to 2005 in Israel. In addition, a comparison of data from the National Birth Defects Registry (NBDR) and Hospital records will be made. METHODS A retrospective data review of reports to the Israeli NBDR on infants with orofacial clefts in comparison with records reviewed at 13 major hospitals, accounting for 60% of all births in Israel. RESULTS Of 1334 newborns found to be with orofacial clefts all over Israel between 1993 and 2005, 1015 were reported to the NBDR and 319 were unreported but retrieved from hospital files. During this period, of the 976 578 live births found in the 13 participating hospitals, there were 866 newborns with orofacial clefts. Of those, 684 (79%) were nonsyndromic orofacial clefts and 182 (21%) had additional syndromes. The prevalence of nonsyndromic orofacial clefts was 7/10 000 live births, lower than reported outside Israel. Only 65% of orofacial clefts retrieved from the 13 hospitals were reported to the NBDR. A significantly higher orofacial cleft prevalence was found among non-Jews than Jews (11 and 6 of 10 000 live births, respectively), (P < .00 001). CL/P was found more frequently than isolated cleft palate (CP). More males had orofacial clefts than females, mostly unilateral with left side predominance. CONCLUSIONS The prevalence of nonsyndromic orofacial clefts was found to be 7/10 000 live births. The higher orofacial cleft prevalence among non-Jews may be explained by the high prevalence of consanguinity and deprived maternal nutritional status in this population.

Background Regional variations in mortality can be used to study and assess differences in disease prevalence and factors leading to disease and mortality from different causes. To enable this comparison, it is important to standardize the mortality data to adjust for the effects of regional population differences in age, nationality and country of origin. Methods Standardized mortality ratios (SMR) were calculated for the districts and sub-districts in Israel, for total mortality by gender as well as for leading causes of death and selected specific causes. Correlations were assessed between these SMRs, regional disease risk factors and socio-economic characteristics. Implications for health policy were then examined. Results Total mortality in the Northern District of Israel was not significantly different from the national average; but the Haifa, Tel Aviv, and Southern districts were significantly higher and the Jerusalem, Central, Judea and Samaria districts were lower. Cancer SMR was significantly lower in Jerusalem and not significantly higher in any region. Heart disease and diabetes SMRs were significantly higher in many sub-districts in the north of the country and lower in the south. SMRs for septicemia, influenza/pneumonia, and for cerebrovascular disease were higher in the south. Septicemia was also significantly higher in Tel Aviv and lower in the North, Haifa and Jerusalem districts. SMRs for accidents, particularly for motor vehicle accidents were significantly higher in the peripheral Zefat and Be’er Sheva sub-districts. Conclusion The SMR, adjusted for age and ethnicity, is a good method for identifying districts that differ significantly from the national average. Some of the regional differences may be attributed to differences in the completion of death certificates. This needs to be addressed by efforts to improve reporting of causes of death, by educating physicians. The relatively low differences found after adjustment, show that factors associated with ethnicity may affect mortality more than regional factors. Recommendations include encouraging good eating habits, exercise, cancer screening, control of hypertension, reduction of smoking and improving road infrastructure and emergency care access in the periphery.

Aims: To explore previously unreported rates and trends in opioid-related mortality in Israel, 2005–2014. Methods: Data was obtained from the national database on causes of death. Drug poisoning deaths were divided into opioid-related deaths and deaths related to other drugs according to International Classification of Diseases (ICD)-10 code of underlying cause, and included drug poisoning of accidental, intentional or undetermined intent. Age-adjusted rates were calculated per 100,000 population. Rate ratios were calculated and a logistic model constructed to compare the risk of opioid-related deaths in both halves of the decade (2006–2009 and 2009–2013) and between various demographic groups. Results: While age-adjusted rates of deaths related to other drugs remained relatively stable, rates of opioid-related deaths significantly decreased during this period across all groups. During the study period, the number of opioid-related deaths in Israel declined from 1.3 to 0.3 per 100,000. Opioid-related deaths were more common among men, young adults and immigrants from the Former Soviet Union. Conclusions: Rates of opioid-related deaths in Israel were low compared to those reported in the United States and United Kingdom. In addition, the decline in opioid-related deaths in Israel is contrary to trends observed in the United States and United Kingdom. Factors that may contribute to these differences are discussed.

Obesity was linked to altered immunity, but also to favorable outcomes among patients with infectious disease (ID) in some settings. We assessed the association between adolescent body mass index (BMI) and ID mortality. BMI of 2 294 139 Israeli adolescents (60% men; age 17.4±0.3 years) was measured between 1967 and 2010. The outcome, obtained by linkage with official national records, was death due to ID as the underlying cause. Multivariable Cox proportional hazards models were applied. During 42 297 007 person-years of follow-up (median 18.4 years), there were 689 deaths from ID (mean age 44.1±10.5 years). Adjusted hazard ratios (HR) were 1.039 (1.011–1.068) and 1.146 (1.099–1.194) among men and women, respectively, per unit increment in BMI (P for sex interaction=4.4 × 10−5). Adjusted hazard ratios among men were 1.2 (1.0–1.5), 1.9 (1.4–2.5) and 2.5 (1.5–4.2) for those with high-normal BMI (22.0–24.9 kg m−2), overweight and obese, respectively, compared with the 18.5⩽BMI

Context As opposed to coronary heart disease (CHD) mortality, cardiovascular mortality attributed to non-CHD causes has increased. Objective To evaluate the association of body mass index (BMI) in late adolescence with mortality attributed to non-CHD cardiovascular sequelae. Design and Setting A nationwide cohort. Participants A total of 2,294,139 adolescents examined between 1967 and 2010. Interventions Height and weight were measured at age 17. All cardiovascular disease-specific outcomes, coded by the Central Bureau of Statistics from death notifications as the underlying cause of death, were obtained by linkage. Cox hazards models were applied. Main Outcome Measurements Death attributed to fatal arrhythmias, hypertensive heart disease, cardiomyopathies, arterial disease, heart failure, and pulmonary embolism. Results During 42,297,007 person-years of follow-up, there were 3178 deaths due to cardiovascular causes, of which 279, 122, 121, 114, 94, and 70 were attributed to the main outcomes, respectively. BMI was positively associated with all study outcomes with hazard ratios (HRs) per unit increment in BMI ranging from 1.09 [95% confidence interval (CI): 1.03 to 1.16] for arterial disease to 1.16 (95% CI: 1.11 to 1.21) for hypertensive heart disease. When BMI was treated as a categorical variable, a graded increase in risk was evident from the high-normal (22.0 to

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Cardiac catheterization service in the periphery, as a case study for health disparities reducing policy. (DOCX 14 kb)

Rationale, aims and objectives Israel's healthcare system has been facing increasing hospital bed shortage over the last few decades. Community-based services and shortening length of stay have helped to ease this problem, but hospitals continue to suffer from serious overload and saturation. The objective of this study is to present hospitalization trends in Israel's internal medicine departments. Methods The data is based on the National Hospital Discharges database (NHDR) in the Israeli Health Ministry, pertaining to hospitalizations in all internal medicine departments nationwide between 2000 and 2012. Results Total yearly hospitalization days, representing healthcare burden, had increased by 4.2% during the study period, driven mainly by the most advanced age groups. The rate of total hospitalization days per 100,000 people for all the age groups has decreased by 17.6%, but the oldest patient group had a modest reduction in comparison (7.5%). The parameter of age correlated with length of stay and readmission rates, and neither decreased during the surveyed years. Conclusions These results demonstrated that the healthcare burden on acute internal medicine services has been reduced mostly for middle-aged populations but only modestly for elderly populations. The length of hospital stay and the readmission rates have reached and maintained a plateau in recent years, regardless of age. The findings of this study call for planning specific to elderly populations in light of changing demographics. Possible directions may include renewed emphasis on internal medicine and geriatric medicine, and efforts to shorten hospitalization time by extended utilization of multidisciplinary primary care.

In light of the worldwide increase in childhood obesity, we examined the association between body-mass index (BMI) in late adolescence and death from cardiovascular causes in adulthood.We grouped data on BMI, as measured from 1967 through 2010 in 2.3 million Israeli adolescents (mean age, 17.3±0.4 years), according to age- and sex-specific percentiles from the U.S. Centers for Disease Control and Prevention. Primary outcomes were the number of deaths attributed to coronary heart disease, stroke, sudden death from an unknown cause, or a combination of all three categories (total cardiovascular causes) by mid-2011. Cox proportional-hazards models were used.During 42,297,007 person-years of follow-up, 2918 of 32,127 deaths (9.1%) were from cardiovascular causes, including 1497 from coronary heart disease, 528 from stroke, and 893 from sudden death. On multivariable analysis, there was a graded increase in the risk of death from cardiovascular causes and all causes that started among participants in the group that was in the 50th to 74th percentiles of BMI (i.e., within the accepted normal range). Hazard ratios in the obese group (≥95th percentile for BMI), as compared with the reference group in the 5th to 24th percentiles, were 4.9 (95% confidence interval [CI], 3.9 to 6.1) for death from coronary heart disease, 2.6 (95% CI, 1.7 to 4.1) for death from stroke, 2.1 (95% CI, 1.5 to 2.9) for sudden death, and 3.5 (95% CI, 2.9 to 4.1) for death from total cardiovascular causes, after adjustment for sex, age, birth year, sociodemographic characteristics, and height. Hazard ratios for death from cardiovascular causes in the same percentile groups increased from 2.0 (95% CI, 1.1 to 3.9) during follow-up for 0 to 10 years to 4.1 (95% CI, 3.1 to 5.4) during follow-up for 30 to 40 years; during both periods, hazard ratios were consistently high for death from coronary heart disease. Findings persisted in extensive sensitivity analyses.A BMI in the 50th to 74th percentiles, within the accepted normal range, during adolescence was associated with increased cardiovascular and all-cause mortality during 40 years of follow-up. Overweight and obesity were strongly associated with increased cardiovascular mortality in adulthood. (Funded by the Environment and Health Fund.).

Objectives To determine all-cause and specific-causes mortality, in the years 1999–2008, among opioid-dependent users treated at methadone maintenance treatment (MMT) clinics in Israel and to compare the obtained results with data from relevant studies worldwide. Method The records of patients treated at MMT units were linked to the nationwide database of causes of death. Information about the Israeli general population from the Central Bureau of Statistics was used for comparison to match sex and age to the cohort under study. Crude mortality rates (CMRs) per 100 persons per year (PY) and standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated. Results The overall CMR for MMT users was 1.49/100 PY (CI 1.40–1.59) and was not associated with gender, age at entering MMT, ethnicity, and immigrant status. The leading causes of mortality were sudden/undefined death (0.31/100 PY, CI 0.26–0.35), overdose (0.22/100 PY, CI 0.17–0.27), and cancer (0.15/100 PY, CI 0.12–0.18). The MMT users were 12.2 times more likely to die from all causes than people from the general population. Overall, our estimates were comparable with the figures pooled from relevant studies. Conclusions The results suggest that the excess mortality of MMT users is associated with an increased morbidity, which alone or in combination with service-related risks, lead to worse outcomes.

There have been very few prospective studies of death by suicide in the general population. Rather, studies of suicide have generally used psychological autopsies, a method that has the potential weakness of recall bias.To examine correlates of death by suicide among a community-based nonclinical sample prospectively assessed years before death by suicide.We analyzed data from an epidemiological study of a 10-year birth cohort (n = 4,914) conducted in Israel in the 1980s, with follow-up mortality data over 25 years.Eight participants died by suicide during follow-up (6/100,000 per year; mean follow-up to suicide = 18.3 ± 2.0 years), the majority of whom were rated as functioning relatively well at baseline. Male sex, psychiatric hospitalizations, major depressive disorder, and previous suicide attempts were associated with later suicide.In this nonclinical sample of persons assessed between ages 25 and 34, several correlates of suicide were identified, but the majority of persons who died by suicide were relatively high functioning at baseline. Major precursors of suicide may be more proximal factors of acute or chronic negative changes in life circumstances.

Background The interpregnancy interval (IPI) has been reported to influence the outcome of pregnancy and birth. We performed a national study in Israel to determine the impact of IPI on multiple adverse perinatal outcomes. Study Design This longitudinal cohort study used birth certificates of siblings born to the same biological mother, with at least one previous birth and a subsequent singleton pregnancy. Adverse pregnancy outcomes included preterm delivery, very preterm birth, small for gestational age (SGA), very SGA (VSGA), early neonatal death and major congenital malformations. Multivariate logistic regression was performed for each outcome. Results The study included 440,838 of a total of 846,845 reported live births in Israel over 5 years; excluded were primiparas (32%), multifetal births (4.9%) and those with incomplete data (10.9%). For IPIs shorter than 6 months, there were significantly increased risks for preterm birth (OR=1.23), SGA (OR=1.14), VSGA (OR=1.15), early neonatal death (OR=1.62) and congenital malformations (OR=1.14). Intervals of 60 months or longer had higher risks for preterm birth (OR=1.39) and VSGA (OR=1.16). Conclusion Optimal IPI recommendation of >11 months is an accessible and low-cost means to improve multiple adverse perinatal outcomes.