Largest Healthcare Provider Research Articles

Mapping the patient journey and treatment patterns in early-stage (stage I-III) non-small cell lung cancer

IntroductionWe map the patient journey from symptom onset to intervention and describe primary treatment in a retrospective population-based cohort study of patients in a large healthcare-provider. MethodsNewly diagnosed adult patients diagnosed with stages I-III non-small cell lung cancer (NSCLC) between 2016 and 2019 were identified from the Israel National Cancer Registry and chart review was performed to extract de-identified data. The following timelines were constructed: from symptom onset to imaging, imaging to biopsy, and biopsy to primary treatment initiation. Cutoff: 31st December 2021. The initial symptom was captured up to one year prior to biopsy. ResultsAmong 302 patients (41 % female, 70 % >=65 years, 79 % former or current smoking, 62 % adenocarcinoma), 34.1 % stage I, 10.3 % stage II, 42.1 % stage III and 13.6 % unknown (AJCC ver. 8). In the baseline year, 80.5 % of patients reported at least one symptom to their physician, and 12.3 % reported four or more symptoms. The most common symptoms reported were cough (29.8 %), pneumonia (24.2 %), chest pain (18.5 %), bronchitis (17.5 %) and wheezing (17.2 %). For patients with an initial symptom (n=243) median time from symptom onset to imaging was 5.5 months (95% CI:4.8–6.3), and time from imaging to primary treatment initiation was 2.6 (2.3–2.9) months in all patients. Total duration from symptom to intervention was 8.5 months (7.6–9.3). Over 93 % of stage I patients underwent surgery and 4.9 % received definitive radiation. Over 83 % of stage II patients underwent surgery; of these, 54.8 % received adjuvant/neoadjuvant chemotherapy. Of stage III patients, 68.5 % received definitive chemoradiation (half received durvalumab), and the remaining underwent surgery with adjuvant/neoadjuvant treatment. ConclusionA total of 80.5 % of patients were symptomatic and the median duration from symptom onset to treatment initiation was 8.5 month long. Improving patient and physician awareness to lung cancer symptoms, and the introduction of screening programs are essential for reducing those delays.

Applying neural network algorithms to ascertain reported experiences of violence in routine mental healthcare records and distributions of reports by diagnosis.

Experiences of violence are important risk factors for worse outcome in people with mental health conditions; however, they are not routinely collected be mental health services, so their ascertainment depends on extraction from text fields with natural language processing (NLP) algorithms. Applying previously developed neural network algorithms to routine mental healthcare records, we sought to describe the distribution of recorded violence victimisation by demographic and diagnostic characteristics. We ascertained recorded violence victimisation from the records of 60,021 patients receiving care from a large south London NHS mental healthcare provider during 2019. Descriptive and regression analyses were conducted to investigate variation by age, sex, ethnic group, and diagnostic category (ICD-10 F chapter sub-headings plus post-traumatic stress disorder (PTSD) as a specific condition). Patients with a mood disorder (adjusted odds ratio 1.63, 1.55-1.72), personality disorder (4.03, 3.65-4.45), schizophrenia spectrum disorder (1.84, 1.74-1.95) or PTSD (2.36, 2.08-2.69) had a significantly increased likelihood of victimisation compared to those with other mental health diagnoses. Additionally, patients from minority ethnic groups (1.10 (1.02-1.20) for Black, 1.40 (1.31-1.49) for Asian compared to White groups) had significantly higher likelihood of recorded violence victimisation. Males were significantly less likely to have reported recorded violence victimisation (0.44, 0.42-0.45) than females. We thus demonstrate the successful deployment of machine learning based NLP algorithms to ascertain important entities for outcome prediction in mental healthcare. The observed distributions highlight which sex, ethnicity and diagnostic groups had more records of violence victimisation. Further development of these algorithms could usefully capture broader experiences, such as differentiating more efficiently between witnessed, perpetrated and experienced violence and broader violence experiences like emotional abuse.

Unveiling the effects of innovation awards on organizational innovations: comparison of bottom-up and top-down innovations

PurposeThis paper aims to explore the effects of innovation awards on subsequent innovation behaviors in organizations. Specifically, the authors investigate whether winning an external innovation award helps diffuse the award-winning innovations and develop additional innovation projects in the organization. Furthermore, the authors study the contextual influence of innovators’ organizational hierarchy on experiencing and using the winning consequence.Design/methodology/approachThe authors collected survey data from clinics and hospitals that participated in a state-level innovation award program sponsored by a large health-care insurer and provider in Midwestern states. The authors tested the hypotheses using ordinary least squares regressions and supplemented the method with a post hoc analysis using Fisher’s least significant difference test.FindingsThe authors find that awards help a “bottom-up” innovation (i.e., an innovation initiated by a lower-level employee) disseminate at a larger scale due to award-bestowed legitimacy and reputation, whereas a “top-down” innovation (i.e., an innovation initiated by a top manager) does not experience the same benefit. On the other hand, the organizations that won the innovation award with a “top-down” innovation showed a higher number of additional innovation projects after winning, as manager–innovators experienced a boost in their confidence to engage in further innovation projects.Originality/valueThis paper offers a unique and nuanced examination of how innovation awards influence organizational innovation. By bridging literatures on awards and innovation, the authors propose the mechanisms through which innovation awards confer legitimacy and reputation upon the award winners and their innovations. Furthermore, the authors add insights into the recent academic interests in employee-driven innovation by showing the different benefits of innovation awards depending on the innovators’ organizational hierarchies.

Phosphodiesterase-5 Inhibitors and Dementia Risk: A Real-World Study.

Biological and scarce epidemiological evidence suggested that phosphodiesterase-5 inhibitors (PDE5i) might reduce dementia risk. We aimed to examine the association between PDE5i and dementia using real-world data. Two retrospective cohorts within the database of Clalit, the largest healthcare provider in Israel (2005-2023), were studied. The first cohort included new daily users, older than 50 years of age, of low-dose tadalafil, prescribed for benign prostatic hypertrophy (BPH), propensity-score matched to new-users of alpha-1 blockers, and analyzed using 2-year lag time. The second cohort included patients with erectile dysfunction, with/without any PDE5i treatment, using time-dependent analysis. Individuals in the cohorts were followed through May 2023 for the occurrence of dementia. The first cohort included 5,204 tadalafil initiators propensity-score matched to 18,565 alpha-1 blockers initiators. There was no association between tadalafil use and dementia risk, HR = 0.99 (95% CI: 0.88-1.12), p = 0.927. Similar results were obtained in a competing risk analysis, and in a sensitivity analysis in which we restricted the cohort to patients older than 60 years at cohort entry. The second cohort of 133,336 patients with erectile dysfunction included new users and nonusers of any PDE5i. In a mean follow-up of 7.9 years, 8,631 patients were newly diagnosed with dementia. In a time-dependent multivariable analysis, PDE5i use was not associated with reduced dementia risk, HR = 0.95 (95% CI: 0.86-1.04). Results were not changed in sensitivity analyses (patients older than 60 years or stratification by PDE5i type). This study suggests that the use of PDE5 inhibitors is not associated with decreased risk of dementia.

Secondary prophylaxis for Clostridioides difficile infection for patients on non-C. difficile antibiotics: a retrospective cohort study

ObjectivesRecurrent Clostridioides difficile infection (CDI) poses healthcare challenges and morbidity. Preventing recurrence with prophylactic oral CDI antibiotics lack consensus. MethodsWe used data from the largest healthcare provider in Israel to identify all adults aged 18 years or older diagnosed with a first episode of CDI (Index CDI) between February 2018 and December 2022 and subsequently received a non-CDI antibiotic within 2–8 weeks. Patients who received a concurrent prophylactic CDI antibiotic constituted the CDI prophylaxis group. Multivariable Cox proportional hazard regression models were used to examine the association of secondary CDI prophylaxis with CDI recurrence according to the severity of the index CDI (primary objective) and with 4- and 8-week all-cause mortality (secondary objective). ResultsA total of 434 eligible patients were included. Among them, 327 did not receive CDI antibiotic prophylaxis, while 107 did. CDI antibiotic prophylaxis was associated with a significant risk reduction of CDI recurrence with an adjusted HR of 0.51 (95% CI, 0.27–0.97). The magnitude of the association was modified by the severity of the index CDI episode (P for interaction 0.0182). Specifically, the HR for recurrence was 0.163 (95% CI 0.045–0.593) for non-severe CDI, and 1.242 (95% CI 0.524–2.946) for severe CDI. No significant association was found between CDI antibiotic prophylaxis and 4–8 weeks mortality. ConclusionSecondary prophylaxis with CDI antibiotics appears to be associated with a reduced risk of recurrence in patients with previous non-severe CDI episode. Further studies are needed to confirm this finding.

Socioeconomic factors associated with use of telehealth services in outpatient care settings during the COVID-19

BackgroundTo examine potential changes and socioeconomic disparities in utilization of telemedicine in non-urgent outpatient care in Nevada since the COVID-19 pandemic.MethodsThis retrospective cross-sectional analysis of telemedicine used the first nine months of 2019 and 2020 electronic health record data from regular non-urgent outpatient care in a large healthcare provider in Nevada. The dependent variables were the use of telemedicine among all outpatient visits and using telemedicine more than once among those patients who did use telemedicine. The independent variables were race/ethnicity, insurance status, and language preference.ResultsTelemedicine services increased from virtually zero (16 visits out of 237,997 visits) in 2019 to 10.8% (24,159 visits out of 222,750 visits) in 2020. Asians (odds ratio [OR] = 0.85; 95% confidence interval [CI] = 0.85,0.94) and Latinos/Hispanics (OR = 0.89; 95% CI = 0.85, 0.94) were less likely to use telehealth; Spanish-speaking patients (OR = 0.68; 95% CI = 0.63, 0.73) and other non-English-speaking patients (OR = 0.93; 95% CI = 0.88, 0.97) were less likely to use telehealth; and both Medicare (OR = 0.94; 95% CI = 0.89, 0.99) and Medicaid patients (OR = 0.91; 95% CI = 0.87, 0.97) were less likely to use telehealth than their privately insured counterparts. Patients treated in pediatric (OR = 0.76; 95% CI = 0.60, 0.96) and specialty care (OR = 0.67; 95% CI = 0.65, 0.70) were less likely to use telemedicine as compared with patients who were treated in adult medicine.ConclusionsRacial/ethnic and linguistic factors were significantly associated with the utilization of telemedicine in non-urgent outpatient care during COVID-19, with a dramatic increase in telemedicine utilization during the onset of the pandemic. Reducing barriers related to socioeconomic factors can be improved via policy and program interventions.

Distributions of recorded pain in mental health records: a natural language processing based study

ObjectiveThe objective of this study is to determine demographic and diagnostic distributions of physical pain recorded in clinical notes of a mental health electronic health records database by using natural...

Effect of a Spiritual Care Training Program to Build Knowledge, Competence, Confidence and Self-awareness Among Australian Health and Aged Care Staff: An Exploratory Study.

The aim of this study was to evaluate a new spiritual care training program with health and aged care staff. A four-module program was delivered to 44 participants at a large Catholic health and aged care provider in Australia. Pre, post and 6week follow-up surveys were administered and included measures of spiritual care competency, confidence, perspectives of spirituality and spiritual care, spiritual well-being, and satisfaction. Paired sample t-tests showed total scores of participants' spiritual well-being, spiritual care competency and confidence significantly improved following the training and were largely maintained at follow-up. Perspectives on spirituality and spiritual care did not significantly change over time.

Trends of Diagnosis, Disease Course, and Treatment of Atopic Dermatitis 2012-2021: Real-World Data from a Large Healthcare Provider.

In the last decade, new treatments for atopic dermatitis (AD) have emerged. We aimed to describe trends of the diagnosis, disease course, and treatment of AD over a decade (2012-2021) using data from Maccabi Healthcare Services (a 2.7-million-member healthcare provider in Israel). The AD prevalence was stable (4.0% on 31 December 2021 vs. 4.3% on 31 December 2012). The annual AD incidence was also stable (5.8/1000 in 2012 and 5.7/1000 in 2021). AD-related treatment use was highest in the first year post-diagnosis, and it included, among children (n = 87,414) vs. adults (n = 36,865), low-potency topical corticosteroids (TCS) (41.8% vs. 27.1%), mid-potency TCS (30.1% vs. 28.1%), high-potency TCS (34.9% vs. 60.3%), topical calcineurin inhibitor (10.8% vs. 10.1%), phosphodiesterase-4-inhibitor (0.3% vs. 0.7% overall; approved in 2019), phototherapy (0.1% vs. 2.3%), and systemic/biologic treatments (13.0% vs. 13.3%). Among children diagnosed in 2012 and followed through to 2021 (n = 5248), 21.5% had ≥1 AD diagnosis/treatment 10 years later (among 3223 adults: 38.3%). We conclude that the incidence and prevalence rates of AD were comparable to those in similar database studies and remained relatively stable over the past decade. The results underscore the burden of medication use among children and adults, particularly in the first year after AD diagnosis, and the low rate of AD diagnosis among patients originally diagnosed as children 10 years earlier.

Improving our understanding of the social determinants of mental health: a data linkage study of mental health records and the 2011 UK census

ObjectivesTo address the lack of individual-level socioeconomic information in electronic healthcare records, we linked the 2011 census of England and Wales to patient records from a large mental healthcare provider....

Operational shock: A method for estimating cyber security incident costs for large Australian healthcare providers

ABSTRACT This paper introduces a novel cyber incident cost estimation methodology, applicable to large Australian healthcare providers. A review demonstrates the poor utility of current risk estimation approaches and the vulnerability of healthcare networks is evaluated using Leibniz’s law of indiscernibles, and Evans’ theory of vague objects. Finally, a quantitative cost calculation method is proposed, merging temporal and impact variables with service data from the Australian Institute of Health and Welfare. This research demonstrates that existing attempts to measure cyber incident risk produces vague results. This is evidenced by 929 Australian healthcare data breaches recorded over 5 years, a AU$0.6bn annual national risk exposure, and low levels of healthcare cyber maturity across three states. The likelihood of data breaches is reported as 99.4%, with known ICT vulnerabilities exceeding 207,000. After logically concluding that healthcare networks are fundamentally insecure, an ‘operational shock’ calculation method is modelled against the AIHW data, to illustrate realistic cyber incident costs. This returns an exposure across Australia’s acute care hospital network of AU$148.1 m from a single incident that takes 1 week to resolve. In considering this quantum, risk transfer options using cyber insurance and improved agency cyber risk programs are required to mitigate significant financial risks.

The Israel National Brain Repository .The establishment and uniqueness of the first brain bank in Israel

AbstractBackgroundPost‐mortem human brain tissue is the gold‐standard for neurodegenerative disease diagnosis and is invaluable for elucidating cellular and molecular mechanisms. Therefore, neurodegenerative disease brain banks are a critical component of research to advance diagnosis and develop effective disease modifying therapies. The Israel National Brain Repository (INBR) was established in 2018 at the Sheba Medical Center via a collaboration with the Mount Sinai Neuropathology Brain Bank in New York. Israel is a unique country with a diverse population including substantial populations of individuals of European descent, Middle‐Eastern North African (MENA) descent, and combinations of both.MethodINBR predominantly recruits from two prospective longitudinal cohort studies whose participants are at high dementia risk: older adults with type 2 diabetes (the Israel Diabetes and Cognitive Decline study) and middle‐aged offspring of people with Alzheimer’s Disease (The Israel Registry for Alzheimer’s Prevention). Participants in both cohorts are phenotyped for cognition, lifestyle, brain imaging, blood biomarkers, and genetics. Biospecimen collection and processing protocols are aligned with other Neurobiobanks in the USA (see flowchart). Additionally, all participants in both cohorts are members of the second largest healthcare provider in Israel, the Maccabi Healthcare Services, permitting linkage to longitudinal medical records dating from 1998.ResultN = 450 participants have signed intent to autopsy. Among the N = 285 with race/ethnicity data available, 30% are MENA. 14 brain and 6 spinal cord donations have been completed. At time of death, donors had an average age of 81.1 years, 10 had normal cognition, 3 had dementia, and one had amyotrophic lateral sclerosis.ConclusionThe potential strengths of the INBR is in the population characteristics of Israel, the ethnic diversity and admixture, the linkage to 25‐years of medical records data, and the small size of the country allowing donations to be received from anywhere in the country. The main challenge we face is cultural barriers to brain donation that exist among some segments of Israeli society. The ultimate goal is to capitalize on the strengths and uniqueness of INBR to develop novel therapies for dementia.

Organizing Care Around Conditions: An Expanded Model of Value-Based Health Care

Summary Restructuring the provision of health care around the condition being treated can reduce fragmentation, improve patient care, and lay the groundwork for value-based health care (VBHC). The authors researched the current use of four models in several health care organizations: the Integrated Practice Unit, first described in the context of VBHC in 2013 and three additional condition-based organizational structures defined by the Dutch Linnean Initiative. This qualitative study, using interviews with VBHC experts from 15 large health care providers worldwide, explores these four different ways to implement VBHC. All have different characteristics regarding staff, colocation, level of independence, and leadership. These models have not been previously studied in this way. Further research can delve into the framework concepts to enhance or validate the findings.

Association Between Guillain-Barré Syndrome and COVID-19 Infection and Vaccination: A Population-Based Nested Case-Control Study.

Existing data regarding occurrence of Guillain-Barré syndrome (GBS) after coronavirus disease 2019 (COVID-19) infection and vaccination are inconclusive. We aimed to assess the association between GBS and both severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and COVID-19 vaccine. We conducted a nested case-control study in a cohort of 3,193,951 patients aged 16 years or older, without a diagnosis of prior GBS, from the largest health care provider in Israel. Participants were followed from January 1, 2021, until June 30, 2022, for the occurrence of GBS. Ten randomly selected controls were matched to each case of GBS on age and sex. We assessed both SARS-CoV-2 infection and COVID-19 vaccine administration in the prior 6 weeks in cases and controls. Overall, 76 patients were diagnosed with GBS during follow-up and were matched to 760 controls. A positive test for SARS-CoV-2 was detected in 9 (11.8%) cases and 18 (2.4%) controls. An administration of COVID-19 vaccine was detected in 8 (10.5%) cases (all Pfizer-BioNTech [BNT162b2] vaccine) and 136 (17.9%) controls (134 Pfizer-BioNTech vaccine). Multivariable conditional logistic regression models showed that the odds ratio for GBS associated with SARS-CoV-2 infection and COVID-19 vaccine administration was 6.30 (95% CI 2.55-15.56) and 0.41 (95% CI 0.17-0.96), respectively. The results were similar when exposure to SARS-CoV-2 infection or COVID-19 vaccine administration was ascertained in the prior 4 and 8 weeks, although did not reach statistical significance for COVID-19 vaccine at 4 weeks. Our study suggests that SARS-CoV-2 infection is associated with increased risk of GBS, whereas Pfizer-BioNTech COVID-19 vaccine is associated with decreased risk of GBS.

Outsourcing the Management of Reusable Medical Devices in a Chain-Wide Care Setting: Mixed Methods Feasibility Study.

Managing reusable medical devices incurs substantial health care costs and complexity, particularly in integrated care settings. This complexity hampers care quality, safety, and costs. Studying logistical innovations within integrated care can provide insights to medical devices use among staff effectively. This study aimed to establish the feasibility of a logistical intervention through outsourcing and a web portal. The goal was to provide insights into users' acceptability of the intervention, on whether the intervention was successfully implemented, and on the intervention's preliminary efficacy, thus benefiting practitioners and researchers. This paper presents a mixed methods feasibility study at a large chain-wide health care provider in the Netherlands. The intervention entailed outsourcing noncritical reusable medical devices and introducing a web portal for device management. A questionnaire gauged perceived ordering and delivery times, satisfaction with the ordering and delivery process, compliance with safety and hygiene certification, and effects on the care delivery process. Qualitative data in the form of observations, documentation, and interviews were used to identify implementing challenges. Using on-site stocktaking and data from information systems, we analyzed the utilization, costs, and rental time of medical devices before and after the intervention for wheelchairs and anti-pressure ulcer mattresses. Looking at the acceptability of the intervention, a high user satisfaction with the ordering and delivery process was reported (rated on a 5-point Likert scale). With respect to preliminary efficacy, we noted a reduction in the utilization of wheelchairs (on average, 1106, SD 106 fewer utilization d/mo), and a halted increase in the utilization of anti-pressure ulcer mattresses. In addition, nurses who used the web portal reported shorter ordering times for wheelchairs (-2.7 min) and anti-pressure ulcer mattresses (-3.1 min), as well as shorter delivery times for wheelchairs (-0.5 d). Moreover, an increase in device certification was reported (average score of 1.9, SD 1.0), indicating higher levels of safety and hygiene standards. In theory, these improvements should translate into better outcomes in terms of costs and the quality of care. However, we were unable to establish a reduction in total care costs or a reduced rental time per device. Furthermore, respondents did not identify improvements in safety or the quality of care. Although implementation challenges related to the diverse supply base and complexities with different care financers were observed, the overall implementation of the intervention was considered successful. This study confirms the feasibility of our intervention, in terms of acceptability, implementation success, and preliminary efficacy. The integrated management of medical devices should enable a reduction in costs, required devices, and material waste, as well as higher quality care. However, several challenges remain related to the implementation of such interventions.

Masked anemia and hematocrit elevation under sodium glucose transporter inhibitors: findings from a large real-world study.

Sodium glucose transporter inhibitors (SGLT2i) therapy is associated with an increase in hematocrit as a class effect. There is a lack of information regarding the clinical magnitude and significance of hematocrit elevation, especially cardiovascular outcomes in patients with polycythemia and possible masking of lower hemoglobin levels as a sign of potential severe disease. A retrospective study utilizing large community healthcare provider electronic database. Hematocrit levels and variables with potential effect on hematocrit change were compared before and during SGLT2i treatment in adults with type 2 diabetes mellitus. Study population included 9646 patients treated with Dapagliflozin or Empagliflozin between 01.2015 and 06.2019. Hematocrit levels were significantly higher after treatment initiation (2.1%), with higher median elevation among male vs female (2.3% vs. 1.8%). Anemia prevalence was significantly lower under treatment (20% vs. 31.6%). In multivariable model, gender, smoking status, SGLT2i type, pretreatment hematocrit, diabetes duration, body mass index and estimated glomerular filtration rate change significantly effected hematocrit change. In the current study SGLT2i treatment was associated with significant hematocrit elevation, polycythemia and lower anemia prevalence. Further studies are needed to determine the clinical significance and approach to patients with pretreatment or on treatment polycythemia and the approach to patients with lower-normal hemoglobin levels under SGLT2i treatment.

Association between SARS-CoV-2 infection and new-onset atrial fibrillation

BackgroundAtrial fibrillation (AF) is associated with substantial morbidity and mortality. New-onset AF (NOAF) has been related recently to SARS-CoV-2 infection; however, the evidence supporting this link is still scarce. We aimed to examine the association between SARS-CoV-2 infection and NOAF. MethodsWe conducted a nested-case control study in a cohort of 2,931,046 adults from the largest healthcare provider in Israel. Subjects were followed from March 1st, 2020, until June 30th, 2022, for the occurrence of NOAF. Ten randomly selected controls were matched to each case of NOAF on age, sex, and duration of follow-up. Exposure to SARS-CoV-2 infection in the prior 30 days was assessed in cases and controls. To account for surveillance bias we performed a lag-time analysis and assessed the association with a negative control exposure (low back pain). Data was analyzed using conditional logistic regression. ResultsDuring the follow-up 18,981 patients developed NOAF and were matched to 189,810 controls. The mean age of cases and matched controls was 73.8 ± 13 years, and 51.1% of them were women. Multivariable analysis showed that SARS-CoV-2 infection was associated with an increased risk of NOAF; adjusted-OR, 4.24 (95% CI, 3.89–4.62). The association remained significant on lag-time analysis; however, the strength of the association was gradually attenuated with increasing lag-time but stabilized around a lag-time of 20 days. The negative control exposure (low back pain) was associated only with small increased risk of NOAF; adjusted-OR of 1.13 (95% CI, 1.02–1.26). ConclusionSARS-CoV-2 infection appears to be associated with increased risk of NOAF.

Association between COVID-19 vaccination and myasthenia gravis: A population-based, nested case-control study.

Existing data regarding the link between COVID-19 vaccine and myasthenia gravis (MG) are scarce. We aimed to assess the association between Pfizer-BioNTech vaccine with both new-onset MG and MG exacerbation. For the first aim, we conducted a nested case-control study in a cohort of 3,052,467 adults, without a diagnosis of MG, from the largest healthcare provider in Israel. Subjects were followed from January 1, 2021 until June 30, 2022 for the occurrence of MG. Ten randomly selected controls were matched to each case of new-onset MG on age and sex. For the second aim, a nested case-control study was conducted in a cohort of 1446 MG patients. Four randomly selected MG patients (controls) were matched to each case of MG exacerbation. Exposure to COVID-19 vaccine in the prior 4 weeks was assessed in cases and controls. Overall, 332 patients had new-onset MG and were matched with 3320 controls. Multivariable conditional logistic regression models showed that the odds ratio (OR) for new-onset MG, associated with COVID-19 vaccine, was 1.14 (95% CI 0.73-1.78). The results were consistent in sensitivity analysis that used more stringent criteria to define MG. Overall, 62 patients with MG exacerbation were matched to 248 MG controls. The multivariable OR for MG exacerbation, associated with COVID-19 vaccine, was 1.35 (95% CI 0.37-4.89). All results were similar when the prior exposure to COVID-19 vaccine was extended to 8 weeks. This study suggests that Pfizer-BioNTech vaccine is not associated with increased risk of new-onset nor exacerbation of MG.

Trends in occurrence of takotsubo syndrome and association with SARS-CoV-2 infection and COVID-19 vaccination.

Takotsubo syndrome (TTS) is a serious heart disease associated with significant morbidity and mortality. TTS has been related to SARS-CoV-2 infection and COVID-19 vaccine; however, the current data are scarce. We aimed to examine the associations between SARS-CoV-2 infection and its vaccine with TTS. We conducted a nested case-control study in a cohort of 3 237 909 adults from the largest healthcare provider in Israel. Patients were followed from 1 March 2020 until 31 December 2021 for the occurrence of TTS. Ten randomly selected controls were matched to each case of TTS on age, sex, and duration of follow-up. Exposure to SARS-CoV-2 infection and COVID-19 vaccine in the prior 30 days was assessed in cases and controls. During the follow-up 144 patients developed TTS and were matched to 1440 controls. The mean age of cases and their matched controls was 71.4 ± 12 years, and 136 (94.4%) of them were women. Conditional logistic regression analysis showed that SARS-CoV-2 infection and COVID-19 vaccine were not associated with an increased risk of TTS; odds ratio (OR) = 2.04 [95% confidence interval (CI), 0.50-8.2] and 0.87 (0.49-1.54), respectively. The absolute number of TTS cases in the prepandemic period (March-December 2018-2019) was 82 in 2018 and 80 in 2019. The number of TTS cases decreased to 56 during the corresponding period of 2020 (first pandemic year) and increased back to 81 in 2022. No significant association was found between SARS-CoV-2 infection or COVID-19 vaccination and TTS occurrence.

Guideline-Directed Low-Density Lipoprotein Cholesterol Management After Acute Ischemic Stroke: Findings from a National Health Care Service

Patients with ischemic stroke are at high risk for future cardiovascular events and should be treated intensively with lipid-modifying agents. Combination lipid-lowering therapies are often needed to achieve updated guideline-directed treatment goals. However, real-world data on intensification of lipid-lowering therapies and attainment of low-density lipoprotein cholesterol (LDL-C) targets early after ischemic stroke are limited. We extracted data from the largest healthcare provider in Israel on patients hospitalized with acute ischemic stroke between January 2020 and February 2022. Included were 3,027 patients surviving ≥1 year after stroke, with documented LDL-C levels and lipid-lowering medications at 2 time periods (0 to 3months and 6 to 12months after discharge). Participants were classified according to preexisting stroke and/or coronary artery disease. The use of combination lipid-lowering therapy (ezetimibe and/or proprotein convertase subtilisin/kexin type 9 [monoclonal antibodies] inhibitor plus statin) in the study population increased between the 2 timepoints from 3.6% to 5.1%, reaching 10.5% in those with previous coronary artery disease and stroke. LDL-C levels <70 and <55mg/100ml were attained by 42.3% and 22.9% of patients early after hospitalization, and in 49.5% and 27.1% during 6 to 12months after hospitalization, respectively. Attainment of guideline-recommended LDL-C goals was higher in patients treated with combination lipid-lowering therapies and in those with preexisting cardiovascular disease. In conclusion, despite the advances in drug development and the availability of several mechanisms to lower cholesterol levels, the attainment of guideline-recommended LDL-C targets after acute ischemic stroke is suboptimal. Intensification of treatment with combination lipid-lowering therapies after hospitalization is uncommonly performed in clinical practice, even in those with preexisting cardiovascular disease.