Tel Aviv Sourasky Medical Center Research Articles

Real-time survival prediction in emergency situations with unbalanced cardiac patient data

Cardiac disease is a major cause of morbidity and mortality worldwide. Currently, most researchers focus on identifying risk factors and treatment of cardiac disease. There has been little research on real-time prediction of patient survival in emergency situations with unbalanced data, which is critical to cardiac patient treatment. 2099 records were collected from cardiac patients at the Tel-Aviv Sourasky Medical Center. Using these records, a survival prediction model was built using empirical thresholding logistic regression with unbalanced cardiac patient data. This research (1) provided a simplified, highly efficient and flexible model to predict survival of patients with cardiac disease; (2) revealed important factors that influence survival prediction; and (3) discussed key points related to prediction with unbalanced medical data. The identified risk factors will help doctors concentrate on the most important factors for patient survival. This study provided novel technical and practical insights for patient survival analysis and prediction that traditionally suffers from the common unbalanced data problem.

Indeterminate nodules by the Bethesda system for reporting thyroid cytopathology in Israel: Frequency, and risk of malignancy after reclassification of follicular thyroid neoplasm with papillary-like features

ObjectiveWe aimed to determine the frequency and risk of malignancy (ROM) for indeterminate thyroid nodules, categories III (B3) and IV (B4) of the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), at a large institution in Israel. Additionally, we investigated the impact of redefining follicular neoplasm with papillary-like nuclear features (NIFTP) as non-malignant on malignancy rates. MethodsIn this retrospective study of all thyroid fine needle aspirations (FNAs) performed at Tel Aviv-Sourasky Medical Center between January 2013 and December 2015, we assessed ROM for B3 and B4 nodules. Potential risk factors thought to affect a-priori ROM were assessed. Suspected NIFTP lesions were re-examined, and if proven, reclassified as benign. Results3701 nodules were sampled in 2919 FNAs performed on 2674 patients. B3 reports comprised 7.7% of all nodules (n = 284); B4 represented 3.6% (n = 132). In multivariate logistic regression, male gender, being of former Soviet Union origin, and smoking increased ROM for B3 nodules by a factor of 7.97 (P = 0.002; CI: 2.2–23.4), 9.15 (P = 0.021; CI:1.4–60.0), and 11.0 (P = 0.001; CI 2.8–44.8), respectively. Reclassifying NIFTP decreased ROM from 14% to 12.5% for B3, and from 26.7% to 25% for B4 nodules. NIFTP comprised 9.5% of previously diagnosed resected malignant tumors. ConclusionsThe relative frequencies of B3 and B4 nodules and their associated malignancy rates were consistent with previous series. Risk factors identified for malignancy may help characterize patients most likely to benefit from surgery. Reclassifying NIFTP had a substantial impact on the ROM in the resected tumors previously diagnosed as malignant.

Six Hours of Manual Ventilation With a Bag-Valve-Mask Device Is Feasible and Clinically Consistent.

Manual ventilation of intubated patients is a common intervention. It requires skill as well as physical effort and is typically restricted to brief periods. Prolonged manual ventilation may be unavoidable in some scenarios, for example, extreme mass casualty incidents. The present study tested whether nurses are capable of appropriately manually ventilating patients for 6 hours. Volunteers performed ventilation on an electronic simulator for 6 hours while their own cardiorespiratory variables and the quality of the delivered ventilation were measured and recorded. The volunteers scored their perceived level of effort on a standard Borg Scale. Research laboratory at the Emergency Department, Tel Aviv Medical Center. Ten nursing staff members of the Tel Aviv Sourasky Medical Center, 25-43 years old. Volunteers ventilated manually a lung simulator for 6 hours. The subjects' physiologic states, including blood pressure, heart rate, respiratory rate, and oxygen saturation, showed no significant changes over time. The quality of delivered ventilation was somewhat variable, but it was stable on the average: average tidal volume ranged between 524.8 and 607.0 mL (p = 0.33). There was a slight but significant increase (7.3-10.9 L/min [p = 0.048]) in minute volume throughout the test period, reaching values consistent with mild hyperventilation. The subjects scored their perceived working effort as very light to fairly light, with a nonsignificant gradual increase in the Borg score as the study progressed. Manual ventilation of intubated patients can be performed continuously for 6 hours without excessive physical effort on the part of the operator. The quality of delivered ventilation was clinically adequate for all of them. There was a mild but significant trend toward hyperventilation, albeit within safe clinical levels, which was due to an increasing ventilatory rate rather than an increase in tidal volume.

Early post-marketing experience with edaravone in an unselected group of patients with ALS

Introduction: Treatment with edaravone has shown efficacy in a subgroup of patients with amyotrophic lateral sclerosis (ALS). However, it has been estimated that <7% of ALS patients fulfill the stringent inclusion criteria of the trial. In the current study, we aimed to explore retrospectively the efficacy of edaravone in unselected ALS patients. Methods: Demographic and clinical data were retrospectively collected for 22 patients who opted for treatment with edaravone and 71 untreated ALS patients attending the ALS clinic at Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, between May 2017 and January 2018. Clinical data were extracted for a baseline visit at treatment onset, and for pre-baseline and post-baseline visits, roughly 6 months apart from the baseline visit. Results: Baseline demographic and clinical characteristics were similar between edaravone treated and untreated patients, except for shorter disease duration in edaravone treated patients. Muscle strength, ALS Functional rating scale (ALSFRS-R), and respiratory function were similar between edaravone treated and untreated patients, including monthly rate of decline before and after baseline visit. Among treated patients, 7 had major respiratory complications occurring between 8 days to 7 months after treatment initiation, during or within hours following infusions. Discussion: Results of our study comparing edaravone treated and untreated patients in a real-life setting showed no differences in the rate of monthly decline of ALSFRS-R, in line with previous reports in ALS patients not treated with edaravone, and a previous clinical trial. Our findings might suggest that edaravone is not effective in unselected ALS patients.

Correction to: Psoriasis in systemic lupus erythematosus: a single-center experience.

Prof. Ari Polachek on of the author of the published version of this article missed to add his second affiliation which is the Department of Rheumatology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. The new affiliation is now added and presented correctly in this article.

Clinical utility of pan-microbial PCR assays in the routine diagnosis of infectious diseases

The goals of the study were to examine the analytical properties and the clinical utility of pan-microbial PCR (PM-PCR) assays in a retrospective study conducted in 2014–2015 at the Tel-Aviv Sourasky Medical Center. PM-PCR included in-house assays for pan-bacterial, pan-fungal, and pan-mycobacterial PCR followed by sequencing. The clinical utility of the assays was decided based on defined criteria/categories. There were 585 PM-PCR tests performed on samples from 306 patients. The positivity rates of PM-PCR for bacterial, fungal, and mycobacterial infections were 72/316 (22.7%), 16/186 (8.6%), and 6/83 (7.2%), and the sensitivity values were 65%, 76%, and 85%, respectively. PCR results had influenced the management in 14/82 (17%) of PCR-positive cases and in 13/222 (5.8%) of PCR-negative cases (P = 0.005). The causes for the low clinical utility were related to lack of effect on the initial treatment in PCR-negative cases and concurrent positive cultures or presumed contamination in PCR-positive cases.

Severe central obesity or diabetes can replace weight loss in the detection of frailty in obese younger elderly - a preliminary study.

PurposeUnwanted weight loss is one of the established criteria for the diagnosis of frailty. However, the relevance of this criterion to detect frailty in obese older adults has not been assessed. In particular, with the exception of malignancy, unwanted weight loss is not commonly seen in older obese subjects. Therefore, we tested the possibility that some obesity phenotypes and/or diabetes might be more useful in the detection of frailty in this setting.Patients and methodsA preliminary cross-sectional study of 50 consecutive subjects was conducted at The Institute of Endocrinology, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center. Inclusion criteria were: young elderly (aged 65–75 years), with general and/or abdominal obesity, without cancer. Frailty was assessed directly using the Fried model, the five-item fatigue, resistance, ambulation, illnesses, and loss of weight (FRAIL) scale. Eventually, in the assessment of frailty, the weight loss criterion was replaced by one or several of obesity/diabetes-related variables each time: severity of obesity by body mass index, waist circumference (and their interaction), body fat, and diabetes. The receiver operating characteristic curves for functional impairment indices were plotted to compare the usefulness of the frailty accepted and adjusted models.ResultsThe prevalence of frailty and pre-frailty in this cohort were 7/50 (14%) and 27/50 (54%), respectively, but unwanted weight loss was seen in three subjects (6%) only. The level of abdominal obesity had the strongest correlation with functional score (r=0.292, P<0.05). Frailty models which included either severe abdominal obesity or diabetes in lieu of unwanted weight loss had good sensitivity rates per each frailty score as compared with the original Fried model.ConclusionFor detecting and/or screening for the frailty syndrome in obese young elderly, the level of abdominal obesity or diabetes may provide a useful marker.

Efficacy and safety of Nivolumab in non-small cell lung cancer patients in Tel-Aviv tertiary medical center: Facing the reality.

Nivolumab is a human IgG4 programmed death (PD)-1 immune checkpoint inhibitor antibody, which is approved in Israel for the treatment of patients with advanced non-small cell lung cancer (NSCLC). It is also administered to individuals with disease progression during or after platinum-based chemotherapy, without a need to determine the level of PD-L1 expression in the tumor. The present study aimed to evaluate the survival and efficacy of Nivolumab treatment. A retrospective analysis was performed at a thoracic oncology service in a tertiary referral center (Tel-Aviv Sourasky Medical Center), on patients with NSCLC (squamous and non-squamous). All patients were treated with Nivolumab 3 mg/kg, administered intravenously every 2 weeks as part of a compassionate use program. The survival data was analyzed after 22 months. The overall survival (OS) was 34.9%, while the progression free survival (PFS) was 19.3%. The median PFS from the first dose of Nivolumab to treatment discontinuation was 4 months. A response assessment was performed in the 62 patients who received at least four cycles of Nivolumab, out of the 77 patient cohort. There was a complete response in 1 patient, a partial response in 11 patients, stable disease in 25 patients and progressive disease in 25 patients. The observed response rate of Nivolumab as a service treatment in unselected patients with unknown PD-L1 status NSCLC was 19%. The disease control rate was 60%. In the present study Nivolumab was given to a cohort of patients representing those seen in daily clinical practice, as opposed to a clinical trial setting. Survival and efficacy results strongly support the continued use of Nivolumab as a treatment for NSCLC.

Model-based and Model-free Machine Learning Techniques for Diagnostic Prediction and Classification of Clinical Outcomes in Parkinson\u2019s Disease

In this study, we apply a multidisciplinary approach to investigate falls in PD patients using clinical, demographic and neuroimaging data from two independent initiatives (University of Michigan and Tel Aviv Sourasky Medical Center). Using machine learning techniques, we construct predictive models to discriminate fallers and non-fallers. Through controlled feature selection, we identified the most salient predictors of patient falls including gait speed, Hoehn and Yahr stage, postural instability and gait difficulty-related measurements. The model-based and model-free analytical methods we employed included logistic regression, random forests, support vector machines, and XGboost. The reliability of the forecasts was assessed by internal statistical (5-fold) cross validation as well as by external out-of-bag validation. Four specific challenges were addressed in the study: Challenge 1, develop a protocol for harmonizing and aggregating complex, multisource, and multi-site Parkinson’s disease data; Challenge 2, identify salient predictive features associated with specific clinical traits, e.g., patient falls; Challenge 3, forecast patient falls and evaluate the classification performance; and Challenge 4, predict tremor dominance (TD) vs. posture instability and gait difficulty (PIGD). Our findings suggest that, compared to other approaches, model-free machine learning based techniques provide a more reliable clinical outcome forecasting of falls in Parkinson’s patients, for example, with a classification accuracy of about 70–80%.

Risk factors for recurrent Clostridium difficile infection in a tertiary hospital in Israel.

To estimate the rate and identified risk factors for recurrent Clostridium difficile infection (rCDI) in Israel. We conducted a retro-prospective case-control study of all adult (age ≥ 18years) patients with an initial episode of CDI (iCDI) at Tel Aviv Sourasky Medical Center from January 1, 2012 to December 31, 2014. We collected demographic, clinical, and epidemiological information for patients who were classified as recurrent (cases) and non-recurrent (control) groups. In total, 648 patients with iCDI were identified in the study. During the 36-month study period, 82 (12.7%) patients had at least one rCDI identified. We identified several factors as independent variables significantly associated with recurrent CDI: functional disability, severity of the initial infection, continuous non-Clostridium difficile antibiotic treatment with third-generation cephalosporins or clindamycin, and iCDI treatment with metronidazole and vancomycin; however, neutropenia had high measure of effect as a predictor for rCDI (adjusted odds ratio, 7.9; 95% confidence interval, 1.27-49.58; p = 0.026). The identification of the main modifiable risk factors for recurrent CDI, continuous non-Clostridium difficile antibiotics after diagnosis of the initial infection, and antibiotic treatment with third-generation cephalosporins or clindamycin are critical in reducing the spread of recurrent infection with Clostridium difficile in hospital.

Pediatric burns in Israeli natives versus asylum seekers living in Israel: Lessons learned

BackgroundBurn injuries are one of the leading causes of morbidity and mortality in the pediatric population.In early childhood, burns have a wide range of adverse long-term consequences ranging from functional impairment to psychological implications.Children from low-income and middle-income countries are at a higher risk of suffering from burn injuries. In the last 10 years the population of asylum seekers from low-income countries in Israel has increased dramatically.About 25,000 or 60% of asylum seekers are living in the Tel Aviv area, making up roughly 6% of the city’s total population (about 405,000). AimA retrospective study aimed to profile the pediatric burn injuries treated at the Tel Aviv Sourasky Medical Center over the last 9 years in an effort to examine the distinct characteristics of African asylum seekers who suffer burn injuries in comparison with Israeli nationals. Patients & MethodsMedical records of 876 patients under the age of 18 years presenting between 2007–2015 were retrospectively reviewed. The parameters collected included gender, causality, total body surface area (TBSA), burn depth and patient outcome. ConclusionsThere was no significant difference regarding: age; male-female ratio; scald-types burns; limb involvement. However, hospitalization and length of hospital stay were significantly higher among asylum seekers, as was family burden. Questions may be raised regarding prevention, education & social support. Our research provides a small glimpse into the world of asylum seekers in Israel. We hope it will serve as a window into the much grander problems that this population faces on a daily basis.

Outcomes of Craniofacial Open Surgery in Octogenarians.

Introduction The steady increase in average life expectancy has led to a rise in the number of referrals of elderly patients for major operations. It is not clear whether age itself is a risk factor for morbidity and mortality after skull base operations. We investigated a possible link among a cohort of patients older than 80 years of age who underwent those surgeries in our department. Methods We conducted a retrospective analysis of all patients who underwent skull base surgery at the TASMC (Tel Aviv Sourasky Medical Center) between 2000 and 2016. Results A total of 369 patients underwent open skull base surgeries in our institution, and 13 were patients older than 80 years. The median age of the octogenarians was 83.4 (range 80-89), and the male-to-female ratio was 7:6. Twelve patients had major systemic comorbidities. Four patients had major complications associated with surgery: three had early wound complications, and one each had early central nervous system complications, early and late systemic complications, and late orbital complications. This complication rate is comparable to that of our younger group of 356 patients. The overall survival rate was measured for 30 days, 1 year, and 3 years, and it was not significantly different between the octogenarians and that of the younger patients. Further comparison of the elderly group with 13 matched younger patients revealed no difference of morbidity and mortality between the two groups. Conclusions Despite their systemic comorbidities, the morbidity and mortality rates associated with skull base surgery in octogenarians appear to be comparable to that of younger patients undergoing the same procedures.

Invited Commentary

Invited Commentary

Disaster Preparedness in the Blood Bank

When a natural or manmade disaster occurs, the first place the wounded are relocated to is the hospital. Disasters generate many types of injuries that may require the use of blood products. Blood Banks need to be prepared for a rapid influx of patients. Because of recent world events, the blood community has established guidelines to assist Blood Banks with creating successful Emergency Operations Procedures. Blood Banks can use these guidelines to create mock scenarios and tabletop exercises to estimate how the blood supply will be affected in the wake of disasters such as pandemics and blood shortages. Retrospective review of past disaster experiences such as earthquakes, airline crashes, and bombings can be used to evaluate what went well and what improvements to the process need to be made. Developing a disaster plan is a multistep process that includes determining the need for blood products, routes of communication, how to mobilize hospital staff, and how to procure more blood products. Once a plan is created, it should be practiced and improved upon, so flaws in the plan can be corrected and the best possible care for patients can be provided. ABBREVIATIONS:CLSI - Clinical Laboratory Standards Institute, AABB - organization formerly known as the American Association of Blood Banks, ED - emergency department, EMS - emergency medical service, EOP - emergency operations plan, MRCC - Medical Resource Control Center, MCI - Mass Casualty Incident, TASMC - Tel Aviv Sourasky Medical Center, MAC - Medical Alert Center

Failure of initial disease control in bullous pemphigoid: a retrospective study of hospitalized patients in a single tertiary center.

Bullous pemphigoid (BP) is the most prevalent autoimmune blistering skin disease in Western countries and in Israel. Initial disease control is achieved in 60-90% of BP patients within 1-4 weeks of corticosteroid therapy. In the remainder of patients, recalcitrant disease is controlled with additional immunosuppressive treatment. We aimed to evaluate the rate of BP patients who needed adjuvant therapy to achieve initial disease control and to identify potential predictors for recalcitrant disease. We conducted a retrospective study of newly diagnosed BP patients who were hospitalized at the Tel Aviv Sourasky Medical Center between the years 2008-2014. We performed statistical analyses to assess the association between clinical factors and failure of initial disease control. Among 114 hospitalized patients with newly diagnosed BP, 1.8% presented with oral mucosa involvement. Seven patients (6.1%) required systemic agents in addition to corticosteroids to achieve disease control. Hypertension (P = 0.048), involvement of the head region (P = 0.042), and metformin treatment (P = 0.02) were significantly more prevalent among patients with recalcitrant disease. The low frequency of recalcitrant BP (6.1%) and the rarity of involvement of the oral mucosa (1.8%) in this study suggest that Israeli BP patients present a milder phenotype compared to similar patients from other geographic areas. Hypertension, head involvement, and metformin therapy were found to be significantly associated with the need for adjuvant therapy to achieve initial control, suggesting that these parameters may serve as predictors of treatment response in BP.

Does Acinetobacter baumannii Serve as a Source for blaNDM Dissemination into Enterobacteriaceae in Hospitalized Patients?

The goal was to study the possibility that Acinetobacter baumannii serve as an epidemiologically significant source for transmission of the blaNDM gene to Enterobacteriaceae by horizontal gene transfer (HGT) in hospitalized patients. The study was done at the Tel-Aviv Sourasky Medical Center from December 2014 until August 2015. Clinical and surveillance rectal cultures were collected as per hospital policies and were analyzed for the presence of New Delhi metallo-beta-lactamase-producing Enterobacteriaceae (NDME) and A. baumannii (NDMAb). Isolates were typed by pulsed-field gel electrophoresis (PFGE). The location of the blaNDM gene within the Tn125 transposon was studied by sequencing. A transmission event (TE) was determined if patients shared the same PFGE type of either NDME or NDMAb and were simultaneous in the same ward. HGT-related TE was considered if the two isolates shared identical blaNDM gene allele and transposon. There were 16 NDMAb- (clinical, 10; surveillance, 4; both, 2) and 13 NDME- (clinical, 3; surveillance, 8; both, 2) infected/colonized patients. All NDMAb isolates except two harbored the blaNDM-1 allele that was located within a Tn125 transposon and was plasmid borne. The majority of patients (n = 10/16) were infected by one PFGE type of NDMAb, and five clonal TEs were identified. NDME were either Escherichia coli (n = 4) or Klebsiella pneumoniae (n = 9) of different PFGE types with only one NDME TE. The blaNDM gene was within a Tn125 in three K. pneumoniae isolates. Although one HGT-related TE between NDMAb and K. pneumoniae was epidemiologically suspected, the low similarity between the Tn125 transposons (75.7%) excluded that possibility. In conclusion, whereas NDMAb appears to disseminate by clonal spread, we did not find evidence for HGT-mediated transmission in NDME in hospitalized patients.

The ability of the wide range CRP assay to classify individuals with low grade inflammation into cardiovascular risk groups

BackgroundHigh sensitivity C-reactive protein (hsCRP) has become a routine assessment tool to discriminate between patients at low, intermediate or high risk for cardiovascular events using the threshold values of 1 and 3mg/L, respectively. Over the past years, several studies have proposed the wide range C-reactive protein (wrCRP) as an alternative to the hsCRP in various clinical scenarios. However, the potential use of wrCRP in assessing the cardiovascular risk has not yet been evaluated. MethodsBoth wrCRP and hsCRP were evaluated in 15,780 apparently healthy individuals who underwent a routine annual checkup in the Tel Aviv Sourasky Medical Center. Individuals with CRP levels >5mg/L were excluded. Agreement between the two methods was observed using the Bland-Altman method and the concordance correlation coefficient. Deming regression was used to build a calibration equation. Reclassification of individuals' risk level was observed and Cohen's kappa was used to evaluate risk agreement. ResultsA high correlation (r=0.98) along with a significant difference (p<0.001) between hsCRP and wrCRP raised the need for calibration. A simple calibration equation (Adjusted wrCRP=0.3136+0.8803×wrCRP) led to high agreement which enabled 8.4% reclassification of the risk group. A change in the intermediate risk threshold value from 1 to 0.9mg/L led to an almost perfect agreement (kappa=0.87, p<0.001) and a low reclassification rate (7.6%), with under 0.05% of the population undergoing a major reclassification (from high to low risk or vice versa). ConclusionsIn the era of limited financial resources, wrCRP assay may be used as a reasonable routine assay to evaluate the cardiovascular risk in patients undergoing a routine annual checkup.

Does Choline PET/CT Change the Management of Prostate Cancer Patients With Biochemical Failure?

The FDA approved C-11 choline PET/computed tomography (CT) for imaging patients with recurrent prostate cancer in 2012. Subsequently, the 2014 NCCN guidelines have introduced labeled choline PET/CT in the imaging algorithm of patients with suspected recurrent disease. However, there is only scarce data on the impact of labeled choline PET/CT findings on disease management. We hypothesized that labeled-choline PET/CT studies showing local or regional recurrence or distant metastases will have a direct role in selection of appropriate patient management and improve radiation planning in patients with disease that can be controlled using this mode of therapy. This retrospective study was approved by the Tel Aviv Sourasky and Sheba Medical Center's Helsinki ethical review committees. Patient characteristics including age, PSA, stage, prior treatments, and pre-PET choline treatment recommendations based on NCCN guidelines were recorded. Patients with biochemical failure and without evidence of recurrence on physical examination or standard imaging were offered the option of additional imaging with labeled choline PET/CT. Treatment recommendations post-PET/CT were compared with pre-PET/CT ones. Pathologic confirmation was obtained before prostate retreatment. A nonparametric χ test was used to compare the initial and final treatment recommendations following choline PET/CT. Between June 2010 and January 2014, 34 labeled-choline PET/CT studies were performed on 33 patients with biochemical failure following radical prostatectomy (RP) (n=6), radiation therapy (RT) (n=6), brachytherapy (n=2), RP+salvage prostate fossa RT (n=14), and RP+salvage prostate fossa/lymph node RT (n=6). Median PSA level before imaging was 2 ng/mL (range, 0.16 to 79). Labeled choline PET/CT showed prostate, prostate fossa, or pelvic lymph node increased uptake in 17 studies, remote metastatic disease in 9 studies, and failed to identify the cause for biochemical failure in 7 scans.PET/CT altered treatment approach in 18 of 33 (55%) patients (P=0.05). Sixteen of 27 patients (59%) treated previously with radiation were retreated with RT and delayed or eliminated androgen deprivation therapy: 1 received salvage brachytherapy, 10 received salvage pelvic lymph node or prostate fossa irradiation, 2 brachytherapy failures received salvage prostate and lymph nodes IMRT, and 3 with solitary bone metastasis were treated with radiosurgery. Eleven of 16 patients retreated responded to salvage therapy with a significant PSA response (<0.2 ng/mL), 2 patients had partial biochemical responses, and 3 patients failed. The median duration of response was 500±447 days. Two of 6 patients with no prior RT were referred for salvage prostatic fossa RT: 1 received dose escalation for disease identified in the prostate fossa and another had inclusion of "hot" pelvic lymph nodes in the treatment volume. These early results suggest that labeled choline PET/CT imaging performed according to current NCCN guidelines may change management and improve care in prostate cancer patients with biochemical failure by identifying patients for referral for salvage radiation therapy, improving radiation planning, and delaying or avoiding use of androgen deprivation therapy.

Incidence and Risk Factors for Community and Hospital Acquisition of Clostridium difficile Infection in the Tel Aviv Sourasky Medical Center.

OBJECTIVES To estimate the incidence and identified risk factors for community-acquired (CA) and hospital-acquired (HA) Clostridium difficile infection (CDI) METHODS We conducted 2 parallel case-control studies at Tel Aviv Sourasky Medical Center from January 1, 2011, to December 31, 2014. We identified persons with CDI, determined whether infection was community or hospital acquired, and calculated incidence rates from 2007 to 2014. We collected demographic, clinical, and epidemiological information for CDI cases and hospitalized control cases and estimated the odds ratio with 95% confidence interval using conditional logistic regression. RESULTS In total, 1,563 CDI cases were identified in the study. The incidence rate of CA-CDI and HA-CDI increased by 1.6-fold and 1.2-fold, respectively, during 2012-2014. However, the incidence rate of CA-CDI was 0.84 per 100,000 (95% CI, 0.52-1.30), the rate for HA-CDI was 4.7 per 10,000 patient days (95% CI, 4.08-5.38), respectively, in 2014. We identified several factors as independent variables significantly associated with HA-CDI: functional disability, presence of nasogastric tube, antibiotic use, chemotherapy, infection by extended-spectrum β-lactamases, and mean of albumin values. Risk factors independently associated with CA-CDI were close contact with a family member who had been hospitalized in the previous 6 months, inflammatory bowel disease, and home density index (adjusted odds ratio, 25.7; 95% confidence interval, 3.99-165.54; P=.001). CONCLUSIONS The identification of the main modifiable risk factors for HA-CDI (antibiotic exposure and hypoalbuminemia) and for CA-CDI (close contact with a family member who had been hospitalized in the previous 6 months) is likely to optimize prevention efforts; these factors are critical in preventing the spread of CDI. Infect Control Hosp Epidemiol 2017;38:912-920.

Oncologic patients attitudes and participation in clinical trials.

e18029 Background: Clinical trials are an essential part of the oncological care. However, literature indicates low accrual of only 2-4% of the oncologic population. One of the leading known barriers is the patient's hesitant attitude toward participation. This study aimed to evaluate the patients' population treated in the Tel Aviv Sourasky Medical Center (TASMC) oncology division and their understanding of clinical research in order to improve local recruitment strategies. Methods: An observatory, questionnaire based research was conducted. Patients receiving active oncology treatment in the TASMC oncologic day care unit were asked to complete an anonymous questionnaire, which was comprised of two main parts: the first evaluate demographic information and past experience in clinical research. The second investigated basic knowledge true/false test regarding clinical trials. The questionnaire was validated by both external and internal validity tests (α-Cronbach validity test) and was approved by the local ethics committee. Results: Two hundred patients completed the questionnaires. Median age was 60. 64% would consider participating in a clinical study. 23% (N = 46) had past experience in research, and compared to those with no experience they were found to have higher academic education (67.4% vs 36.9%, p &lt; 0.0001), be more secular (76.1% vs 58.3, p = 0.037) and to have a better understanding of medical research (84.4%, vs 36.5%, p &lt; 0.0001). They were also more inclined to participate in a future research (73% vs 44.9%, p = 0.01). Of those who would decline to participate and had failed the knowledge test (score less than 60%), the most frequent concern was related to the placebo arm (p = 0.055), ability to reject consent, and to trust issues with the treating oncologist. Conclusions: Despite a noteworthy readiness to enroll in clinical trials among the TASMC oncologic population, there were found significant knowledge and basic understanding gaps regarding clinical trials. Further efforts are needed to better understand specific accrual barriers and to develop an adapted information system.