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Background We planned an observational study to assess obstetric anesthesia services nationwide. We aimed to assess the effect of the anesthesia workload/workforce ratio on quality and safety outcomes of obstetric anesthesia care. Methods Observers prospectively collected data from labor units over 72 h (Wednesday, Thursday and Friday). Independent variables were workload (WL) and workforce (WF). WL was assessed by the Obstetric Anesthesia Activity Index (OAAI), which is the estimated time in a 24-h period spent on epidurals and all cesarean deliveries. Workforce (WF) was assessed by the number of anesthesiologists dedicated to the labor ward per week. Dependent variables were the time until anesthesiologist arrival for epidural (quality measure) and the occurrence of general anesthesia for urgent Cesarean section, CS, (safety measure). This census included vaginal deliveries and unscheduled (but not elective) CS. Results Data on 575 deliveries are from 12 maternity units only, primarily because a major hospital chain chose not to participate; eight other hospitals lacked institutional review board approval. The epidural response rate was 94.4%; 321 of 340 parturients who requested epidural analgesia (EA) received it. Of the 19 women who requested EA but gave birth without it, 14 (77%) were due to late arrival of the anesthesiologist. Median waiting times for anesthesiologist arrival ranged from 5 to 28 min. The OAAI varied from 4.6 to 25.1 and WF ranged from 0 to 2 per shift. Request rates for EA in hospitals serving predominantly orthodox Jewish communities and in peripheral hospitals were similar to those of the entire sample. More than a fifth (13/62; 21%) of the unscheduled CS received general anesthesia, and of these almost a quarter (3/13; 23%) were attributed to delayed anesthesiologist arrival. Conclusions Inadequate WF allocations may impair quality and safety outcomes in obstetric anesthesia services. OAAI is a better predictor of WL than delivery numbers alone, especially concerning WF shortage. To assess the quality and safety of anesthetic services to labor units nationally, observational data on workforce, workload, and clinical outcomes should be collected prospectively in all labor units in Israel.

An amendment to this paper has been published and can be accessed via the original article.

Background Frequent attenders in primary care are a professional challenge for family physicians, and the medical costs of their care can be very high. Some of them suffer from somatization and are concerned solely with their physical complaints, although somatic complaints are the most common presentation of anxiety and depression. To assess and treat these patients comprehensively, a multidisciplinary clinic was created in the community. Methods This study describes the first 40 patients referred to the clinic. All patients completed a mental health screening questionnaire and a functional assessment of health. The utilization of medical resources was assessed by chart review for the year before and the year after the first encounter in the clinic. The intervention consisted of a comprehensive bio-psychosocial consultation where life history and medical symptoms were woven together into a new narrative. The intervention also included pharmacological treatment and short-term psychological interventions. Results The majority of referred patients were women and their average age was 52 years. Headache was the leading symptom, followed by fatigue. The mean number of reported symptoms for each individual patient was 10. Mental health problems were mainly somatization, depression and anxiety. The average yearly costs per person of US$4035 were reduced to US$1161 the year following referral. Conclusions The integrated approach of the clinic satisfied at least three needs: of the patient, of the referring physician and of the health maintenance organization. The results of this uncontrolled pilot study suggest that this intervention helped to modify illness behaviour, decreasing the costs of medical investigations.

An innovative program introduces fifth-year medical students to geriatrics and critically focuses their attention on the associated, vitally important, public health network. The one day course is included in the obligatory clerkship for Epidemiology and Preventive Medicine. The medical student subsequently approaches the option of a clerkship in the sixth year with a more positive understnading of the subject of geriatrics as a whole. This one-day program provides a good introduction to geriatric education, judging by the interest expressed by the students in each of the four years that the program has been running.

Surgical stress and general anesthesia suppress immune functions, including natural killer cell cytotoxicity (NKCC). This suppression could be attributable, at least in part, to opiates. We have previously shown that large-dose fentanyl administration suppressed NKCC in rats. The present study sought to compare the effects of two anesthetic protocols, based on large- (LDFA) versus small (SDFA)-dose fentanyl anesthesia on NKCC in the perioperative period. Forty patients were included in this study; half were assigned to each protocol of anesthesia. In each anesthetic group, half the patients were undergoing surgery for malignant diseases, and half for benign conditions. Blood samples were collected during the perioperative period. NKCC was assessed using the chromium release assay. Initially, both types of anesthesia similarly suppressed NKCC, with a peak effect 24 h after surgery. The two types of anesthesia, however, differed in the rate of recovery of NKCC suppression. By the second postoperative day, NKCC returned to control values in the SDFA patients, whereas NKCC was still significantly suppressed after LDFA. These results indicate that LDFA causes prolonged suppression of NK cell function. Whether this suppression might have a long-term impact on the overall outcome, especially in cancer patients, remains to be determined.

PROBLEM: The increased reactivity of maternal lymphocytes in reciprocal mixed-maternal-paternal lymphocyte cultures (MMPLC), observed in the presence of control serum after immunotherapy, suggests that immunization with paternal lymphocytes may induce a highly significant cell mediated immune response in specifically alloactivated maternal lymphocytes. METHOD: Reciprocal one-way MMPLC were set up with responding maternal or paternal lymphocytes and mitomycin C-treated stimulating lymphocytes. Cultures were set up for 6 days in the presence of 15% maternal or control serum. The degree of lymphocyte stimulation was measured by tritiated thymidine uptake. RESULTS: In maternal serum, after immunotherapy, a highly significant blocking effect on MMPLC was observed in both directions. The extent of the blocking effect in maternal serum and the stimulation in control serum was much higher, after immunotherapy, in two cases of abortions, as compared to cases with normal pregnancy outcome. CONCLUSIONS: Although the number of cases is very small, it may be that in abortions, in the presence of maternal serum, disturbances in the balance of cytokines or/and specific antibodies could have cytotoxic effects on MMPLC and down regulate, or “block” the specific response. For a possibly better utilization of the MMPLC test in the prediction of pregnancy outcome after immunotherapy, it may be important to examine specific antibodies in maternal serum, to investigate specifically induced cytokines in MMPLC and to evaluate T cell subsets in MMPLC in the presence of maternal and control serum.

The effect of colostrum of mothers of preterm and full-term newborns on the phagocytic activity for latex particles by normal peripheral blood polymorphonuclear cells was examined. The results showed that human colostrum contains a phagocytosis-promoting factor(s), which not only increases the number of phagocytic cells, but also stimulates the phagocytic activity of the individual cell. This factor(s) was more active in preterm colostrum. Thus, while term colostrum increased the number of phagocytic cells by 95% in comparison with the control, preterm colostrum enhanced the number of phagocytic cells by 300%. Similarly, term colostrum increased the phagocytic capacity of the individual cell by 51%, whereas preterm colostrum by 137%. The difference between the results in all experimental points was statistically highly significant.

The 'SCUD' raids on Israel during the Gulf War afforded a rare opportunity to examine the effect of mass acute fear on the cardiac health of the general population. Press reports suggested an alarming rise in cardiac deaths during the first missile raids. In order to ascertain this statement, we examined the Emergency Room records of a community hospital in the affected area and all the death certificates in the local region. The periods studied were from 1 January to 28 February 1991, and the equivalent weeks in 1990. The Emergency Room records showed that there was an increased rate of cardiac complaints throughout the war, most marked during the first week. However, this was not accompanied by an increased cardiac mortality, either in the hospital or in the region as a whole, except during the first week. A similar increase in cardiac mortality occurred during the same week the previous year. The increased incidence of acute cardiac events during the first week of the war was probably a coincidence, and not a direct consequence of mass fear. Panic, occasioned by press reports, may have led to a lower threshold of referral which persisted throughout the war.

A postal questionnaire was sent to a random sample of Israeli gynaecologists and family physicians to study their attitudes to primary care gynaecology. The gynaecologists (n = 50) tended to think that family physicians should not be involved at all, except for adolescent sex education. The family physicians (n = 60) thought that they should be managing menstrual disorders, vaginal discharges, family planning counselling, prescription of oral contraceptives, insertion of intrauterine devices, routine antenatal and postnatal care, sexually transmitted diseases, breast examinations, and menopausal counselling. Both professions agreed that high risk pregnancies, hospital deliveries, infertility, and PAP smears were in the gynaecologists' domain. The younger family physicians and those in rural practice held these views more strongly than their older colleagues in urban practice. The results are discussed in the light of the patients' and the doctors' diverse interests.

Background: Women with deleterious mutations in BRCA genes are at increased risk of breast cancer. However, the penetrance of the genetic trait may be regulated through environmental factors. This multinational case-only study tested the interaction between oral contraceptive use and genetic susceptibility in the occurrence of breast cancer. Methods: We recruited 3,123 patients diagnosed with breast cancer before the age of 45 years. Participants were classified according to their probability of carrying a BRCA mutation on the basis of their family history of breast and ovarian cancer. According to a case-only approach, the frequency of relevant exposures among breast cancer cases with high probability of BRCA mutation (“genetic cases”) was compared with the frequency of the same exposures among breast cancer cases with a low probability of BRCA mutation (“sporadic cases”). The interaction odds ratios (OR) and 95% confidence intervals (CI) for oral contraceptive use were estimated by unconditional logistic regression, after controlling for potentially confounding variables. Results: The analysis was carried out comparing 382 “genetic” and 1,333 “sporadic” cases. We found a borderline significant interaction between genetic breast cancer and oral contraceptive use for ever users compared with never users (OR, 1.3; 95% CI, 1.0-1.7). The greatest interaction OR was found for women who started using pill at 18 to 20 years (OR, 1.6; 95% CI, 1.1-2.3). Conclusion: These results suggest that BRCA mutation carriers, as well as women with a significant family history of breast and ovarian cancer are more vulnerable to exogenous hormones in oral contraceptives. (Cancer Epidemiol Biomarkers Prev 2009;18(7):2107–13)

Eighteen community-dwelling first-stroke survivors, aged 45 to 65, underwent following examinations: Romberg's Test, standing on the unaffected leg, Emory Fractional Ambulation Profile, the Berg Balance Test, the Timed 'Up and Go' Test and the Duke Health Profile. They were then randomly divided into two matched groups of 9 subjects each. The study group (SG) received Tai Chi exercises and the control group (CG) physiotherapy exercises focused on improvement of balance, both groups for 1 h twice weekly for 12 weeks. On completion of exercises, SG subjects showed improvement in social and general functioning whereas CG subjects showed improvement in balance and speed of walking. It is concluded that there are potential and no adverse effects in Tai Chi practice in stroke survivors.

We studied three groups of Israeli Jewish schoolchildren in and surrounding Petach Tikva, Israel, cross-sectionally, at ages 9-10, 13-14, and 16-18 years, and compared lipid and lipoprotein levels and age-associated lipoprotein patterns in the same age groups of boys and girls in neighboring Israeli Moslem Arab schools during 1986-1987. Moslem children displayed striking differences in the levels of lipids and age-associated patterns of lipoproteins compared with Jewish schoolchildren. The mean total cholesterol levels were lower in the Moslem children, in both sexes, in every age grouping. High density lipoprotein cholesterol (HDL-C) levels were significantly higher at age 16-18 in the Moslem boys than in the Jewish boys. While the Jewish boys displayed a previously reported "typical" pattern of lower HDL-C levels postpuberty compared with prepuberty, the Moslem boys had markedly higher mean HDL-C levels at age 16-18 compared with those at age 9-10. The Moslem girls also had higher HDL-C levels at age 16-18 than those observed in the age 9-10 group. Concomitantly higher HDL-C levels (HDL-C/total cholesterol (%)) were seen in the Moslem boys and girls, at age 16-18 compared with age 9-10, but were not observed in the Jewish children. The identification of an ethnic group in whom HDL-C appears to increase at or near puberty could provide opportunities to elucidate factors that may increase HDL-C in individuals or in populations.

Sir.—Acute hepatitis due to infection with the hepatitis A (HA) virus is common in children. Most of these children are asymptomatic. The disease is usually mild to moderate and is characterized by jaundice, anorexia, vomiting, and abdominal pain. Ascites accompanying infection with the HA virus was reported previously only twice in children.1,2In 6 years, we encountered five children with acute HA associated with ascites. Patients and Methods.—Five children with HA and ascites were observed in the outpatient clinic of Hasharon Hospital, Petach Tiqwa, Israel, between 1984 and 1989. Results of the diagnostic workup and clinical evaluation are presented in the Table and in the illustrative patient report. To evaluate the occurrence of ascites in acute hepatitis, 30 children with HA underwent abdominal ultrasound studies. These 30 children were randomly recruited from the community for this study, and their clinical symptoms were mild to moderate. None required

• During a mumps outbreak between 1987 and 1988, six children presented with symptoms of acute cerebellar involvement as the sole neurologic complication. The neurologic symptoms followed parotitis and lasted for up to 3 weeks. Serologic evidence was suggestive of recent mumps infection. Symptoms spontaneously resolved in all patients without any residual signs or symptoms during 2- to 2.5-year follow-up. ( AJDC . 1992;146:930-931)

In National Health Care Systems excessive reappointments at consultative clinics can result in over utilization of those services and/or too much retention of patients which frustrates family physicians in their interest for continuity of care for chronic patients. In order better to understand many consultants' complaints about overwork, we examined the proportion of patients who were given follow-up appointments by type of specialty in 2840 consecutive services requested in a multispecialist centre of a prepaid system in Israel, analysing as well the suspected disparity between this proportion and the consultants' perceptions on this subject. The results of this study show that 44.7% of patients at consultant clinics were given follow-up appointments, and that there was a marked disparity between the real and the subjectively estimated rates of follow-up in surgical specialties (rate-ratio 2.4). This suggests that a problem exists in the knowledge that consultants have of the structure of their own practices.

We describe a neonate who presented with multiple severe malformations including polyorchidism. To our knowledge this is the second case reported with ipsilateral testes located intra-abdominally. Chromosomal studies in cases of polyorchidism have been reported previously only once and the patient exhibited a normal karyotype. Our patient had a chromosome 21 long arm deletion. Interestingly, a trisomy 21 patient has been reported with agonadism. We suggest that genes on chromosome 21 may have some role in gonadal development.

The capacity of peripheral blood mononuclear cells (PBMC) isolated from patients with Alzheimer's disease to produce interleukin-1 and -2 (IL-1, IL-2) was compared to that of cells from age-matched controls and young healthy subjects. There was no difference in the production of both interleukins between patients and their age-matched controls. On the other hand, the production of IL-1 by the PBMC of healthy young volunteers was significantly higher than that of the cells from patients and subjects of the other two groups. Although the results indicated a higher production of IL-2 by PBMC from younger individuals, the difference in comparison with the other two groups was not statistically significant.

Reciprocal one-way mixed mother-newborn lymphocyte cultures (MMNLC) containing alternatively maternal or newborn responding (R) or stimulating (S) cells were investigated in both directions in primiparae at three different times: a few hours after delivery, and at 4 and at 16 weeks. Cultures were grown in the presence of maternal and pooled control serum prepared from the blood of five to eight unrelated healthy donors. Four weeks after delivery in maternal and in control serum a significant increase in MMNLC reactivity could be observed, which disappeared at 16 weeks when a pronounced decline in MMNLC values in both directions was found. The suppressive effect of maternal serum was more pronounced at delivery, still evident 4 weeks later, and insignificant after 16 weeks. The results of this study suggest that 4 weeks after delivery, maternal sensitization to fetal histocompatibility antigens can be detected in primiparae with MMNLC; and that 16 weeks later, this was no longer detectable with the same test.

Population monitoring of birth defects provides a means for detecting relative changes in their frequency. Many varied systems have been developed throughout the world since the thalidomide tragedy of the early 1960s. Although it is difficult to pinpoint specific teratogenic agents based on rises in rates of a particular defect or a constellation of defects, monitoring systems can provide clues for hypothesis testing in epidemiological investigations. International coordination of efforts in this area resulted in the founding of the International Clearinghouse for Birth Defects Monitoring Systems (ICBDMS) in 1974. In this paper we will describe the functions and basic requirements of monitoring systems in general, and look at the development and activities of the ICBDMS. A review of known and suspected environmental teratogenic agents (eg, chemical, habitual, biological, physical, and nutritional) is also presented.

Patient dissatisfaction with the care they receive in general practice is sometimes expressed as a formal complaint. We report our experience with an hierarchical complaints procedure. The annual rate of complaints received by the area medical director of a local health centre serving 11 500 patients was 100 per 10 000 registered patients. The medical officer for the region (regional population 160 000) received 4 complaints per 10 000 patients. The regional Public Complaints Committee received 0.1 complaint per 10 000 patients per year and the Israeli National Health Service Ombudsman received 0.2 complaints per 10 000 patients per year from the same region. Almost all dissatisfaction relating to style of practice was dealt with at the local level, while complaints relating to matters of substance or ethics quickly reached the higher authorities. The complaints procedure was thus shown to distinguish between temporary breakdowns of the doctor-patient relationship and inadequacies of the system of care and to handle the relevant complaints appropriately.

Concomitance of different primary malignant neoplasms in the same individual has been observed and explained by several possible mechanisms. For urogenital malignancies in concomitance with lymphoid or with intestinal malignancies some data indicate that common etiologic factor(s) with pleiotropic effects may be involved. Concomitance of these particular different primary malignant neoplasms must therefore be kept in mind in the evaluation of patients' conditions.

A study of all newly diagnosed patients with gallbladder and biliary tract cancer in Israel during a five-year period indicates that cholelithiasis plays a major part in the aetiology of gallbladder cancer. This conclusion is based on the following findings: ( a ) high frequency of gallstones in gallbladder cancer cases compared with biliary tract cancer and the general population; ( b ) similar frequency of gallstones in gallbladder cancer in both sexes and in all ethnic groups; ( c ) similar sex and ethnic population trends in the incidence of cholelithiasis and of gallbladder cancer.

Serum prolactin levels and sexual function were evaluated in 28 men from 60 to 64 years of age and in 44 men from 65 to 70 years of age. All subjects were married, physically healthy, and had no psychopathology or marital problem. About a third of the men aged 60 to 70 years suffered from impotence. No obvious correlation between elevated levels of serum prolactin and impotence was obtained. Subjects aged 65 to 70 who had decreased libido exhibited a significant elevation of serum prolactin levels, while subjects of the same age group who had reserved (normal) libido appeared to have low serum prolactin levels. Nine of ten men aged 60 to 70 years with serum prolactin levels above 40 ng/ml reported decreased libido. Potent men of both age groups (60-70 years) with high prolactin levels showed a tendency to have a decrease in frequency of sexual intercourse. Thus, it seems that mild hyperprolactinemia in aging men may be associated with decreased sexual desire and frequency of sexual activity.

To determine age and ethnic patterns of blood lipid levels in childhood and adolescence and to extend previous adult and late adolescent Israeli data to prepubertal ages, the levels of plasma total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) were determined among 1,153 schoolchildren in the area of Petah-Tikva. Half of the children were born to immigrants from Yemen. Among boys, TC levels progressively decreased as age increased from 10–11 to 14–15 years (159 to 142 mg/dl). The age-specific TC and HDL-C means among boys are compatible with an initial swift fall with age, followed by a rise restricted to TC during puberty. Among girls, progressively lower means through ages 12–13 and increasingly higher ones for older age groups are also compatible with puberty-determined changes, previously observed in American cohorts. The differences in TC were only partly accounted for by lower HDL-C means at higher ages (52 mg/dl in the youngest and 45 mg/dl in the oldest age group, respectively, among boys, compared with 53 mg/dl for girls at both ages 9 and 16–17). TG levels in boys, but not in girls, showed age differences paralleling those found for HDL-C, but in an inverse direction. TC means were lower as age increased only among female offspring of European-born Jews (159 to 148 mg/dl, ages 9–12 compared with ages 13–17), a phenomenon that requires further study. Overall, TC and HDL-C were clearly higher among girls than boys beginning at ages 12–13, with little or no sex differences in TG. The sex differences in TC, contrary to previous studies, were not fully accounted for by HDL-C sex differences. The ethnic variability paralleled previous findings in Israeli adults and adolescents, showing low TC levels among male offspring of Yemenite and other Asian-born fathers. The ethnic differences among girls were small. No specific pattern of age-related lipid changes was found in the group of Yemenite origin, who represented offspring of parents with notoriously low levels of coronary heart disease incidence.

The data for 445 patients admitted to all the general hospitals in Israel during a 4-year period in whom a definite diagnosis of biliary system cancer was made were studied. The findings confirm those of previous reports and indicate that the pattern of the disease in the community is similar to that in selected hospital material.

One hundred and seventy-three Jewish women of child-bearing age attending their family doctor were asked about their contraceptive practices and attitudes. Medical means of contraception were used by 42% of the women and coitus interruptus by 44%. Although coitus interruptus is prohibited by Jewish ritual law, its use in fact applies to all age groups of women, irrespective of religiousness or family size. The small group of contraceptive pill users (17%) were younger, had smaller families and expressed a greater readiness to consider abortion in case of accidental pregnancy than the rest of the sample. They were less observant of the religious laws and might be described as 'modern' compared with the larger group of 'traditional' women. The latter preferred the intrauterine device and had larger families, but would not consider abortion, which is forbidden by Jewish law in most cases. The evidence demonstrated that the mainly traditional patients do not conform to the pattern of behaviour prescribed by their religion as closely as expected. As a result of this survey the authors are actively advocating the intrauterine device as a more effective, acceptable alternative to coitus interruptus.

Survival analysis based on a nationwide study of patients in Israel with gallbladder cancer revealed a relatively better survival in two subgroups: (1) patients with a localized tumor at operation and (2) patients with papillary adenocarcinoma. Further breakdown demonstrated that these two factors are interrelated, ie, patients with papillary adenocarcinoma have a relatively higher frequency of localized tumors. Consequently, the group of localized papillary adenocarcinoma of the gallbladder had a median survival extending beyond five years after diagnosis as compared with one month for the total group.