Nationwide Evaluation of Quality of Care Indicators for Individuals with Severe Mental Illness and Diabetes Mellitus, Following Israel's Mental Health Reform

Diabetes Mellitus (DM) is more common among individuals with severe mental illness (SMI). We aimed to assess quality-of-care-indicators in individuals with SMI following the 2015 Israel's Mental-Health-reform. We analyzed yearly changes in 2015-2019 of quality-of-care-measures and intermediate-DM-outcomes, with adjustment for gender, age-group, and socioeconomic status (SES) and compared individuals with SMI to the general adult population. Adults with SMI had higher prevalences of DM (odds ratio (OR) = 1.64; 95% confidence intervals (CI): 1.61-1.67) and obesity (OR = 2.11; 95% CI: 2.08-2.13), compared to the general population. DM prevalence, DM control, and obesity rates increased over the years in this population. In 2019, HbA1c testing was marginally lower (OR = 0.88; 95% CI: 0.83-0.94) and uncontrolled DM (HbA1c > 9%) slightly more common among patients with SMI (OR = 1.22; 95% CI: 1.14-1.30), control worsened by decreasing SES. After adjustment, uncontrolled DM (adj. OR = 1.02; 95% CI: 0.96-1.09) was not associated with SMI. Cardio-metabolic morbidity among patients with SMI may be related to high prevalences of obesity and DM rather than poor DM control. Effective screening for metabolic diseases in this population and social reforms are required.

Prenatal exposure to phthalates and emotional/behavioral development in young children

INTRODUCTION

Endocrine disrupting chemicals (EDCs) such as phthalates, found in our daily environment, are nowadays suggested to be associated with adverse outcomes. Prenatal exposure was found associated with neurodevelopmental complications such as behavioral difficulties in school age children.

AIM

To explore the association between intrauterine exposure to phthalates and emotional/behavioral development of 24 months old toddlers.

METHODS

Women were recruited at 11-18 weeks of gestation and provided spot urine samples, analyzed for phthalate metabolites (DEHP, DiNP, MBzBP). Offspring were examined at 24 months of age, using standard maternal report, regarding developmental and behavioral problems (CBCL, ASQ-3, HOME questionnaires) (N = 158). To explore the associations between metabolite levels and developmental outcomes, multivariate GLM analysis (General Linear Model) was used according to tertiles and developmental scores on each developmental outcome.

RESULTS

Associations of Di-(2-ethylhexyl) phthalate (DEHP) maternal exposure with behavioral-developmental outcomes were found only in boys. Compared with boys with lower DEHP maternal exposure, boys with high DEHP maternal exposure had lower developmental score in personal social abilities in the ASQ-3 questionnaire (50.68 + 8.06 and 44.14 + 11.02, high and low DEHP, respectively, p = 0.03), and more internalizing problems (for example, emotionally reactive score in high and low DEHP: 53.77 + 7.41 and 50.50 + 1.19, respectively, p = 0.029; anxious or depressed score: 53.38 + 5.01 and 50.75 + 1.34, respectively, p = 0.009; and somatic complaints scores 64.03 + 10.1 and 55.84 + 7.84, respectively, p = 0.003), and externalizing problems (49.28 + 8.59 and 43.33 + 9.11, respectively, p = 0.039). No differences were found in the development and behavior problems between high and low DEHP maternal exposure level in girls.

CONCLUSION

Maternal DEHP metabolite concentrations measured in first trimester urine was associated with children's emotional/behavioral developmental problems in 24-months old boys, supporting accumulating evidence of DEHP as a potentially harming chemical and call for environmental attention.

Is There a Familial Tendency for Same Sex Offspring? A Lesson Learned from a Large Non-Selected Israeli Population

BACKGROUND

While the ratio of male to female births (sex-ratio at birth [SRB]) in humans is remarkably stable on the population level, there are many families with multiple same-sex offspring.

OBJECTIVES

To identify a putative sub-population with skewed SRB and explore potential factors affecting the SRB.

METHODS

A retrospective cohort study including 66,054 families with up to nine same-sex offspring evaluated between 2003 and 2015 at Hadassah-Hebrew University Medical Center. Outcome measures were observed prevalence and SRB of families with up to nine same-sex offspring in a single family. Analyses included the effect of parity, month and year of delivery, inter-delivery interval, and presence of a sequence of previous same-sex offspring on the SRB.

RESULTS

The study comprised 193,411 live-born babies with SRB of 1.057 in favor of males. The proportion of SRB in families with up to nine same-sex offspring did not differ from the calculated presumed proportion. Furthermore, none of the tested factors (parity, month and year of delivery, inter-delivery interval, and the sequence of previous same-sex offspring) were significantly associated with SRB.

CONCLUSIONS

SRB was not associated with any of the tested demographic characteristics. We could not identify a skew in SRB even in families with up to nine consecutive same sex offspring. This finding suggests that in the majority of the population the chance of a male or female fetus in each pregnancy remains similar in every pregnancy, regardless of any of the tested variables.

Newborn infant urinary cotinine and birth outcomes in the Jerusalem Environment Mother and Child Cohort Study

BACKGROUND

Environmental tobacco smoke (ETS) exposure during pregnancy can cause preterm delivery and childhood cancer. The aim of this study was to measure ETS exposure in pregnant women and in newborn infants in Israel using urinary cotinine measurements, to assess predictors of ETS exposure in these vulnerable groups, and to assess associations with birth effects (birth weight, birth length, head circumference) in newborn infants.

METHODS

We analyzed urinary cotinine and creatinine in 265 non-smoking pregnant women and 97 newborns, and analyzed associations with self-reported exposure to ETS, paternal smoking, sociodemographic variables and with birth outcomes (birth weight, birth length, head circumference).

RESULTS

37.7% of pregnant women and 29.0% of infants had urinary cotinine concentrations above the level of quantification (LOQ) of 1 μg/L, whereas 63.8% and 50.5%, respectively, had urinary cotinine concentrations above the level of detection (LOD) of 0.5 μg/L. Median unadjusted and creatinine adjusted urinary concentrations of cotinine in pregnant women were 0.7 μg/L, and 0.9 μg/g creatinine, respectively, and in newborn infants were 0.5 μg/L, and 1.3 μg/g creatinine, respectively. We did not find an association between maternal and infant urinary cotinine level. Maternal (but not infant) urinary cotinine was significantly associated with paternal smoking (p < 0.05). Infant (but not maternal) cotinine above the LOQ was negatively associated with birth weight (p < 0.05).

CONCLUSIONS

In this high socioeconomic cohort, almost a third of newborn infants born to non-smoking mothers had quantifiable levels of urinary cotinine. This is the first study showing that newborns with quantifiable urinary cotinine levels have lower birth weight.

Decreasing urinary organophosphate pesticide metabolites among pregnant women and their offspring in Jerusalem: Impact of regulatory restrictions on agricultural organophosphate pesticides use?

INTRODUCTION

Maternal urinary levels of dialkyl phosphate (DAP) metabolites of organophosphate pesticides (OP) during pregnancy are associated with adverse outcomes in the offspring. Between 2012 and 2014, eighteen active OP ingredients were restricted or banned in Israel for agricultural use.

AIM

We aimed to study trends of urinary DAP metabolites among pregnant women and their offspring in the era of the new regulations.

METHODS

Pregnant women were recruited at 11-18 weeks of gestation and provided spot urine samples (n = 273). Soon after birth, neonatal urine samples were collected (n = 107). All urine specimens analyzed for DAP metabolites. Trends in DAP metabolites were tested using Mann-Kendall trend statistic (M-K S) and linear regression models were constructed to estimate the association between calendar period and DAP levels between September 2012 and March 2016.

RESULTS

Over the study period, median maternal ∑DAP levels decreased from 248 nmol/L to 148 nmol/L. Time of recruitment was associated with a statistically significant decrease in DAP metabolites, which remained significant after multivariate adjustment. Overall, the results for the analysis of before and after June 2014 showed a significant decrease in ∑DAP of -0.198 log10 nmol/L (95%CI: -0.311,-0.084) which corresponds with a decrease of 36.6% in ∑DAP. A similar trend was found for DAP metabolites in neonatal urine. Compared to other studies, pregnant women in Jerusalem had higher ∑DAP levels, even at the end of the study period.

CONCLUSION

We observed significant reductions in maternal and neonatal DAP urinary levels during the period of 2012-2016. Regulations restricting agricultural use of OP seem to be effective in reducing population exposure to OP, in an era when residential use of OP is banned.

Cardiac Structure and Function and Frailty in Subjects Aged 85 and 86 Years

Frailty is a biologic syndrome reflecting a state of decreased physiological reserve of increasing importance in cardiovascular disease given the aging of the population. The relation between frailty and indexes of cardiac structure and function remains unclear, particularly in the "oldest old." The objective of this study was to examine the association between cardiac function and frailty in an age-homogenous, community-dwelling population of subjects aged 85 and 86 years. Subjects were recruited at ages 85 to 86 from the Jerusalem Longitudinal Cohort Study that has followed an age-homogenous cohort of Jerusalem residents. Subjects underwent echocardiography at their place of residence with standard assessment of cardiac structure and function. Frailty was defined according to the "phenotype of frailty" including at least 3 of the following: weakness, slowness, low physical activity level, exhaustion, and weight loss; 405 subjects (193 men and 212 women) were enrolled in the study. Subjects defined as frail had significantly lower ejection fraction compared with the non-frail group (53.7 ± 0.09% vs 56.4 ± 0.09%; p <0.04). In addition, frail subjects had increased LV mass index (130.6 ± 36.2 g/m(2) vs 119.2 ± 31.1 g/m(2); p <0.03) and LA volume index (41.9 ± 14.7 cm(3)/m(2) vs 36.7 ± 13.1 cm(3)/m(2); p <0.001). Indexes of diastolic function (E/e)' were not significantly different in the 2 groups (11.5 vs 11.8; p = NS). In this age-homogenous cohort of the oldest old, structural changes and indexes of systolic but not diastolic function were associated with frailty.

A large head circumference is more strongly associated with unplanned cesarean or instrumental delivery and neonatal complications than high birthweight

OBJECTIVE

Fetal size impacts on perinatal outcomes. We queried whether the fetal head, as the fetal part interfacing with the birth canal, might impact on obstetric outcomes more than birthweight (BW). We examined associations between neonatal head circumference (HC) and delivery mode and risk of perinatal complications as compared to high BW.

STUDY DESIGN

This was an electronic medical records-based study of term singleton births (37-42 weeks' gestation) from January 2010 through December 2012 (N = 24,780, 6343 primiparae). We assessed risks of unplanned cesarean or instrumental delivery and maternal and fetal complications in cases with HC or BW ≥95th centile (large HC, high BW) vs those with parameters <95th centile (normal). Newborns were stratified into 4 subgroups: normal HC/normal BW (reference, n = 22,548, primiparae 5862); normal HC/high BW (n = 817, P = 213); large HC/normal BW (n = 878, P = 265); and large HC/high BW (n = 537, P = 103). Multinomial multivariable regression provided adjusted odds ratio (aOR) while controlling for potential confounders.

RESULTS

Infants with HC ≥95th centile (n = 1415) were delivered vaginally in 62% of cases, unplanned cesarean delivery 16%, and instrumental delivery 11.2%; 78.4% of infants with HC <95th centile were delivered vaginally, 7.8% unplanned cesarean, and 6.7% instrumental delivery. Odds ratio (OR) for unplanned cesarean was 2.58 (95% confidence interval [CI], 2.22-3.01) and for instrumental delivery OR was 2.13 (95% CI, 1.78-2.54). In contrast, in those with BW ≥95th centile (n = 1354) 80.3% delivered vaginally, 10.2% by unplanned cesarean (OR, 1.2; 95% CI, 1.01-1.44), and 3.4% instrumental delivery (OR, 0.46; 95% CI, 0.34-0.62) compared to infants with BW <95th centile: spontaneous vaginal delivery, 77.3%, unplanned cesarean 8.2%, instrumental 7.1%. Multinomial regression with normal HC/normal BW as reference group showed large HC/normal BW infants were more likely to be delivered by unplanned cesarean (aOR, 3.08; 95% CI, 2.52-3.75) and instrumental delivery (aOR, 3.03; 95% CI, 2.46-3.75). Associations were strengthened in primiparae. Normal HC/high BW was not associated with unplanned cesarean (aOR, 1.18; 95% CI, 0.91-1.54), while large HC/high BW was (aOR, 1.93; 95% CI, 1.47-2.52). Analysis of unplanned cesarean indications showed large HC infants had more failure to progress (27.7% vs 14.1%, P < .001), while smaller HC infants had more fetal distress (23.4% vs 16.9%, P < .05).

CONCLUSION

A large HC is more strongly associated with unplanned cesarean and instrumental delivery than high BW. Prospective studies are needed to test fetal HC as a predictive parameter for prelabor counseling of women with "big babies."

Urinary organophosphate metabolite levels in Palestinian pregnant women: results of the Middle East Regional Cooperation Project

The purpose of the study was to measure urinary organophosphate (OP) metabolites in Palestinian pregnant women, and to compare levels with those in pregnant women in Jerusalem and women from the general population in Israel. We measured six dialkyl phosphates in urine samples collected from 148 pregnant women from the West Bank area. Median total dimethyl phosphate (DM(total)) levels were significantly lower in Palestinian women compared to Jerusalem pregnant women and women in Israel (p = 0.041). In Palestinian women reporting that their place of residence was near an agricultural field, DM(total) levels were significantly higher (p = 0.037). Lower urinary excretion of dimethyl phosphate pesticide metabolites in Palestinian women compared to Israeli women may result from lower consumption of fruits and vegetables in the Palestinian population. Our findings highlight differences in OP pesticide exposure in populations with close geographical proximity but with differences in culture, diet, lifestyle, and regulatory oversight of pesticides.

Palliative Sedation at the End of Life

Palliative sedation (PS) is indicated for refractory symptoms among dying patients. This retrospective descriptive study examines PS in an Israeli hospice. Palliative sedation was defined as PS to unconsciousness (PSU), PS proportionate to symptoms (proportional palliative sedation [PPS]), or intermittent PS (IPS). Among 179 patients who died during 2012, PS was used among 21.2% (n = 38): (PSU 34.2%, PPS 34.2%, and IPS 31.6%), using midazolam (n = 33/38), halidol (21/38), and concurrent morphine (n = 35/38). Indications included agitation (71%), pain (36.8%), and dyspnea (21%). Survival following initiation of PS was 73 ± standard deviation 54 hours. No differences in survival were observed according to who initiated the decision to use PS (patients/medical staff/family) or type of PS (PSU/PPS/IPS). Survival following PS was longest with higher sedative doses, an observation that may help dispel fears concerning the use of PS to hasten death.

Cholesterol, statins, and longevity from age 70 to 90 years

BACKGROUND

The importance of cholesterol as a risk factor among older people, particularly among the very old, is controversial. Whether or not hypercholesterolemia warrants medical concern, and whether statins are beneficial among very old people, remain unresolved common clinical dilemmas. This study examines whether increased total cholesterol (TC) was associated with higher mortality from age 70 to 90, and if statins had a protective effect.

METHODS

A representative sample (born 1920-1921) from the Jerusalem Longitudinal Cohort Study (1990-2010) was assessed at ages 70, 78, and 85 for fasting serum TC, low-density (LDL), and high-density lipoprotein (LDL); triglycerides; statin usage; social, functional, and medical domains; and all-cause mortality data (1990-2010). TC was analyzed as either continuous (10 mg/dL increments) or dichotomous variable (high TC >200 mg/dL). Cox proportional hazards models determined mortality hazard ratios (HRs), adjusting for TC, statin treatment, gender, self-rated health, smoking, hypertension, diabetes, ischemic heart disease, neoplasm, body mass index, albumin, and triglycerides.

RESULTS

Prevalence of high TC at ages 70, 78, and 85 was 75% (n = 344), 65% (n = 332), and 34% (n = 237), and statin use was 0%, 17.9%, and 45.4%, respectively. Survival was increased (not significantly) among subjects with high TC >200 mg/dL versus ≤200 mg/dL from ages 70 to 78, 78 to 85, and 85 to 90: 79.1% versus 73.3% (log rank P = .16), 68.7% versus 61.5% (P = .10), and 73.4% versus 70.3% (P = .45), respectively. Survival was significantly increased among subjects treated with statins versus no statins at ages 78 to 85 (74.7% vs 64.3%, log rank P = .07) and 85 to 90 (76.2% vs 67.4%, P = .01). After adjustment, TC (continuous or dichotomous) was not associated with mortality from 70 to 78, 78 to 85, or 85 to 90. In contrast, statins at age 85 were associated with decreased mortality from age 85 to 90 (adjusted HR 0.61, 95% confidence interval 0.42-0.89).

CONCLUSIONS

Among older people, cholesterol levels were unrelated to mortality between the ages of 70 and 90. The protective effect of statins observed among the very old appears to be independent of TC.

Is the quality of donated semen deteriorating? Findings from a 15 year longitudinal analysis of weekly sperm samples

BACKGROUND

Studies suggest that global semen quality is declining, but the debate remains open owing to geographic variation.

OBJECTIVES

To evaluate temporal trends of sperm parameters - namely concentration, motility and total motile sperm count - in sperm donated during the period 1995-2009.

METHODS

In a retrospective longitudinal cohort study we analyzed the sperm count and motility of 2182 semen samples provided on a weekly basis by 58 young, healthy, fertile, university-educated, paid donors.

RESULTS

Despite the lowering of criteria for sperm parameters satisfactory for donation that were implemented in 2004, 38% of applicants for sperm donation are now rejected based on semen quality as compared to a third of applicants 10-15 years ago (P < 0.001). If the old strict criteria were in place 88% of candidates would be rejected today (P < 0.0001). Over the study period, the average sperm parameters dropped from a concentration of 106 +/- 25 million spermatozoa/ml with 79% +/- 4.3% motility to 68 +/- 14 million/ ml with 66% +/- 4.5% motile sperm (P < 0.0001, P < 0.0001, respectively). The total motile sperm count per ejaculate also decreased, from 66.4 +/- 18.2 million to 48.7 +/- 12 million (P < 0.005). When the previous criteria were implemented for the analysis of the latest group of sperm donors, only 18% of donors had an acceptable sperm quality, with an average concentration of 87 +/- 12 million spermatozoa/ml, 73% +/- 2.6% motile sperm and total motile sperm count of 53.1 +/- 3.8 million per ejaculate - still significantly lower than 15 years ago (P= 0.01, P= 0.003, P= 0.058 respectively).

CONCLUSIONS

The rapid deterioration of sperm quality among fertile semen donors is alarming and may lead to cessation of sperm donation programs.

Cardiac structure and function as predictors of mortality in persons 85 years of age

Individuals aged > 85 years are the world's most rapidly growing age group and have a high incidence of cardiovascular mortality. The objective of this study was to prospectively determine the prognosis of abnormal cardiac structure and function in an age-homogenous, community-dwelling population of subjects born in 1920 and 1921. Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed with a portable echocardiograph at the subjects' places of residence. Standard echocardiographic assessment of cardiac structure and function was performed. Five-year mortality was assessed through a centralized government database. Five hundred two subjects (235 men, 267 women) were enrolled in the study, of whom 107 (21%) had died at the time of 5-year follow-up. Subjects who died had significantly higher left atrial volume indexes (42.3 ± 16.5 vs 36.6 ± 12.5 ml/m2, p < 0.01) and left ventricular mass indexes (133.1 ± 47.6 vs 119.8 ± 30.6 g/m2, p < 0.05). Ejection fractions were significantly lower in subjects who died (52.5 ± 11.5% vs 56.4 ± 9.4%, p < 0.003), but indexes of left ventricular diastolic function were not significantly different between the 2 groups (E/e' ratio 13.0 ± 5.3 vs 12.2 ± 4.9, p = 0.18). In conclusion, elevated left atrial volume index and left ventricular mass index and decreased LV systolic function predicted 5-year mortality in a community-dwelling population of subjects aged 85 years, even after correction for possible confounders. Left ventricular diastolic dysfunction did not predict 5-year mortality in this cohort.

Infertility associated with precoital ovulation in observant Jewish couples; prevalence, treatment, efficacy and side effects

BACKGROUND

Religious (halachic*) infertility' results from precoital ovulation prior to immersion in a ritual bath (mikveh) 7 days after menstruation, as mandated by Jewish religious law. Previous authors recommended treatment with estradiol to postpone ovulation and enhance pregnancy rates.

OBJECTIVES

To evaluate the prevalence of halachic infertility in an ultra-Orthodox jewish community, and assess the efficacy of estradiol treatment in postponing ovulation and increasing pregnancy rates.

METHODS

We reviewed 88 cycles, of which 23 were control cycles and 65 estradiol-treated cycles, and analyzed the files of 23 women who were treated with 6 mg estradiol/day from day 1 for 5 days of the cycle.

RESULTS

The prevalence of precoital ovulation in the infertile population was 21%. Most of the patients (94%) ovulated before day 13 of the cycle. A short follicular phase due to low ovarian reserve orthyroid endocrinopathy was noted in 12% of the patients. While 64% of the women reported consultation with a Rabbinate authority, 68% of the patients sought medical therapy. Estradiol postponed ovulation for at least one day in 89% of the treatment cycles. Ovulation post-mikveh occurred in 73% of estradiol-treated cycles. The pregnancy rate was 12.5% per cycle and the cumulative pregnancy rate 35% per woman. Half the patients reported spotting during estradiol-treated cycles, and this postponed coitus.

CONCLUSIONS

Precoital ovulation is a major reason for infertility among observant couples attending fertility clinics. Estradiol treatment is effective in delaying ovulation and restoring fecundity; however, it causes some adverse effects that may decrease its effectiveness.

Cardiac structure and function in persons 85 years of age

Individuals aged >85 years constitute the world's most rapidly growing age group. Despite the rapid growth of this population and its high incidence of cardiovascular morbidity, normative data concerning cardiac structure and function are limited. The objective of this study was to define cardiac structure and function in an age-homogenous, community-dwelling population of subjects born in 1920 and 1921. Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed using a portable echocardiograph at the subject's place of residence. Standard echocardiographic assessment of cardiac structure and function was performed. Four hundred fifty subjects (219 men, 231 women) were enrolled in the study. The cohort exhibited large left atrial volumes (64.6 ± 26 ml) and high left ventricular (LV) mass indexes (122 ± 36 g/m(2)) with normal LV volumes. Ejection fractions were preserved (55.3 ± 10.2%), but tissue Doppler s-wave velocities (lateral 7.8 ± 2.1 cm/s, septal 6.7 ± 1.9 cm/s) were reduced. Reduced tissue Doppler e waves (lateral 7.3 ± 2.2 cm/s, septal 6.2 ± 2 cm/s) and elevated E/e' ratios (12.2 ± 4.9) indicated significantly impaired diastolic function. In conclusion, the findings of this study demonstrate a high prevalence of left atrial enlargement, elevated LV mass, evidence of LV systolic dysfunction with preserved ejection fractions, and significant LV diastolic dysfunction in a community-dwelling cohort of 85-year-olds. The finding of elevated E/e' ratios in a subset free of known cardiovascular disease should be considered when clinical assessment of LV diastolic dysfunction in this age group is performed.

Frailty, cognitive impairment and mortality among the oldest old

INTRODUCTION

Both frailty and cognitive impairment are increasingly prevalent with advancing age. Nonetheless among the oldest old their relationship is poorly described. This study examines the association between frailty status and cognitive impairment at age 85 and their impact on 5-year mortality.

METHODS

A representative sample of 840 community dwelling people from the Jerusalem Longitudinal Cohort Study was comprehensively assessed at age 85. Frailty was defined according to the "phenotype of frailty", as including at least three of the following: weight loss, slowness, weakness, exhaustion and low physical activity levels. Pre frailty was defined as 1-2/5 criteria. Cognitive impairment was assessed according to the Mini Mental State Examination (MMSE). Mortality data was collected from age 85-90.

RESULTS

A total of 164 (19.5%) were frail, 470 (56%) were pre frail and 206 (24.5%) were not frail, with prevalence of MMSE≤24 being 53.3%, 15%, and 7.4% respectively. A uniform pattern of increased adverse health, affective, disease and functional measures were associated with frailty status. Frailty status was significantly associated with cognitive impairment, with an Odds Ratios of 3.77 (95%CI 1.42-9.99) for MMSE≤24 after adjustment for socio demographic, medical mood and functional covariates. Among frail, pre frail and non frail subjects, 5-year mortality was 44.5%, 20.4%, 13.6% respectively. Mortality among frail subjects with or without cognitive impairment was 54.2% vs. 54.9%, p=0.9). Adjusting together for frailty, MMSE, education and gender, the Hazards ratio for 5-year mortality for frailty was 3.861 (95%CI 2.4-6.2), and for MMSE≤24 was 1.25 (95%CI 0.87-1.78).

CONCLUSIONS

Among the oldest old, frailty status was significantly associated with cognitive impairment; after adjustment, frailty alone was predictive of subsequent mortality.

High prevalence of left ventricular hypertrophy in octogenarian women: The Jerusalem Longitudinal Cohort Study

BACKGROUND

Left ventricular hypertrophy (LVH) is more frequent in women and increases with age; however, it is unclear whether this finding is true in the very elderly. The objective of this study was to examine gender differences in the prevalence of LVH in a very elderly cohort.

METHODS

Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Three hundred and thirty-nine of the subjects from the most recent set of data collection in 2005-2006 underwent echocardiography in addition to structured interviews and physical examination.

RESULTS

The overall prevalence of LVH was high and significantly higher among women (60% vs 43%, p=0.0023). Systolic blood pressure (SBP) was significantly higher in women with LVH compared with women without LVH (p<0.01) and both groups of men (p<0.005). Women with LVH were three times more likely than women without LVH and 6.5 times more likely than men with LVH to believe that a BP of 160/100 mmHg represents their BP goal (p<0.05).

CONCLUSIONS

This study demonstrates a high prevalence of LVH in a very elderly population, a finding significantly more pronounced in women and related to SBP.

Normal body mass index rather than obesity predicts greater mortality in elderly people: the Jerusalem longitudinal study

OBJECTIVES

To examine the association between body mass index (BMI) and mortality in older people.

DESIGN

A longitudinal cohort study of an age-homogenous, representative sample born in 1920/21.

SETTING

Community-based home assessments.

PARTICIPANTS

West Jerusalem residents born in 1920/21 examined at baseline in 1990 (n=447), with additional recruitment waves in 1998 (n=870) and 2005 (n=1,086).

MEASUREMENTS

Comprehensive assessment of health variables including BMI (m/kg(2)) at ages 70, 78, and 85. The primary outcome of mortality was collected from age 70 to 88 (1990-2008). Adjusted Cox proportional hazards analysis was used to calculate hazard ratios (HRs) for mortality according to unit increase in BMI.

RESULTS

A unit increase in BMI in women resulted in HRs of 0.94, (95% confidence interval (CI)=0.89-0.99) at age 70, 0.95 (95% CI=0.91-0.98) at age 78, and 0.91 (95% CI=0.86-0.98) at age 85. Similarly, in men, HRs were 0.99 (95% CI=0.95-1.05) at age 70, 0.94 (95% CI=0.91-0.98) at age 78, and 0.91 (95% CI=0.86-0.98) at age 85. A time-dependent analysis of 450 subjects followed for 18 years confirmed the above findings; a unit increase in BMI resulted in HRs of 0.93 (95% CI=0.87-0.99) in women and 0.93(95% CI=0.88-0.98) in men. Eliminating the first third of follow-up mortality to account for possibility of reverse causality did not change the results.

CONCLUSION

Higher BMI was associated with lower mortality from age 70 to 88.

Sex ratio is remarkably constant

OBJECTIVE

To study whether the sex of the offspring is related to increasing parental age, gravidity, and parity, hypothesizing an altered male-to-female sex ratio with the advancing parental age.

DESIGN

A large retrospective cohort study.

SETTING

The study analyzed birth records of Hadassah Hebrew University Medical Center in Jerusalem from June 2003 to December 2006.

PATIENT(S)

35,837 birth records were analyzed including 941 multifetal deliveries, excluding foreign inhabitants (n = 744), missing data for the main study outcome (n = 2) and parturients over 50 years to control for egg donation (n = 26).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Male-to-female sex ratio.

RESULT(S)

The male-to-female sex ratio of all the newborns was 1.05. This ratio did not change significantly with either maternal or paternal age. Neither gravidity nor parity affected the male-to-female ratio. The only factor that affected the regression of sex ratio was the length of gestation.

CONCLUSION(S)

Sex ratio at birth is remarkably constant. No association was found between parental age or birth order and neonatal sex ratio.

Low Alanine Aminotransferase Activity in Older People Is Associated with Greater Long-Term Mortality

OBJECTIVES

To find possible association between liver enzymes and mortality in older people.

DESIGN

A prospective cohort study.

SETTING

Jerusalem.

PARTICIPANTS

A systematically selected representative sample of 455 70-year-old ambulatory individuals was prospectively followed for 12 years.

MEASUREMENTS

An extensive social and medical profile was developed at age 70 using a detailed interview and physical and ancillary examination. Information on mortality was obtained annually. Differences in survival between subjects stratified according to liver enzyme levels were assessed using the Kaplan-Meier method. Multivariable survival analyses using a Cox proportional hazards model were performed to determine the association between liver enzyme levels at age 70 and mortality over 12 years.

RESULTS

Median alanine aminotransferase (ALT) activity of the study population was 11.00 U/L for women and 13.00 U/L for men. Twelve-year survival rates for women with ALT below and above the median levels were similar (78%). For men, these rates were 54% and 65%, respectively (P < .001). Proportional hazards models demonstrated that this greater mortality risk was independent of numerous common risk factors for mortality (hazard ratio (HR) = 1.5, 95% confidence interval (CI) = 1.08-2.19). Adding an interaction between sex and low ALT to the model demonstrated a higher risk of mortality for men with low ALT levels (HR = 2.42, 95% CI = 1.15-5.08). No such risk was demonstrated for the other liver enzymes.

CONCLUSION

ALT activity represents a strong and independent surrogate marker for mortality in community-dwelling elderly men.

Duration not severity of the climacteric syndrome predicts resumption of hormone therapy after discontinuation: a prospective cohort study

BACKGROUND

Predictive factors of women who are unable to quit prolonged hormonal therapy (HT) are largely unknown. We sought to identify predictors for the resumption of HT after the discontinuation of treatment.

METHODS

A cohort prospective study was conducted allocating menopausal women treated with HT for over 3 years. Menopausal symptoms were monitored periodically after HT cessation by the Greene climacteric scale.

RESULTS

Eighty-two women participated in the study. Age, the age of menopause, BMI, HT duration, the type of regimen, reasons cited to discontinue HT and the method of discontinuation did not differ between the subjects who successfully discontinued HT and those who failed to quit HT. Only the prevalence of vasomotor symptoms when HT was first prescribed significantly differed between the groups (P = 0.03). Comparable maximal Greene score was recorded in both groups. Over time, the subjects who returned to HT had higher Greene score [Hazard ratio 1.25, confidence interval (CI) 95% (1-1.07)] and significantly higher vasomotor score [Hazard score 1.22, CI 95% (1.02-1.46)].

CONCLUSIONS

The history of hot flashes and the duration of menopausal symptoms upon HT discontinuation predict the resumption of HT. Thus, the return to HT is expected in individuals who are intolerant of prolonged climacteric syndrome.