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During the last 20 years, a dramatic increase in antibiotic resistance among pneumococci has been observed and linked to increasing antibiotic consumption [1-4]. Several studies have suggested that reduction in antibiotic consumption leads to a reduction in the antibiotic resistance of Streptococcus pneumoniae in the community [2, 5-7]. However, other studies could not demonstrate such an effect [8-10]. The relationship between antibiotic consumption and resistance is complex. Some antimicrobial agents select resistant pneumococcal strains more effectively than others [8, 11-15]. Moreover, the rate of the decrease in resistance expected after a decrease in antibiotic use depends on both the fitness cost of resistance for the bacteria and the extent of the reduction in consumption [16, 17]. If fitness cost is minimal or if the reduction in antibiotic use is small, antibiotic resistance may continue increasing, albeit perhaps more slowly, or it may decline gradually. However, if resistance exacts a strong fitness cost (with respect to transmissibility) on the bacteria, then a quick and significant decrease in resistance would be expected after a major decrease in antibiotic consumption [18]. A recent study in rats suggested that penicillin resistance in S. pneumoniae, particularly high-level resistance, carries a substantial fitness cost [19]. Another recent study showed a fitness cost of fluoroquinolone-resistant mutants of S. pneumoniae [20]. A complicating factor is the presence of dual and multiple resistance, because reduction mainly in the use of a single antibiotic may not result in the expected reduction in resistance, because of coselection of resistance caused by the continued use of other antibiotics [18]. Surveillance of antibiotic prescriptions in children

Excessive use of the emergency department (ED) is associated with increased costs and workload in the ED, patients' inconvenience and disruption of the continuity of care. The study's goal was to describe trends in ED utilization among Bedouins living in southern Israel. A retrospective cross-sectional study was conducted in primary care clinics in southern Israel. Patients included Bedouin and Jewish patients insured by Clalit Health Services. Data was retrieved from a central database. The number of visits to the ED and age-adjusted rates of ED visits during 2000-2003 were determined in the Bedouin vs. Jewish population. All visits that ended in hospitalization were excluded. Data was stratified according to patients' residence (semi-nomadic vs. urban Bedouins) and referral origin. Age-adjusted rates of ED visits decreased from 42.9/1000 patients/month in 2000 to 38.3/1000 patients/month in 2003. There were more ED visits in the Bedouin as compared to Jewish population (38.3/1000 vs. 21.8/1000 patients/month). The decrease in ED utilization was more prominent among adult semi-nomadic Bedouins (from 60.8/1000 to 40.3/1000 patients/month). The proportion of referrals by the family physician to ED significantly decreased (among urban Bedouins: from 54.3% to 43.2%, p

Selective immunoglobulin E (IgE) deficiency (IgED) is defined as serum levels of IgE more than or equal to 2 kIU/L and is associated with immune dysregulation and autoimmunity. This study aimed to investigate a prevalence of atherosclerotic cardiovascular disease (ASCVD) in population with IgED. Within the electronic patient record (EPR) database of Leumit Health Care Services (LHS) in Israel, data capture was performed using IBM Cognos 10.1.1 BI Report Studio software. The case samples were drawn from the full study population (n = 18,487), having any allergy-related symptoms and/or those requesting antiallergy medications and performed serum total IgE measurement during 2012 at LHS. All subjects aged more than or equal to 40 years old, with serum total IgE less than 2 kIU/L were included in case group. Control group was randomly sampled from the remained subjects, with a case-control ratio of 10 controls for each case (1:10). The comorbid cardiovascular diseases during less than or equal to 10 years before serum total IgE testing were identified and retrieved using specific International Classification of Diseases, 9th Revision, Clinical Modification diagnostic codes. There were 103 in case and 1030 subjects in control group. Compared with control group patients, the case group had significantly more arterial hypertension [34 (37.7%) versus 187 (18.2%), p < 0.001], ischemic heart disease (IHD) [26 (25.2%) versus 87 (8.4%), p < 0.001], carotid stenosis [5 (4.9%) versus 7 (0.7%), p = 0.003], cerebrovascular disease (CVD) [3 (2.9%) versus 5 (0.5%), p = 0.029], and peripheral vascular disease (PVD) [4 (3.9%) versus 9 (0.9%), p = 0.024]. IgED is associated with higher prevalence of arterial hypertension and ASCVD.

Monilethrix is a structural defect of the hair shaft usually inherited in an autosomal dominant fashion and caused by mutations in the hHb1, hHb3, and hHb6 keratin genes. Autosomal recessive inheritance in this disease has been sporadically reported. We encountered 12 Jewish families from Iraq, Iran, and Morocco with microscopic findings of monilethrix, but with no evidence of vertical transmission. Since no mutations were found in these three hair keratin genes, we examined nine chromosomal regions containing gene clusters encoding skin and hair genes. On chromosome 18q, a common haplotype in the homozygous state was found among all seven Iraqi patients, but not in 20 controls (P

Intake of drugs is considered a risk factor for psoriasis. The aim of this study was to investigate the association between drugs and psoriasis. A case-control study including 110 patients who were hospitalized for extensive psoriasis was performed. A control group (n = 515) was defined as patients who had undergone elective surgery. A case-crossover study included 98 patients with psoriasis. Exposure to drugs was assessed during a hazard period (3 months before hospitalization) and compared to a control period in the patient's past. Data on drug sales were extracted by data mining techniques. Multivariate analyses were performed by logistic regression and conditional logistic regression. In the case-control study, psoriasis was associated with benzodiazepines (OR 6.9), organic nitrates (OR 5.0), angiotensin-converting enzyme (ACE) inhibitors (OR 4.0) and non-steroidal anti-inflammatory drugs (NSAIDs) (OR 3.7). In the case-crossover study, psoriasis was associated with ACE inhibitors (OR 9.9), beta-blockers (OR 9.9), dipyrone (OR 4.9) and NSAIDs (OR 2.1). Extensive psoriasis may be associated with intake of ACE inhibitors, NSAIDs or beta-blockers.

To identify patients with depression, in primary care clinics in Israel, using the MINI (Mini-International Neuropsychiatric Interview) as a screening tool and to evaluate the health services utilization and costs of the patients identified.Phone interviews (between 1997 and 2000) and health services utilization data extracted from computerized databases.Three primary care clinics belonging to Clalit Health Services (HMO).A random sample of 2755 patients, aged 21-65.MINI score results, utilization data.The study included interviews with 2507 patients. The screening questionnaire identified 5.9% with major depression, 1.6% with minor depression and 14.3% with depressive symptoms. Higher rates of depression were found among women, immigrants, secular or traditional religious Jews, and the unemployed. Those identified with major depression had higher health services utilization and costs. Logistic regression analysis showed that depression was related to older age, female gender, fewer years of education and among seculars. Depressed patients had significantly more somatic comorbidity.Health services utilization and costs of people identified as depressed by the screening tool were higher. Depressive patients had higher comorbidity, which might be partially responsible for the higher cost.

Pityriasis amiantacea (PA) is an inflammatory disease of the scalp characterized by asbestos-like shiny scales that bind to the proximal part of the hair shaft. PA may be an isolated disorder or a reaction pattern associated with other inflammatory disorders. Previous reports did not demonstrate a clear association between PA and bacterial infections. A controlled prospective study was performed to identify the role of bacterial skin infections in patients with PA. In all patients, bacterial cultures were taken from the scalp. A group of 32 patients with various other scalp disorders served as a control group. Thirty-two patients were included in the study. There were 30 women (93.8%) and 2 men (6.2%) with a mean age of 23.1 years (SD 11.9 years). Twenty-five patients (78.1%) were of Bedouin origin and 7 were of Jewish origin (21.9%). Staphylococcus aureus was isolated in 26 patients with PA (81.3%) as compared with 1 patient (3.1%) from the control group (p=0.0001). The patients were treated by a combine...

AIM: To investigate the prevalence and clinical characteristics of Helicobacter pylori (H. pylori)-infected dyspeptic patients with selective immunoglobulin E deficiency (IgEd). METHODS: All individuals who underwent serum total immunoglobulin E (IgE) measurement at the Leumit Healthcare Services (Israel) in 2012 were identified in an electronic database search (n = 18487). From these, selected case group subjects were ≥ 12 years of age and had serum total IgE < 2 kIU/L (n = 158). The control group was selected from a random sampling of the remaining subjects ≥ 12 years of age to obtain a case-control ratio of 1:20 (n = 3160). Dyspeptic diseases, diagnosed no more than 5 years before serum total IgE testing, were identified and retrieved from the electronic database using specific International Classification of Diseases diagnostic codes. Results of C13-urea breath tests were used to identify subjects infected with H. pylori. Categorical variables between case and control subjects were analyzed using Fisher’s exact tests, whereas continuous variables were analyzed using χ2 tests. RESULTS: Dyspepsia was present in 27.2% (43/158) of case subjects and 22.7% (718/3160) of controls. Of these, significantly more case subjects (32/43, 74.4%) than controls (223/718, 31.1%) were positive for H. pylori (P < 0.01). Esophagogastroduodenoscopy was performed in 19 case and 94 control subjects, revealing that gastritis was more prevalent in IgEd case subjects than in controls (57.9% vs 29.8%, P < 0.05). Furthermore, a significantly greater proportion of case subjects presented with peptic duodenal ulcers (63.2% vs 15.9%, P < 0.01). Histopathologic examination showed marked chronic inflammation, lymphoid follicle formation and prominent germinal centers, with polymorphonuclear cell infiltration of gastric glands, that was similar in case and control biopsy tissues. Finally, IgEd case subjects that underwent esophagogastroduodenoscopy were more likely to exhibit treatment-refractory H. pylori infections that require second-line triple antibiotic therapy (47.4% vs 11.7%, P < 0.01). CONCLUSION: IgEd is associated with higher rates of H. pylori-associated gastritis and peptic duodenal ulcers.

After a new formulation of levothyroxine was distributed in Israel, side effects were reported to the Ministry of Health generating extensive media coverage. The purpose of this study was to determine whether the new formulation was associated with a change in thyroid-stimulating hormone (TSH) levels of treated patients and to evaluate the effect of the extensive media coverage on the incidence of laboratory test performance.Retrospective-cohort and crosssectional analysis.All patients from the Leumit Health Services of Israel treated with levothyroxine between October 2009 and February 2012 were included in the study. A retrospective cohort was constructed of patients treated and maintained within the desired target range (0.35-5 mIU/L) from January to July 2010. A longitudinal analysis was conducted to calculate the monthly distribution of TSH levels from laboratory tests during routine care over 26 months. Data were stratified by cohort and noncohort patients.Data were captured for 18,106 levothyroxine-treated patients; 1140 were included into the retrospective cohort. In both subpopulations a sharp rise in the number of tests performed monthly is observed at the peak of media coverage during October and November 2011. In the retrospective cohort the proportion of TSH results within target range fell to a low of 67.5% during December 2011, with 25.3% between 5.01 and 20 mIU/L. Results20 mIU/L then peaked at 3.8% indicating an increase in patients who stopped taking levothyroxine.These results demonstrate the power of mass media to influence patient behavior and to foment a public health scare.

Three vector-borne diseases, Mediterranean spotted fever, cave fever, and simple cutaneous leishmaniasis, are endemic to Israel. These diseases may pose a significant health hazard to visitors to this area. The objective of this article is to supply the essential information concerning these diseases to physicians who are unfamiliar with them, with the intention of preventing disease by better traveler education and enabling prompt recognition and treatment outside the endemic areas. Mediterranean spotted fever is a rickettsiosis transmitted by a dog tick and presenting as a high fever with headache and typical rash. Cave fever is a borrelial infection transmitted by a soft tick and presenting as a relapsing febrile disease. Both diseases can be prevented by avoiding endemic areas and ticks, and respond well to treatment with tetracycline. Cutaneous leishmaniasis is a protozoan infection of the skin transmitted by the sandfly and presenting as an indurated erythematous cutaneous nodule. It responds to topical paromomycin and to intralesional or systemic sodium stibogluconate, but the best policy is to take the proper precautions and avoid infection.

Policy development to manage new off-label uses of medications is an issue relevant to health policy stakeholders internationally. Retrospective drug utilization analyses may be useful to identify practice trends in the use of drugs for unapproved (off-label) uses. Since drug use evaluations (DUE) are generally performed for expensive medications or when safety concerns warrant increased scrutiny, patterns of off-label use of inexpensive drugs will probably be undetected. Tamoxifen citrate, an estrogen receptor antagonist, is indicated in Israel exclusively for palliative [sic: meaning adjuvant] treatment of breast cancer. This DUE was motivated by observations that tamoxifen may be used off-label for indications without evidence of safety or efficacy.To assess the extent of off-label prescribing of tamoxifen and ascertain what evidence is available supporting the use of the drug for the off-label indications observed.A retrospective DUE of tamoxifen was performed for the 12 months of calendar year 2008 in a 650,000-member HMO in Israel for patients who received at least 1 prescription for tamoxifen. All patients for whom tamoxifen was dispensed in 2008 were identified from pharmacy claims data. The HMO's electronic patient record (EPR) was subsequently queried to identify the diagnoses of patients who received tamoxifen and exclude those patients who had a diagnosis code (ICD-9-CM 174.x or 175.x) for breast cancer. An EPR chart review was also performed to identify and exclude patients who had a diagnosis or treatment of breast cancer that was recorded in free text. For the patients who did not have a diagnosis code or free-text description of breast cancer, the recorded off-label diagnoses and ICD-9-CM codes in the EPR during the visit when tamoxifen was first prescribed were tabulated. A literature search was conducted to collect information supporting the use of tamoxifen for the observed off-label indications. We defined the use as "supported" if studies were found in PubMed, Cochrane database, or Micromedex that supported the clinical decision to use the drug for the off-label indication.877 patients were treated with tamoxifen in 2008 of whom 826 (94.2%) had a diagnosis of breast cancer, and 51 patients (5.8%) received the drug from 41 physicians in 7 medical specialty categories for 25 different off-label diagnoses. Of these 25 diagnoses, 33 patients (64.7% of 51 patients with off-label use) received tamoxifen for 8 diagnoses that were associated with some evidence to support their off-label use. Malignant neoplasm of ovary (n = 13) and female infertility (n = 13) were the most commonly recorded indications with some evidence to support off-label use. Of the 13 women treated for infertility, 9 (69.2%) had been treated with clomiphene citrate prior to being treated with tamoxifen, suggesting that some physicians may be experimenting with tamoxifen as second-line treatment.Tamoxifen was found to be used off-label in only 5.8% of the patients who received the drug in 2008 in this HMO, and only 18 patients (2.1%) received tamoxifen for a diagnosis that did not have some supporting evidence of efficacy. Since off-label prescribing of tamoxifen was found to be relatively rare, this HMO did not impose a prior authorization requirement for this drug and instead added an edit in the EPR to block off-label prescribing by requiring the physician to register a diagnosis of breast cancer.

To ascertain whether revocation of a prior authorization (PA) requirement by the Leumit Health Fund of Israel resulted in inferior rates of glycosylated hemoglobin (A1C) testing among new users of expensive diabetes medications.Electronic patient record (EPR) database study.Data on new users of the target drugs and on A1C testing in these patients were extracted from EPR databases for the 6-month period after the revocation. The proportion (95% confidence interval [CI]) of patients who obtained at least 1 A1C test during the 4 months before initiation of treatment was calculated. The data were stratified by month to detect possible trends in rates of testing during the period after the policy change.After the PA requirement was rescinded, A1C testing among incident users of the target drugs dropped from 100% during the PA period to rates ranging from 85.6% (95% CI, 79.7%-91.5%) to 94.4% (95% CI, 90.8%-97.9%). Statistically significant variance in monthly rates of testing was not observed.Prior authorization has been successfully implemented in the managed care setting studied to obtain 100% performance of a laboratory test necessary to monitor drug therapy outcomes in patients with diabetes mellitus. When PA is implemented as a quality assurance strategy, its revocation should be accompanied by continuing education efforts designed to maintain optimal adherence to recommendations for appropriate care.

Objective. The objective of this study was to assess opioid use during 7 years (2000–2006) among Clalit Health Services (CHS) members. Design. Purchasing data of opioids authorized for use in Israel were obtained from the computerized databases of CHS. Patient demographics and cancer morbidity were also extracted. The data were analyzed by converting the purchased opioids to oral morphine equivalents (OMEs). Setting. CHS is the largest health maintenance organization in Israel (3,774,600) and insures almost 54% of the Israeli population. Patients. All CHS members who purchased an opioid at least once during the 7-year study period (2000–2006). Intervention. There were no interventions in this study. Outcome Measures. The ourcome measures of this study were total OME purchased per year, OME (mg) per capita/per year, and OME (mg) daily dose. Results. There were 119,562 patients who purchased an opioid at least once (3.2% of CHS population). Of them, 57.4% were women, 69.0% aged 65 years and above (average age 56.05 years ± 26.7), 7.7% purchased opioids for more than 12 months, and 81.3% purchased opioids for only 1–4 months. A 96% increase in total OME purchased was found between 2000 and 2006 (from 56.4 kg to 110.6 kg). The annual OME purchased per capita increased from 15.7 mg in the year 2000 to 29.3 mg in 2006. The total number of patients who received at least one opioid prescription increased by 60%, while the growth in total number of CHS members was smaller (4.8%). Conclusions. There is a growing use of opioids at CHS during the 7-year period, a potential indicator of the progress made in improving accessibility and availability of opioids in our health care organization in Israel.

The Beer Sheva Psoriasis Severity Score is a novel instrument for the assessment of psoriasis severity, designed for use in routine clinical conditions.To identify the main factors of the BPSS.The sample used to study the BPSS comprised 70 patients with psoriasis vulgaris treated by climatotherapy at the Dead Sea. Psoriasis severity was assessed using BPSS and PASI (Psoriasis Area and Severity Index). Factor analysis was used to identify the main factors of BPSS. Internal consistency analysis was performed. Correlation matrices were generated to compare BPSS factors.Factor analysis demonstrated that BPSS included six factors that explained 74.0% of the variance as follows: patient assessment 26.0%; physician assessment 13.2%; palms and soles involvement 11.9%; genitals, nails, and pruritus 9.0%; face involvement 7.3%; and scalp involvement 6.6%. Total scale Cronbach's alpha was 0.76; alpha for the factors ranged between 0.39 and 0.81.The major factors of BPSS were identified. BPSS may be used as a comprehensive tool for measuring psoriasis severity.

Pre-conceptional folic acid supplementation is an effective way to reduce the incidence of neural tube defects (NTDs). Primary care providers are an important source of information to promote folic acid intake. This study aimed at evaluating primary care physicians' knowledge and attitudes regarding folic acid supplementation for childbearing women.A questionnaire on physicians' knowledge and attitudes, mostly including multiple-choice questions, was delivered by mail to all physicians (n=370) in a large health provider organization in southern Israel in 2006. Data regarding demographics as well as type of specialty, experience, and place of work were collected.Eighty-seven physicians were included in the study (response rate: 24%). Seventy physicians out of 81 (94%) reported routine recommendation of folic acid for their patients. Most physicians admitted that they needed more information regarding folic acid supplementation. Knowledge about folic acid's role in preventing congenital anomalies was suboptimal, with 2% of the physicians correctly estimating the efficacy of folic acid in decreasing the risk of NTDs and 8% recognizing the association between folic acid supplementation and decreased prevalence of malformations other than NTDs. Knowledge about the correct timing (12%) and dosage (47%) of folic acid preparations for average-risk women was also lacking.Primary care physicians report that they routinely prescribe folic acid to women in childbearing age in order to prevent congenital anomalies, but their knowledge about folic acid supplementation is insufficient.

Previous reports have shown a possible association between psoriasis and obesity, ischaemic heart disease, hypertension or diabetes mellitus. However, most of these studies were uncontrolled and were based on small sample sizes. We therefore investigated the association between psoriasis and the metabolic syndrome in a case control study. Case patients were defined as patients with a diagnosis of psoriasis vulgaris. Control patients were subjects who underwent hernioplasty or appendectomy. We used data mining techniques utilizing the database of the southern district of Clalit Health Services. The proportions of patients with diseases that belong to the metabolic syndrome were compared between case and control patients by univariate analyses. chi2 tests were used to compare categorical parameters between the groups. Logistic regression models were used to measure the association between psoriasis and the metabolic syndrome. A total of 340 patients with psoriasis and 6643 controls were included in the study. The mean age of case patients was 47.7 years (SD 10.7 years). There were 50.3% men and 49.7% women. Ischaemic heart disease was present in 23.5% of the patients with psoriasis, compared with 17.2% of the controls (p=0.003). Diabetes mellitus was present in 27.9% of the patients with psoriasis, compared with 19.5% of the controls (p

Full medical coverage may often result in overuse. Cost-sharing and the introduction of a co-payment have been shown to cause a reduction in the use of medical services.To assess the effects of the recently introduced co-payment for consultant specialist services on patient utilization of these services in southern Israel.Computerized utilization data on specialist services for 6 months before and 6 months after initiation of co-payment were retrieved from the database of Israel's largest health management organization.A decrease of 4.5% was found in the total number of visits to Soroka Medical Center outpatient clinics and 6.8% to community-based consultants. An increase of 20.1% was noted in the number of non-actualized visits to the outpatient clinics. A decrease of 6.2% in new visits to hospital outpatient clinics and 6.5% to community clinics was found. A logistic regression model showed that the residents of development towns and people aged 75+ and 12-34 were more likely not to keep a prescheduled appointment.After introduction of a modest co-payment, a decrease in the total number of visits to specialists with an increase in "no-shows" was observed. The logistic regression model suggests that people of lower socioeconomic status are more likely not to keep a prescheduled appointment.

Dermatitis artifacta is not an uncommon disease in military settings. Soldiers may intentionally produce skin lesions to achieve sick leave from military duties. The aim of this work was to describe a series of soldiers with dermatitis artifacta.A prospective study was conducted among soldiers of the Israel Defense Force.Fourteen soldiers from the Israel Defense Force were included in the study. There were 13 men and one woman. The ages of the patients ranged between 19 and 26 years. For all patients, dermatitis artifacta was characterized by the acute appearance of a pruritic rash located on readily accessible areas of the limbs and abdomen. The rash was associated with systemic symptoms for 12 (85.7%) of 14 patients. None of the patients admitted to intentionally inflicting the skin lesions. The rash consisted of erythematous patches with numerous papules and pustules arranged in a linear pattern. All patients were treated with topical corticosteroids, four patients were treated with antibiotics, and three patients were treated with systemic corticosteroids. For all patients, the eruption resolved completely within 1 to 3 weeks.In the context of soldiers standing to gain sick leave by assuming the sick role, dermatitis artifacta can be reliably diagnosed by noting the characteristic location and morphological features of the skin lesions.

The Bedouins in the Negev are a population in transition from traditional nomadic to a western sedentary lifestyle, characterized by changes in dietary habits and reduction in physical activity, with substantial changes in morbidity patterns. To describe the current state of diabetes prevalence and control among the Bedouin population in the Negev and to compare it to the non-Bedouin population.A cross-sectional study was performed utilizing the database of Clalit Health Services. In patients with a confirmed diagnosis of diabetes, the following variables were extracted from the laboratory records: hemoglobinA1c (HgA1C) level, urine microalbumin level and low density lipoprotein (LDL) level. Chi-square test was used to compare categorical parameters between the groups.Age-adjusted prevalence of diabetes was 5.1% in the Bedouin population as compared to 3.7% in the non-Bedouin population (p0.001). Diabetes was more prevalent in urban as compared to rural settlements (5.5% vs. 3.9%, respectively, p0.001). The proportion of Bedouins patients with controlled diabetes (HgA1C7) was significantly lower in Bedouin patients (29.3%) as compare to Non-Bedouin patients (46.7%) (p0.001).Age-adjusted prevalence of diabetes is increased in the Bedouin population as compared to the Non-Bedouin population in southern Israel. Despite similar performance status of laboratory tests and similar treatment regimens, the overall control of diabetes is poorer in the Bedouin population as compared to the Non-Bedouin population. These findings support previous observations that diabetes has become a major public health problem among Bedouins.

Papular urticaria often occurs after bites of insects such as mosquitoes, sandflies, bed bugs and fleas. Multiple bites and local pruritus are characteristic symptoms. Treatment is usually symptomatic and includes antihistamines and corticosteroids. The reappearance of the symptoms can be prevented by successful control of the parasite.To find the causative agent of papular urticaria in afflicted households with involvement of numerous family members, all in a narrow geographic area.We describe the cases of 20 patients belonging to seven families, who presented to the local primary clinic, suffering from papular urticaria.The cat flea, Ctenocephalides felis, was the hematophagous insect responsible for all infestations. The pruritus and the papular urticaria were treated symptomatically with calamine lotion, topical corticosteroids or oral antihistamines. All clinical symptoms disappeared within a few weeks after effective control of the parasites by spraying and fumigating the infested locations.Thorough investigation--including, at times, environmental inspection--is necessary to reach the rewarding discovery of the etiology of household papular urticaria. This condition may arise in other environments of similar character.

Climatotherapy at the Dead Sea (CDS) for patients with psoriasis induces a persistent remission in the majority of patients with psoriasis, is associated with minor side-effects and is pleasant for the patients (1–11). The published literature on CDS describes patients with moderate to severe psoriasis who spend an average period of one month (“long-term”) at the Dead Sea. There are no published data, however, on the effectiveness and characteristics of “short-term” CDS for patients with psoriasis, who spend only 2 weeks at the Dead Sea.The instruments used previously for assessment of response to CDS in psoriasis patients were not stan-dardized. In the last 10 years, the use of a 75% or 50% decrease in Psoriasis Area and Severity Index (PASI75 and PASI50, respectively; 12, 13) has become the gold standard in evaluating the efficiency of psoriasis treat-ment. In a literature review, we found no publications that used the PASI75 or PASI50 instruments to assess the response to CDS in patients with psoriasis. In a previous study we have shown the utility of the Beer Sheva Psoriasis Severity Score (BPSS) to assess pso-riasis severity and response to treatment (14). The objective of the current study was to assess the effectiveness of CDS in a series of patients with psoria-sis treated for a “short-term” period of 2 weeks, using BPSS and PASI, with particular emphasis on PASI75 and PASI50 end-points.METHODS

BackgroundNonattendance for scheduled appointments disturbs the effective management of pediatric pulmonary clinics. We hypothesized that the reasons for non-attendance and the necessary solutions might be different in pediatric pulmonary medicine than in other pediatric fields. We therefore investigated the factors associated with nonattendance this field in order to devise a corrective strategy.MethodsThe effect of age, gender, ethnic origin, waiting time for an appointment and the timing of appointments during the day on nonattendance proportion were assessed. Chi-square tests were used to analyze statistically significant differences of categorical variables. Logistic regression models were used for multivariate analysis.ResultsA total of 1190 pediatric pulmonology clinic visits in a 21 month period were included in the study. The overall proportion of nonattendance was 30.6%. Nonattendance was 23.8% when there was a short waiting time for an appointment (1–7 days) and 36.3% when there was a long waiting time (8 days and above) (p-value < 0.001). Nonattendance was 28.7% between 8 a.m. to 3 p.m. and 37.5% after 3 p.m. (p = 0.007). Jewish rural patients had 15.4% nonattendance, Jewish urban patients had 31.2% nonattendance and Bedouin patients had 32.9% nonattendance (p < 0.004). Age and gender were not significantly associated with nonattendance proportions. A multivariate logistic regression model demonstrated that the waiting time for an appointment, time of the day, and the patients' origin was significantly associated with nonattendance.ConclusionThe factors associated with nonattendance in pediatric pulmonary clinics include the length of waiting time for an appointment, the hour of the appointment within the day and the origin of the patient.