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Objective:The aim of this national population-based study was to identify perinatal and neonatal factors associated with active intensive treatment (AIT) of infants born at the periviable period of 22 to 24 weeks of gestation.Study design:Data from the Israel national very low-birth weight infant database on 2207 infants born alive in 1995 to 2010 at gestational age (GA) 22 to 24 weeks were evaluated. AIT was defined as endotracheal intubation in the delivery room or mechanical ventilation in the neonatal intensive care unit. Multivariable logistic regression analyses were used to identify the independent effect of demographic and perinatal factors on AIT for each gestational week.Result:Of the 2207 infants born at 22 to 24 weeks GA, 1643 (74.4%) received AIT and 564 (25.6%) received comfort care. AIT increased from 25.5% at 22 weeks to 62.7 and 93.5% at 23 and 24 weeks GA, respectively, reflecting a 4.66 (95% confidence interval (CI) 3.32 to 6.54)- and 29.8 (95% CI 19.9 to 44.6)-fold odds for AIT at 23 and 24 weeks GA, respectively, compared with 22-week GA infants. Perinatal treatments associated with AIT included maternal tocolytic therapy (odds ratio (OR) 1.51, 95% CI 1.04 to 2.20), prenatal steroid therapy, both partial (OR 3.30, 95% CI 2.14 to 5.10) and complete (OR 3.17, 95% CI 1.91 to 5.26) and cesarean delivery (OR 2.68, 95% CI 1.88 to 3.83). Each unit increase in birth weight z-score was associated with an OR of 1.58 (95% CI 1.30 to 1.92) for AIT. At 22 weeks GA, maternal tocolytic treatment was associated with higher odds of AIT. In the 23 and 24-week GA infants, maternal infertility treatment, antenatal steroids, cesarean delivery and higher-birth weight z-scores were significantly associated with AIT. Among 23-week GA infants, AIT decreased significantly in the period 2006 to 2010 compared with 1995 to 2000 (OR 0.51, 95% CI 0.34 to 0.77).Conclusion:An active approach in obstetric management of pregnancies appears to impact the neonatologists' decision to undertake AIT treatment in infants born at the border of viability. The higher odds for AIT associated with obstetric interventions might contribute to the reported beneficial effect of antenatal steroids and cesarean delivery on the survival of infants born at the border of viability. [ABSTRACT FROM AUTHOR]

Objectives (1) To determine the prevalence of overweight and at risk for overweight in a sample of 4- to 6-year-old Israeli children; and (2) to delineate factors which may be associated with excess of overweight such as food intake, food habits physical and sedentary activity, family and socio-economic factors. Methods In a cross-sectional survey in six kindergartens in the centre of Israel, 204 children (104 boys), mean age 5.5 years were studied. Results In total, 40% of the children were either at risk for overweight (25%) or overweight (15%). Parents of one-third of all children reported their children ate unbalanced meals; however, caloric intake was not different between the weight groups. Overweight children were reported to eat according to mood status and preferred eating candies. Knowledge of dietary requirements was fairly good and similar in all three weight groups. Screen viewing time was more than twofold greater than the recommended in all weight groups. The rate of parental obesity was not different in the weight groups. Conclusions A high rate of overweight was documented among pre-schoolers in the centre of Israel. Poor lifestyle habits were noted in about one-third of all children; however, no association was found between the poor lifestyle habits and overweight but more overweight children eat according to mood status and preferred eating candies as a snack. [ABSTRACT FROM AUTHOR]

Objective: To present a new systematic approach for summarizing multiple injury diagnosis data into patient injury profiles. Design: International Classification of Diseases, ninth revision, clinical modification injury diagnosis codes were classified using a modification of the Barell body region by nature of injury diagnosis matrix, then grouped by body region, injury nature, or a combination of both. Profiles were built which describe patients' injury combinations based on matrix units, enabling the analysis of patients, and not only the study of injuries. Setting: The Israeli national trauma registry was used to retrieve patient demographic data, injury details, and information on treatment and outcome. Patients or subjects: All hospitalized patients injured in road traffic accidents and included in the trauma registry from January 1997 to December 2000 were included. Main outcome measures: Patient profiles consisting of body regions, injury natures, their combination, and their clinical outcomes. Results: The study population comprised 17 459 patients. Head and neck injuries were the most frequent in all subpopulations except for motorcyclists who sustained most injuries in the extremities. Fractures were the most common injury nature (60%). Pedestrians and drivers had the highest proportion of multiple injuries in both profiles. Forty eight percent of the patients had a single cell profile. The most frequent conditions as a sole condition were extremity fractures (14%), internal injuries to the head (11%), and injuries of other nature to the torso (6%). Mortality, length of stay, and intensive care unit treatment varied dramatically between profiles and increased for multiple injury profiles. Inpatient death was an outcome for 3.3% overall; however, in patients with an internal injury to the head and torso, inpatient death rate was nine times higher, at 31%. Conclusions: Profiles maintain information on body region and nature of injury. The use of injury... [ABSTRACT FROM AUTHOR]

Background: In Israel, some population characteristics and lifestyle patterns make epidemiological research on suicide of particular interest. The Israeli population is characterized by ethnic diversity, with a multi-religious, multi-national mosaic of Jews and Arabs. These subgroups also vary in their suicidal behavior. The aims of the present study were to examine the trends in suicide incidence rates in Israel from 1984 to 1994, to identify sub-populations at high risk for suicide and to identify suicide methods associated with increased risk.Methods: Suicide rate trends in Israel over the period from 1984 to 1994 were examined for four subgroups: Jewish men and women, and Arab men and women. Cases of undetermined external cause (UEC) of death were also considered. Mortality data were obtained from the computerized data files of the Israeli Central Bureau of Statistics, which includes cause of death and sociodemographic variables. Suicide was classified according to the ICD-9 codes.Results: Suicide rates were higher for Jews than for Arabs, and higher for men than for women. The rates among both population and sex groups increased directly with age. A significant increase over the years studied was found for Jewish men, particularly in the 18- to 21-year-old age group. An increase in the use of firearms was noted, mainly in the groups in which total suicide rates increased.Conclusions: The findings of this study highlight the need for further studies to identify both sub-populations at high risk for suicide, and societal trends such as lifestyles, immigration, military service, and media exposure to violence, as first steps toward planning of intervention programs to reduce suicide rates. [ABSTRACT FROM AUTHOR]

The purpose of the present study was to determine whether patients with acute myocardial infarction (AMI) in Killip class II or III are likely to benefit from catheterization and coronary revascularization performed within 30 days of AMI. The study population was drawn from 2 national surveys performed during 1996 and 1998 in 26 coronary care units operating in Israel. Our analysis included 3,113 patients with AMI who were divided into 2 groups according to their admission Killip class: 2,484 patients (80%) in Killip class I, of whom 1,408 (57%) underwent cardiac catheterization and 1,076 were treated noninvasively; and 629 patients in Killip class II or III, of whom 314 (50%) underwent cardiac catheterization and 315 were managed conservatively. Patients in Killip class II or III who were treated invasively had lower mortality rates than their counterparts who were treated noninvasively at 30 days: 7.6% versus 15.6%, respectively (adjusted odds ratio [OR] 0.52, 95% confidence interval [CI] 0.28 to 0.92), and thereafter from 30 days to 6 months, 4.3% versus 13.6%, respectively (OR 0.34, 95% CI 0.16 to 0.68). In Killip class I patients, an invasive versus noninvasive management was not associated with a better outcome at 30 days: 1.6% versus 3.2%, respectively (OR 0.58, 95% CI 0.32 to 1.05), but with similar mortality rates at 30 days to 6 months, 1.9% versus 2.0%, respectively (OR 1.46, 95% CI 0.79 to 2.74). Thus, the present study suggests that patients with AMI in Killip class II or III on admission may benefit from cardiac catheterization and revascularization performed within 30 days from admission, whereas patients with AMI in Killip class I are less likely to benefit from this approach. [ABSTRACT FROM AUTHOR]

Cancer incidence was assessed among a cohort of 10,923 male coronary patients in Israel screened for participation in a secondary prevention trial and compared with national cancer incidence rates. Higher total and age-specific incidence rates of cancer were observed among male coronary patients than among the Israeli male population, but this excess was limited to cancers of the lung, bladder, and colon. [ABSTRACT FROM AUTHOR]

Patients with chronic CAD and a history of cerebrovascular events were compared with patients without prior cerebrovascular events to assess the effect of these events on 5-year prognosis. Despite adjustment for older age and higher comorbidity among patients who had experienced a cerebrovascular event, a history of such an event was associated with an increased risk of 1.86 for total mortality. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to describe Israeli maternity departments' policies regarding cesarean delivery on maternal request, and factors associated with obstetricians' support for cesarean delivery on maternal request in specific scenarios., Methods: This multicenter cross-sectional study included 22 maternity department directors and 222 obstetricians from the majority of Israeli hospitals. Directors were interviewed and completed a questionnaire about their department's cesarean delivery on maternal request policy, and obstetricians responded to a survey presenting case scenarios in which women requested cesarean delivery on maternal request. The scenarios represented profiles referring to the following factors: maternal age, poor obstetric history, pregnancy complications, and psychological problems. The survey also included the obstetricians' socio-demographic information and questions about other issues associated with cesarean delivery on maternal request. The main outcome measures were department policies regarding cesarean delivery on maternal request and obstetricians' support for cesarean delivery on maternal request in specific cases., Results: Policies were divided between allowing and prohibiting cesarean delivery on maternal request (n = 10 and 12, respectively), and varied regarding issues such as informed consent and pre-surgery consultation. Most of the obstetricians (96.5%) did not support cesarean delivery on maternal request in the "reference scenario" describing a young woman with no obstetric complications. Additional factors increased the rate of support. Support was greater among obstetricians aged > 45 (odds ratio = 2.11; 95% confidence intervals 1.33-3.36) and lower among females (odds ratio = 0.58; 95% confidence intervals 0.39-0.86). Obstetricians whose department policy was less likely to allow cesarean delivery on maternal request reported lower rates of support for cesarean delivery on maternal request in most cases., Conclusion: Policies and obstetricians' support for cesarean delivery on maternal request vary broadly depending on clinical profiles and physician characteristics. Department policy has an impact on obstetricians' support for cesarean delivery on maternal request. Health policy will benefit from a framework in which the organizations, physicians, and patients are consulted.

Objective: Very low birth weight (VLBW, ≤1500 g) infants' mortality rates have decreased markedly. We aimed to quantify the relative contribution of changes in the distribution of population characteristics and changes in specific mortality rates on the decline in mortality rates of VLBW infants., Study Design: A population-based observational study of the Israel national VLBW infant database. The study population comprised singleton VLBW infants of 24-32 weeks' gestation born during the epochs 1995-2000 (n = 3728) and 2006-2010 (n = 3246). The Kitagawa methodology was applied to determine the contribution of changes in demographic and perinatal characteristics and changes in specific mortality rates on the decline in mortality between the periods., Results: During the study epochs, VLBW infant mortality rates decreased from 19.7 to 13.8%. Of the 5.9% decrease in mortality, 60.6% was attributed to the decrease in specific mortality rates and 39.4% to changes in the proportions of population characteristics and therapies, predominantly early initiation of prenatal care (8.1%), antenatal steroids (25.1%), and cesarean delivery (8.1%). For most of the demographic and perinatal categories considered the relative contribution of changes in their proportions was <3%, whereas >97% could be attributed to changes in the specific mortality rates for these characteristics., Conclusions: The decrease in preterm VLBW infant mortality was attributable predominantly to changes in variable specific mortality rates whereas changes in the proportions of demographic, perinatal risk factors, and therapies had a limited impact on VLBW infant mortality. Future assessment of determinants of VLBW infant mortality data should be dissected by discriminatory models.

Objective: To compare the effect of pre-pregnancy body mass index (BMI) and inappropriate gestational weight gain (GWG) on adverse obstetrical outcomes among women undergoing assisted reproductive technology (ART) treatments as compared to spontaneously-conceived (SC) pregnancies., Methods: This prospective cohort study included 1058 pregnant women from two medical centres; 504 women who conceived following ART treatments and 554 who conceived spontaneously. The women were recruited at 8 weeks of gestation and follow-up telephone interviews were conducted 6 weeks after delivery. Obstetrical outcomes included pregnancy hypertension, gestational diabetes (GD), low birth weight (LBW) (<2500g) and small for gestational age (SGA). Multivariate analyses were used to assess the effect of pre-pregnancy BMI and inappropriate GWG on these obstetrical outcomes adjusted for risk factors., Results: The effect of pre-pregnancy BMI and inappropriate GWG on adverse obstetrical outcomes did not differ between ART and SC pregnancies. Pre-pregnancy obesity was found to be associated with increased risk for pregnancy hypertension (OR=2.16; 95%CI 1.16-4.03), GD (OR=2.89; 95%CI 1.61-5.17), caesarian section (OR=1.77; 95%CI 1.10-2.85) and SGA (OR=1.91; 95%CI 1.05-3.46). GWG below recommendations was associated with increased risk for GD (OR=1.73; 95%CI 1.06-2.82) and SGA (OR=1.69; 95%CI 1.17-2.40) while GWG above recommendations was associated with increased risk for pregnancy hypertension (OR=1.77; 95%CI 1.02-3.06)., Conclusions: Pre-pregnancy obesity and inappropriate GWG were associated with adverse obstetrical outcomes in both ART and SC pregnancies. Emphasis should be given on the importance of an optimal pre-pregnancy BMI and appropriate GWG during pregnancy., (Copyright © 2018 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.)

Background: Preterm infants are at high risk for long-term morbidities and an increased rate of re-hospitalization., Objective: The aim of this study was to evaluate the type of re-hospitalization of very low birth weight (VLBW) infants, from infancy through adolescence, and to assess the association of neonatal morbidities with specific types of re-hospitalization., Study Design: The study cohort comprised 6,385 VLBW infants who were registered with the Maccabi Healthcare Services (MHS) from their birth hospitalization. Data were collected for up to 18 years (median 10.7 years) following neonatal intensive care unit discharge. Hospitalization types were determined from the MHS coding. Neonatal morbidities included necrotizing enterocolitis (NEC), grades 3-4 intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were calculated using the Cox proportional hazards model., Results: Overall, 3,956 infants were re-hospitalized at least once and a total of 11,595 hospitalization types were identified. NEC, IVH, PVL, and BPD were associated with significantly higher aHRs for general pediatric (aHR 1.28-1.55), general surgical (aHR 1.18-1.46), and pediatric intensive care unit (aHR 1.57-2.04) hospitalizations. IVH and PVL were associated with significantly higher aHRs for orthopedic (aHR 2.12 and 4.88, respectively) and ophthalmology (1.76 and 4.02, respectively) hospitalizations. IVH was associated with a 14.2-fold higher aHR for neurosurgical admissions, and ROP with a 1.62-fold higher aHR for ophthalmology hospitalizations., Conclusion: Among VLBW infants, specific patterns of re-hospitalization types associated with major neonatal morbidities were identified as particularly high risks for orthopedic and ophthalmology hospitalizations in infants with IVH and PVL, and for intensive care admissions in infants with NEC and BPD., (© 2019 S. Karger AG, Basel.)

Wide disparities in knowledge of risk factors and prevention of osteoporosis were demonstrated among midlife Israeli minority women (Arabs and immigrants from the former USSR) compared to Jewish long-time residents. Women who believed osteoporosis to be a serious disease and those who felt susceptible to it reported better knowledge., Purpose: The main goals of this study were to assess knowledge of risk factors and preventive measures for osteoporosis in middle-aged women and to evaluate the relationship of knowledge to personal risk factors and personal perceptions about osteoporosis., Methods: Face-to-face interviews with women aged 45-64 years were conducted during 2004-2006 within three population groups: long-term Jewish residents (LTJRs), immigrants from the former Soviet Union, and Arab women. The survey instrument included five knowledge statements related to the risk after menopause, the risk of smoking, family history of fractures, decreased risk by physical activity, and by use of medications., Results: The findings indicated wide disparities in knowledge about risk factors and preventive behavior of osteoporosis between the two minority groups (immigrants from the former Soviet Union and Arab women) and the majority group of midlife Israeli women. Knowledge of osteoporosis was related to perceived severity of the disease and partly to perceived susceptibility to osteoporosis. Past diagnosis of osteoporosis, current or past smoking status, and BMI were unrelated to knowledge in multivariate analyses., Conclusions: There is a need to improve knowledge of osteoporosis especially among less educated and minority women. Subjective perception of risk was more strongly related to knowledge than actual risk factors and should be targeted in public campaigns. The efforts should be aimed at strengthening women's perception of their own susceptibility to osteoporosis and of the severity of this disease.

The current investigation aimed to assess levels of knowledge about risk factors for heart disease among midlife Israeli women, and to evaluate the relationship of knowledge to personal risk factors and vulnerability to heart disease. Face-to-face interviews with women aged 45-64 years were conducted during 2004-2006 within three population groups: long-term Jewish residents (LTR), immigrants from the former Soviet Union, and Arab women. The survey instrument included six knowledge statements relating to: the risk after menopause, family history, elevated cholesterol level, diabetes, obesity, and warning signs of a heart attack. The findings showed wide disparities in knowledge by educational level and between immigrants and LTR, after taking into account personal risk factors and education. Personal risk factors were not significantly related to the knowledge items, except for personal history of cardiovascular disease, which was associated with knowledge about "warning signs of a heart attack" and "family history." Women who perceived themselves as more vulnerable to heart disease were more likely to identify several risk factors correctly. These findings stress the need to increase knowledge about heart disease, especially among less educated and minority women, and to emphasize the risk of patients' personal status by health providers.

Background: Pregnancy-induced hypertension (PIH) has been associated with a decreased risk of infant mortality in small for gestational age (SGA) preterm infants., Objective: To evaluate the influence of PIH on mortality and major neonatal morbidities in singleton preterm SGA infants, in the presence and absence of acute pregnancy complications., Methods: Population-based observational study of singleton SGA infants, born at 24 to 32 weeks gestation in the period 1995-2010 (n = 2139). Multivariable logistic regression analyses were used to assess the independent effect of PIH on mortality and neonatal morbidities. Acute pregnancy complications comprised premature labor, premature rupture of membranes >6 h, antepartum hemorrhage and clinical chorioamnionitis., Results: In the absence of pregnancy complications, the odds ratio (95% confidence interval) for mortality (0.77; 0.50-1.16), survival without severe neurological morbidity (1.14; 0.79-1.65) and survival without bronchopulmonary dysplasia (BPD) (0.85; 0.59-1.21) were similar in the PIH versus no-PIH groups. In the presence of pregnancy complications, mortality (0.76; 0.40-1.44), survival without severe neurological morbidity (1.16; 0.64-2.12) and survival without BPD (1.04; 0.58-1.86) were also similar in the PIH versus no-PIH groups., Conclusions: PIH was not associated with improved outcome in preterm SGA infants, both in the presence and absence of acute pregnancy complications.

Background: Improved survival of singleton very preterm, very low birth weight (VPTVLBW) infants has been associated with increasing rates of severe neonatal morbidities., Aim: To assess changes in mortality and neonatal morbidities among singleton VPT-VLBW infants., Study Design: Population-based observational study of data collected by the Israel Neonatal Network., Subjects: 10,705 singleton VPT-VLBW infants born at 24-32 gestational weeks in 1995-2010., Outcome Measures: Mortality and major neonatal morbidities over 3 time periods: 1995-2000, 2001-2005, and 2006-2010. Major neurological morbidities comprised intraventricular hemorrhage grades 3-4, periventricular leukomalacia and retinopathy of prematurity grades 3-4., Results: The mortality rate decreased over time from 20.2% to 13.8% for all birth weight and gestational age groups. Compared to the 1995-2000 period, the adjusted odds ratios (aORs) (95% confidence intervals,) for mortality in 2001-2005 and 2006-2010 were 0.78 (0.67-0.90) and 0.72 (0.62-0.84), respectively. The combined outcomes of death or major neurological morbidities, aOR 0.74 (0.65-0.84) and death or major neurological morbidities and/or bronchopulmonary dysplasia aOR 0.85 (0.75-0.96) decreased significantly between the first and last periods. A significant improvement in mortality rates and survival without one or more major neonatal morbidity was observed for all birth weight and gestational age groups. Among 8,886 surviving infants the rates of major neurological morbidities decreased from 16.4% to 12.8%, aOR 0.80 (0.68-0.95)., Conclusion: The improving survival of singleton VTP-VLBW infants was not associated with a concomitant increase in the risk for major neonatal neurological morbidities among surviving infants. Bronchopulmonary dysplasia, however, remained a significant burden. This analysis emphasizes the need to direct efforts towards the prevention and treatment of adverse respiratory sequelae., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Over the last decade, there is growing evidence that exposure to air pollution may be associated with increased risk for congenital malformations., Objectives: To evaluate the possible association between exposures to air pollution during pregnancy and congenital malformations among infants born following spontaneously conceived (SC) pregnancies and assisted reproductive technology (ART) pregnancies., Methods: This is an historical cohort study comprising 216,730 infants: 207,825 SC infants and 8905 ART conceived infants, during the periods 1997-2004. Air pollution data including sulfur dioxide (SO2), particulate matter <10 µm (PM10), nitrogen oxides (NOx) and ozone (O3) were obtained from air monitoring stations database for the study period. Using a geographic information system (GIS) and the Kriging procedure, exposure to air pollution during the first trimester and the entire pregnancy was assessed for each woman according to her residential location. Logistic regression models with generalized estimating equation (GEE) approach were used to evaluate the adjusted risk for congenital malformations., Results: In the study cohort increased concentrations of PM10 and NOx pollutants in the entire pregnancy were associated with slightly increased risk for congenital malformations: OR 1.06(95% CI, 1.01-1.11) for 10 µg/m(3) increase in PM10 and OR 1.03(95% CI, 1.01-1.04) for 10 ppb increase in NOx. Specific malformations were evident in the circulatory system (for PM10 and NOx exposure) and genital organs (for NOx exposure). SO2 and O3 pollutants were not significantly associated with increased risk for congenital malformations. In the ART group higher concentrations of SO2 and O3 in entire pregnancy were associated (although not significantly) with an increased risk for congenital malformations: OR 1.06(95% CI, 0.96-1.17) for 1 ppb increase in SO2 and OR 1.15(95% CI, 0.69-1.91) for 10 ppb increase in O3., Conclusions: Exposure to higher levels of PM10 and NOx during pregnancy was associated with an increased risk for congenital malformations. Specific malformations were evident in the circulatory system and genital organs. Among ART pregnancies possible adverse association of SO2 and O3 exposure was also observed. Further studies are warranted, including more accurate exposure assessment and a larger sample size for ART pregnancies, in order to confirm these findings., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Aim: To assess whether the postnatal growth of preterm very-low-birthweight (VLBW) infants, as determined by measures of postnatal growth failure (PNGF), improved during the period 1995-2010 and to evaluate postnatal growth by gestational age (GA) and intrauterine growth groups., Methods: The study was based on the Israel national VLBW infant database and comprised 13 531 VLBW infants of 24-32 weeks' GA, discharged at a postmenstrual age of ≤40 weeks. Z-scores were determined for weight at birth and discharge. Severe and mild PNGF was defined as a decrease >2 and 1-2 z-scores, respectively. Three time periods were considered: 1995-2000, 2001-2005 and 2006-2010. Multinomial logistic regression was used to assess the independent effect of time period on PNGF., Results: Severe PNGF decreased from 11.7% in 1995-2000 to 7.2% in 2001-2005 and 5.2% in 2006-2010. Infants born in 2006-2010 had sixfold lower odds for severe PNGF than babies born in 1995-2000 (adjusted odds ratio 0.17, 95% confidence interval 0.14-0.21) and

Self-rated health (SRH) has been found to predict future health, yet its importance is unique in the information it captures, beyond more objective measures. This information can include psychosocial and cultural factors that can be important in understanding women's health. Our goal was to test whether long-term Jewish residents (LTJR), immigrant, and Arab women differed in their SRH, whether these differences were maintained after controlling for indicators of health status, and, if so, whether the differences among the three groups reflected psychosocial or socioeconomic factors. A nationally representative sample of 814 women in Israel aged 45-64 years was interviewed (between June 2004 and March 2006) regarding socio-demographics, physical health, health behaviors, and psychosocial aspects. Both immigrant and Arab women reported poorer SRH, physical and mental health, and socioeconomic status. Differences between Arab women and LTJR were mostly explained by differences in health measures (e.g., medications and symptoms) and psychosocial measures (e.g., caregiving load and depressive symptoms) and were eliminated when socioeconomic measures were added to the multiple regression models. Differences in SRH between immigrants and LTJR remained after multiple adjustments, suggesting that they reflected unmeasured cultural factors. Even with universal healthcare coverage in a small country (i.e., with minimal financial and geographical barriers to healthcare) minority groups' health suffers in relation to their socioeconomic and life circumstances.

Objective: To evaluate the risk for congenital malformations diagnosed at birth following assisted reproductive technology (ART) treatments compared with live births conceived spontaneously., Methods: A retrospective cohort study including 9042 live births following ART and 213 288 spontaneously conceived (SC) live births during the period 1997-2004.The cohort was linked to the national live birth registry to determine the outcome of the pregnancies including congenital malformations., Results: An increased adjusted risk for all congenital malformations was observed in ART compared with SC infants [2.4% versus 1.9%; ORadj = 1.45; 95% CI: 1.26, 1.68]. The increased risk was observed in singleton births [2.4% versus 1.8%; ORadj = 1.41; 95% CI: 1.14, 1.71] but not in the ART conceived multiple births [2.5% versus 2.6%.; ORadj = 1.15; 95% CI: 0.90, 1.46]. Significantly increased adjusted risks for nervous, circulatory, digestive and genital system malformations were evident in the ART singleton group compared to SC infants. In addition, increased risks were also observed in separate comparisons of IVF births versus SC [ORadj = 1.28; 95% CI: 1.00, 1.63] and ICSI births versus SC [ORadj = 1.56; 95% CI: 1.31, 1.84]. Data regarding pregnancy termination or congenital malformation diagnosed later in life were not included., Conclusion: Infants born following ART were at significantly increased risk for congenital malformations compared to live birth conceived spontaneously.

Objective: We sought to assess the independent effect of perinatal factors on the risk for bronchopulmonary dysplasia (BPD) in very-low-birthweight infants., Study Design: This was a population-based observational study. Data were prospectively collected by the Israel Neonatal Network. Multivariable analyses identified independent risk factors for BPD., Results: Of 12,139 infants surviving to a postmenstrual age of 36 weeks, 1663 (13.7%) developed BPD. BPD was independently associated with young maternal age (odds ratio [OR], 1.53), maternal hypertensive disorders (OR, 1.28), antepartum hemorrhage (OR, 1.26), male gender (OR, 1.41), non-Jewish ethnicity (OR, 1.23), birth defects (OR, 1.94), small for gestational age (GA) (OR, 2.65), and delivery room resuscitation (OR, 1.86). Stratified analysis by GA groups showed that postdelivery resuscitation had a more pronounced effect with increasing maturity., Conclusion: Perinatal factors and pregnancy complications were independently associated with development of BPD in very-low-birthweight infants. Most risk factors identified were consistent within GA groups., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: The aim of this study was to assess the prevalence and correlates of depressive symptoms among Israeli midlife women from different cultural origins and to identify sociodemographic, lifestyle, psychosocial, health, and menopause status characteristics that could explain cultural differences in depressive symptoms., Methods: Data were collected for the Women's Health in Midlife National Study in Israel, in which women aged 45 to 64 years were randomly selected according to age and ethnic/origin group strata: long-term Jewish residents (n = 540), immigrants from the former Soviet Union (n = 151), and Arab women (n = 123). The survey instrument included a short form of the Center for Epidemiological Studies-Depression Scale dichotomized according to a <10/≥10 cutpoint., Results: The crude prevalence of depressive symptoms was 17%, 39%, and 46% for long-term residents, immigrants, and Arabs, respectively. Among women aged 45 to 54 years, 46% were postmenopausal. After adjustment for sociodemographics, health and menopause status, and lifestyle and psychosocial characteristics, immigrants and Arab women were at a significantly higher risk of depressive symptoms as compared with native-born/long-term Jewish residents (odds ratio, 2.97 and 2.79, respectively). Perimenopause status, numbers of medical symptoms, being unmarried, and negative attitude to aging were positively associated with depressive symptoms, whereas social support and perceived control were associated with lower odds of depressive symptoms. These associations differed across cultural groups when analysis was stratified by study group., Conclusions: Our findings demonstrate that the high level of depressive symptoms among Israeli women is related to cultural/minority status. The high risk for depressive symptoms in these minority groups calls for intervention policy to improve their mental health.

Objectives: To assess risk factors and develop a simple estimate method for poor neonatal outcomes for specific groups of extremely premature infants at birth., Design: Population-based study., Setting: Israel National Very Low Birth Weight Infant Database., Participants: Infants born at 23 to 26 weeks' gestation between January 1, 1995, and December 31, 2008., Intervention: We developed a tool to estimate poor neonatal outcomes for infants born at 24 to 26 weeks' gestation (n=2544) that incorporated factors at birth significantly associated with poor outcomes into a linear regression model., Main Outcome Measures: Poor neonatal outcomes defined as the composite of mortality or severe neurologic or pulmonary morbidity at discharge from the hospital., Results: Major factors associated with poor outcomes at 24 to 26 weeks' gestation were gestational age, male sex, sex-specific birth weight percentile, and lack of prenatal steroid therapy. Estimated poor outcomes for January 1, 2000, to December 31, 2008, were calculated as the sum of the percentages determined for each of the 4 parameters: (1) gestational age (26, 25, and 24 weeks; 0%, 17%, and 34%, respectively), (2) birth weight percentile (>75th, 25th-75th, and < 25th percentiles; 0%,13%, and 26%, respectively), (3) lack of prenatal steroids (16%), and (4) male sex (7%). There was also an intercept value of 25%. Estimated poor outcome rates for the 36 subgroups of infants ranged from 25% to 100%and correlated well with observed rates (intraclass correlation coefficient, 0.93)., Conclusions: The combined outcomes of deaths or severe morbidities in the neonatal period of infants born at 24 to 26 weeks' gestation could be simply estimated at birth. The provision of an appropriate and up-to-date estimate of poor neonatal outcomes for specific infants may be useful in counseling families on treatment options for these infants.

Objective: We hypothesized that maternal diabetes mellitus (DM) increases the risk for mortality, respiratory distress syndrome (RDS), and major complications of prematurity., Methods: Analysis of prospectively collected (1995-2007) Israel National Very Low Birth Weight Infant Database. Maternal DM was recorded as pregestational or gestational. Multivariable logistic regression analysis was used to assess the independent effect of maternal DM status on infant mortality, RDS, and other complications of prematurity., Results: Infants of mothers with pregestational (n = 120) and gestational (n = 825) DM were similar, and their data were pooled for analyses. Mothers with DM were more likely to have received a complete course of prenatal steroids than control mothers. Infants of diabetic mothers (IDM) had a slightly higher gestational age and birthweight than non-IDM's. Distribution of birthweight percentiles and the mean birthweight z scores were similar. Apgar scores were statistically higher in the IDM group. There were no significant differences between the 2 groups in terms of delivery room mortality, RDS, and other major complications of prematurity. Total mortality and bronchopulmonary dysplasia rates were significantly higher in the nondiabetic group. The adjusted odds ratios for mortality, RDS, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity, necrotizing enterocolitis, and patent ductus arteriosus were not significantly increased in the IDM group., Conclusions: With modern management and adequate prenatal care, IDM born very low birthweight do not seem to be at an excess risk of developing RDS or other major complications of prematurity compared with non-IDM.

Objectives: We aimed to study the trends in management and outcome of post CABG patients presenting with acute MI., Background: Primary angioplasty is the treatment of choice in patients with acute myocardial infarction. Saphenous vein grafts used for CABG are large-diameter conduits that tend to accumulate a large mass of thrombus when they are the culprit artery for acute myocardial infarction (MI). We hypothesized that performing PCI in these patients is more complex and possibly results in worse outcome compared to non-CABG patients., Methods: Data for patients with STEMI was obtained from five acute coronary syndromes Israeli biennial Surveys (ACSIS) during 2000-2008. Baseline characteristics, management and outcome of post-CABG patients were compared to non-post CABG patients during 2006-2008 surveys., Results: A total of 9,781 patients were included. About 1,002 (10.2%) were post-CABG. Reperfusion therapy for post-CABG patients (34-48%) was consistently lower compared to non-CABG patients (57-65%). Angiographic outcome in patients with STEMI who underwent primary PCI (17 post-CABG, mean age 66.6 ± 9.1 and 821 non-CABG, age 60.1 ± 12.9) was successful (TIMI flow 3) in 86 and 88%, respectively. Thirty-day mortality was 5.9 and 5.1% (P = 0.89) and MACE rates were 17.6 and 12.5%, respectively (P = 0.54)., Conclusions: Use of primary PCI in post-CABG patients was lower than in non-CABG patients but increased steadily and to a similar extent in both groups. Angiographic and clinical outcome was similar despite assumingly larger thrombus burden in post CABG patients. Therefore, primary angioplasty is appropriate also in post-CABG patients presenting with STEMI., (Copyright © 2011 Wiley-Liss, Inc.)

Objectives: To compare survival rates of hip fracture patients treated within a comprehensive geriatric hip fracture unit (CGHFU) with those undergoing a standard of care treatment (SOCT) in general orthopedic wards., Design: Retrospective chart review., Setting: A geriatric hip fracture unit of a division of geriatric medicine and rehabilitation and departments of general orthopedic surgery of a tertiary hospital., Participants: Participants were 3114 consecutive hip fracture patients: 847 were admitted to CGHFU and 2267 to wards of general orthopedics., Intervention: Surgical repair followed by standard rehabilitation course, Measurement: Mortality rates at 30 days, 90 days, and 1 year., Results: CGHFU population was older (P < .0001), comprised more women (P < .0001), and suffered a greater number of comorbidities (P < .0001). Crude 30-day mortality rates were 1.9% and 3.0% for CGHFU and SOCT, respectively. At 90 days, crude rates were 6.5% and 8.1%, respectively, and 14.8% and 17.3%, at 1 year, respectively. Cox proportional hazard models adjusted for sociodemographics, Comorbidity, and surgery characteristics showed borderline significant lower mortality hazard ratios for CGHFU in comparison with SOCT, for 1-month and 3-month intervals. The adjusted Cox model favored the CGHFU modality of care with regard to 1-year cumulative mortality (hazard ratios 0.78, 95% confidence interval 0.63-0.96, P = .016). Male gender, age, diabetes, and number of operations were predictive of increased 1-year mortality risk in the separate regression models by gender and age group (<85, 85+)., Conclusion: Crude and adjusted mortality rates are lower in a geriatric hip fracture unit, as compared with the common standard of care model of general orthopedic wards. Combined with earlier data on improved functional outcomes of CGHFU, these findings further support the implementation of similar comprehensive orthogeriatric models of care., (Copyright © 2011 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.)

Objective: Since 1995, Israel allows social sex selection (SxS) under certain circumstances. However, data regarding the attitudes of potential users are limited., Methods: The study population composed of a stratified sample of Israeli married men and women at the reproductive age (women aged 17-45, men aged 17-65), who had 1-2, 3, or 4+ children of the same sex. We conducted telephonic interviews with 687 Israeli residents using a structured questionnaire that included the following items: demographic characteristics, opinions regarding SxS, personal interest in expanding the family, and interest in choosing the sex of a future child., Results: Among the group of respondents who wanted to have more children (true potential users of the technology), 42.6% wished to select the sex of a future child. Strong desire for family balancing was found. In a multivariable logistic regression model, being an ultra-orthodox was associated with a lower desire to choose (OR = 0.02; 95% CI: 0.01-0.06), while having more same-sex children was associated with a greater desire to choose (OR = 3.12; 95% CI: 1.54-6.32)., Conclusions: It can be estimated that if SxS were to be freely permitted in Israel, less than half of those for whom SxS is truly relevant would want to use the technology.

Reports among patients with coronary heart disease regarding the association between body mass index (BMI) and long-term mortality are inconsistent, ranging among linear, U-shaped, or inverse (the "obesity paradox") associations. BMI and mortality data were available for 12,466 men with chronic coronary heart disease. BMI was classified as <20 (lean), 20.0 to 22.99, 23.0 to 24.99 (reference), 25.0 to 26.99, 27.0 to 29.99, and >or=30 kg/m(2) (obese). Age-adjusted (direct methods) mortality was investigated within risk factor categories. Adjusted hazard ratios compared with the reference group were estimated using a Cox proportional-hazards model. Two thirds of the patients had BMIs >or=25 kg/m(2). A number of risk factors were progressively more frequent with increasing BMI (age, diabetes, past smoking, and metabolic components). Over a median follow-up period of 12 years, adjusted mortality rates per 1,000 patient-years followed a U-shaped association with BMI. The highest risk was noted in 148 lean (hazard ratio 1.41, 95% confidence interval 1.08 to 1.85) and 1,788 obese (hazard ratio 1.28, 95% confidence interval 1.15 to 1.42) patients. Mortality hazard in patients with BMIs of 20.0 to 29.99 kg/m(2) (84% of patients) did not significantly differ from the reference group (lowest risk). Risk factor presence was associated with higher mortality in every BMI category. Lean patients had a particularly poor prognosis in the presence of past myocardial infarction, smoking, or renal insufficiency. A U-shaped association was found in most subgroups examined. In conclusion, BMI >or=25 kg/m(2) is common in patients with coronary heart disease. A U-shaped association, with highest risk among lean and obese patients, is persistent regardless of risk factor presence. Further data are required to support the need of aggressive weight reduction in patients with BMIs <30 kg/m(2)., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Aims: This study aimed to examine differences in symptom clusters among women in midlife from different cultural origins and to identify sociodemographic, lifestyle, and health characteristics that could account for the differences between the cultural groups in symptom reporting., Methods: Israeli women aged 45-64 were randomly selected according to age and population strata of three groups: long-term Jewish residents (LTR), Jewish immigrants from the former Soviet Union, and Arab women (mostly Israeli-born). Interviews were conducted with 540 LTR, 151 immigrants, and 123 Arab women. The survey instrument included the occurrence and rating of how bothersome to everyday function were 16 symptoms. Three outcome variables included hot flashes and two scales for mental and somatic symptoms extracted from exploratory factor analysis., Results: Multivariate logistic regressions showed that immigrants and Arab women (compared to LTR) had a significantly lower risk of reporting hot flashes and mental and somatic symptoms. Menopausal status was related only to hot flashes. Low education and depression were associated with the three symptom scales, whereas nonhealthy lifestyle was related only to somatic symptoms., Conclusions: Our main finding is that cultural group is an independent predictor of each of the three menopausal symptom scales. A possible explanation for the lower reporting of symptoms among Arab and immigrant groups is that they differ from the LTR in level of acculturation and attitudes toward menopause. These findings support the proposition of a cultural factor in menopausal symptomatology that needs to be addressed by clinicians caring for women at midlife.

Objectives: The goals were to assess risk factors and mortality rate changes over time and to develop simple estimates of mortality rates for specific groups of infants at 23 to 26 weeks of gestation., Methods: Data from the Israel national very low birth weight infant database on 3768 infants born in 1995-2006 with gestational ages (GAs) of 23 to 26 weeks were evaluated, and we developed a tool for estimating infants' mortality rates., Results: Major factors associated with death were GA, gender-specific birth weight percentile, prenatal steroid therapy, and multiple births. There was a steady decrease in mortality rates for all GAs during the study period. In 2004-2006, mortality rates before discharge were 89%, 67%, 46%, and 26% for infants with GAs of 23, 24, 25, and 26 weeks, respectively. Estimated mortality rates were calculated as the sum of the percentages determined for each of 4 parameters, as follows: GA of 26, 25, 24, or 23 weeks, 0%, 17%, 34%, and 51%, respectively (P < .001); birth weight percentile of >75th, 25th to 75th, or <25th, 0%, 16%, and 32%, respectively (P < .001); no prenatal steroid treatment, +22% (P < .001); multiple birth, +7% (P = .1). Estimated mortality rates for the 48 subgroups of infants ranged from 0% to 100% and correlated well with observed rates (intraclass correlation coefficient: 0.89)., Conclusion: Mortality rates for infants born at 23 to 26 weeks of gestation could be estimated simply on the basis of GA, gender-specific birth weight quartiles, prenatal corticosteroid therapy, and multiple births.

Background: Early-onset sepsis (EOS) is associated with significant morbidity and mortality among infants with a very low birth weight (VLBW); however, there is a sparse amount of complete data on large cohorts., Objective: To evaluate the mortality and major morbidities among VLBW infants with EOS., Methods: This was a population-based observational study. Data were prospectively collected by the Israel Neonatal Network on all VLBW infants born in Israel from 1995 through 2005. Univariate and multivariable analyses were performed to assess the independent association of EOS on morbidity and mortality of VLBW infants., Results: The study cohort included 15 839 infants, of whom 383 (2.4%) developed EOS. EOS was associated with significantly increased odds for mortality (odds ratio [OR]: 2.57 [95% confidence interval (CI): 1.97-3.35]), severe intraventricular hemorrhage (OR: 2.24 [95% CI: 1.67-3.00]), severe retinopathy of prematurity (OR: 2.04 [95% CI: 1.32-3.16]), and bronchopulmonary dysplasia (OR: 1.74 [95% CI: 1.24-2.43]). EOS was associated with an increased risk of death and/or severe neurologic morbidity (OR: 2.92 [95% CI: 2.27-3.80])., Conclusions: Although only 2.4% of VLBW infants had an episode of EOS, these infants were at an approximately threefold excess risk of death or major neurologic morbidities.

Background: In acute coronary syndromes (ACSs), blood transfusion (BT) has been associated with worse outcomes. The impact of BT among patients with acute decompensated heart failure (ADHF) remains unknown., Methods: Propensity score analysis of patients with ADHF with and without BT in a national heart failure (HF) survey was used in this study., Results: Of the 4,102 enrolled patients, 2,335 had ADHF, of whom 166 (7.1%) received BT. These patients were older (75.6% vs 73.6%, P = .04), more likely to be females (54.8% vs 43.9%, P = .007), more likely to have diabetes (59.0% vs 51.1%, P = .04) and renal dysfunction (59.0% vs 40.2%, P < .001), and more likely to receive inotropes (16.9% vs 8.0%, P < .001), but they had similar rates of ACS (41.0% vs 39.4%, P = .69) and prior HF (64.5% vs 70.0%, P = .23). Nadir hemoglobin levels were commonly <10 g/dL in BT patients (92.7% vs 8.0%); 15 BT patients had bleeding complications, of which 10 are major bleeding. Major predictors for BT were ACS (OR 1.85, 95% CI 1.15-2.96), inotropes use (OR 2.36, 95% CI 1.22-4.55), and nadir hemoglobin (OR 0.18 per 1 g/dL increase, 95% CI 0.14-0.22). In-hospital, 30-day, 1-year, and 4-year unadjusted mortality rates were higher for BT patients (10.8% vs 5.2%, P = .02; 11.0% vs 8.5%, P = .27; 39.6% vs 28.5%, P = .03; 69.5% vs 59.5%, P = .01, respectively). However, in 103 propensity-matched pairs (c-statistic 0.97), short-term mortality tended to be lower with BT (8.7% vs 14.6%, P = .20; 9.7% vs 18.4%, P = .08; 38.8% vs 42.7%, P = .59; and 72.8% vs 76.7%, P = .52, respectively)., Conclusions: Acute decompensated HF patients receiving BT had worse clinical features and unadjusted outcomes, but BT per se seemed to be safe and perhaps even beneficial.

Objective: The purpose of this study was to determine the incidence, causative pathogens, and risk factors for early onset sepsis (EOS) among very-low-birthweight (VLBW) infants., Study Design: This was a population based observational study. Data were prospectively collected by the Israel Neonatal Network between 1995 and 2005. Multivariable analyses identified independent risk factors for EOS., Results: EOS developed in 383 of 15,839 infants (2.42%). Fifty-five percent of pathogens isolated were gram-negative bacteria. Lack of prenatal care (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.32-2.86), delivery room resuscitation (OR, 2.49; 95% CI, 1.91-3.24), membrane rupture > 24 hours without amnionitis (OR, 2.10; 95% CI, 1.53-2.88), amnionitis with membrane rupture < 24 hours (OR, 4.28; 95% CI, 2.97-6.16), and amnionitis with membrane rupture >or= 24 hours (OR, 8.15; 95% CI, 5.98-11.10) were associated with EOS, but not antenatal steroids or gestational age., Conclusion: EOS was caused mainly by gram-negative bacteria. Prolonged rupture of membranes and amnionitis have an additive effect on EOS with an above 8-fold excess risk when both were present.

Objective: To determine the prevalence, characteristics, and risk factors for nosocomial infections (NIs) in children postcardiac surgery and hospitalized in a pediatric intensive care unit (PICU)., Design: Case control study., Setting: PICU of a tertiary care university-affiliated medical center., Patients and Controls: Between January 1, 1999 and December 31, 2002, 356 children underwent cardiac surgery and were admitted to the PICU (381 admissions). There were 146 episodes (91 patients) of NI according to the Centers for Disease Control and Prevention criteria. The control group (92 patients) was drawn as a random sample from admissions with no evidence of NI., Measurements and Main Results: Data retrieved from medical records included demographic information, type of operation, complexity score, extrinsic risk factors (invasive devices, postoperative complications, etc.), specific pathogens, therapeutic interventions, and outcome. There were 146 episodes of NI during 381 admissions, yielding a nosocomial infection ratio of 38.3%, and a prevalence of PICU-acquired infection of 24.4% (93 admissions with NI out of a total of 381 admissions). The most common NI sites were the bloodstream and the lower respiratory tract (65.8% and 16.4%, respectively). The main causative organisms were Coagulase negative Staphylococcus, Klebsiella pneumonia, and Candida spp. (18.8%, 16.7%, and 15%, respectively). Multivariate analysis revealed the following risk factors for NI: age < 2 months, congenital malformations, post operative complications, and open-chest procedure. The crude mortality rate for patients with NI was 23.7%, compared with 2.2% for patients without NI (p < 0.001). Predictors for mortality in patients with NI were post operative complications, open-chest procedure, sepsis, and urinary tract infection., Conclusions: Our results draw attention to the importance of NI and their influence on survival in pediatric patients undergoing cardiac surgery. Prevention and control measures may reduce these infections and subsequently reduce morbidity and mortality in this vulnerable population.

Low high-density lipoprotein (HDL) cholesterol is a strong independent predictor of cardiovascular risk. The present study was designed to assess the relation between the clinical response to HDL cholesterol modification and serum levels of low-density lipoprotein (LDL) cholesterol in patients with coronary artery disease (CAD). The risk for a major cardiac event (defined as nonfatal myocardial infarction or cardiac death) during a median 7.9-year follow-up period in 3,020 patients with CAD enrolled in the Bezafibrate Infarction Prevention (BIP) trial was related to changes in lipid levels during the study. Baseline LDL cholesterol levels were categorized according to National Cholesterol Education Program Adult Treatment Panel III criteria. Multivariate analysis demonstrated that the benefit of HDL cholesterol increase was most pronounced in patients with low baseline LDL cholesterol (or=160 mg/dl; hazard ratio 0.94, 95% confidence interval 0.75 to 1.17, p = 0.14). A similar relation was shown for risk reduction-associated triglyceride decrements, whereas the benefit of LDL cholesterol reduction was more pronounced in patients with baseline LDL cholesterol >or=130 mg/dl. In conclusion, these data suggest that the clinical response to HDL cholesterol and triglyceride modification is inversely related to baseline LDL cholesterol levels. Thus, combined assessment of baseline and follow-up lipid levels to direct therapeutic goals in patients with CAD may provide incremental prognostic information to secondary prevention that is based solely on LDL cholesterol modification.

Purpose: This study aimed to assess rates of primary and preventive healthcare use among women in midlife from different cultural origins and to identify sociodemographic and health characteristics that could explain cultural differences in health care utilization., Methods: Data were collected for the Women's Health in Midlife National Study in Israel, in which women aged 45-64 were randomly selected according to age and ethnic/origin group strata: Long-term Jewish residents (n = 540), immigrants from the former Soviet Union (n = 151), and Arab women (n = 123). Interviews included measures of primary and preventive visits, clinical screening services (mammogram, Pap smear, bone density), health and lifestyle, and sociodemographics., Main Findings: Long-term residents reported more preventive visits and screening tests and lower use of primary care, compared with immigrants and Arab women. In multivariate analyses, cultural group, education, self-rated health, and health motivation were significantly associated with utilization of primary and preventive care. Ethnic/origin group differences were mostly related to cultural differences and not to financial barriers or medical factors. For example, among the more traditional group, namely, Arab women, low use of preventive gynecologic care seemed to be related to the lack of physicians of the same culture and gender., Conclusions: The findings underscore the importance of the primary care physician, especially in minority groups, as a provider who can identify at-risk groups and serve as a gateway to health promotion. The findings also suggest that the lack of female providers may be one explanation for the low utilization of gynecologic services among women from traditional cultures.

Objective: To investigate the association between delivery mode and grade 3-4 intraventricular hemorrhage in singleton, vertex presenting, very low birth weight (VLBW) (1,500 g or less) liveborn infants., Methods: The Israel National VLBW Infant Database includes perinatal and neonatal data on greater than 99% of all VLBW newborns. A total of 4,658 singleton vertex-presenting infants born at 24-34 weeks were included (1995-2004). Infants with lethal congenital malformations, delivery room deaths, and home deliveries were excluded. Our population-based observational study evaluated the effect of delivery mode and confounding variables on severe intraventricular hemorrhage using univariable and multivariable logistic regression analyses., Results: The rate of severe intraventricular hemorrhage was 10.4%. Cesarean delivery rate was 54.3%. The rate of severe intraventricular hemorrhage was 7.7% for infants delivered by cesarean compared with 13.6% in vaginal delivery (P<.001). However, analysis according to gestational age showed that the rate of severe intraventricular hemorrhage was similar in cesarean and vaginal delivery in all gestational age groups. In the multivariable model, cesarean delivery had no effect on the odds for severe intraventricular hemorrhage (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.77-1.24). Other factors independently associated with severe intraventricular hemorrhage included gestational age (OR 0.71, 95% CI 0.68-0.75 for each week increase), maternal hypertensive disorder (OR 0.43, 95% CI 0.30-0.61), no antenatal steroids (OR 2.70, 95% CI 2.12-3.45), 1-minute Apgar score 0-3 (OR 1.72, 95% CI 1.33-2.21), delivery room resuscitation (OR 2.16, 95% CI 1.65-2.83), and non-Jewish ethnicity (OR 1.28, 95% CI 1.03-1.59)., Conclusion: In this population-based study, the odds for severe intraventricular hemorrhage were not influenced by mode of delivery in vertex-presenting singleton VLBW infants after controlling for gestational age., Level of Evidence: II.

Objective: The objective of this study was to identify factors that were associated with death after discharge from the NICU of very low birth weight infants in a population-based study., Methods: From a national cohort of 13,430 very low birth weight infants who were born in Israel from 1995 to 2003, 10,602 infants were discharged from the hospital and composed the study population. Demographic and clinical data regarding the pregnancy, delivery, and neonatal course were obtained from the Israel national very low birth weight infant database. Data on each case of death during the postdischarge period until 1 year of age were provided by the Ministry of Health from national linked birth and death certificates. Univariate analyses and a multivariable logistic regression analyses were performed to examine the perinatal and neonatal risk factors for postdischarge death., Results: The postdischarge mortality rate was 7.5 per 1000 (80 of 10,602 infants discharged from the hospital). The death rate was significantly higher in non-Jewish infants, infants who were born to young mothers, and infants who were born to low-educated mothers. After adjustment for demographic characteristics and perinatal and neonatal variables, postdischarge mortality was independently associated with congenital malformations, neonatal seizures, necrotizing enterocolitis, and bronchopulmonary dysplasia., Conclusion: Although the postdischarge death rate was relatively low in our cohort of very low birth weight infants, attention should be focused on the subgroups of infants who are at higher risk to decrease their mortality further.

Background: Heart failure (HF) is associated with poor outcome after acute myocardial infarction (AMI). Women have higher mortality rate than men after AMI, however, it is unknown whether women with HF after AMI have different prognosis than men., Aim: To compare the prognosis of men and women with AMI and mild-moderate HF., Methods: We analyzed data of 3456 consecutive patients with AMI hospitalized in all cardiac care units in Israel during two nationwide surveys., Results: Among patients with AMI and HF on admission: women were older, had more risk factors, and were less likely to undergo percutaneous coronary angiography/intervention. Women with HF had higher (7-days, 30-days, and 1-year) crude mortality rates than men. However, adjusted mortality rates were not significantly different between genders., Conclusions: Women with AMI complicated by HF had higher crude mortality rate than men that was eliminated after multivariate analysis, suggesting that the higher mortality rate may be attributed to increased prevalence of risk factors and lower rate of revascularization and medical therapies among women. Women with AMI and HF should be considered as a high-risk subgroup with adverse outcome. It remains to be determined whether more intensive management will improve their prognosis.

Background: CD40 ligand (CD40L) is a trimeric, transmembrane protein of the tumor necrosis factor family and together with its receptor CD40 is an important contributor to the inflammatory processes that lead to atherosclerosis, plaque destabilization, and thrombosis., Methods: In order to assess the association between serum concentrations of CD40 ligand (CD40L) and risk of future ischemic stroke and coronary events among patients with chronic CHD, we obtained baseline serum samples from patients (n = 3090) with chronic CHD enrolled in a secondary prevention trial. With a prospective nested case-control design, we measured baseline CD40L concentration in sera of patients who subsequently developed myocardial infarction, sudden cardiac death or ischemic stroke during follow-up (cases, n = 233) and in 233 age- and gender-matched pairs without any subsequent cardiovascular events., Results: Relative odds for recurrent cardiovascular events per one natural log unit difference of CD40L were 0.97 (95%CI, 0.82-1.16). No increase in relative odds for recurrent cardiovascular events was observed per increasing quartiles of CD40L concentrations. In analysis for individual end-points, different trends of risks were observed beyond the 95 percentile for ischemic stroke (OR 2.22; 95%CI, 0.46-12.5) and for recurrent coronary events (OR 0.35; 95%CI, 0.07-1.37), but falling short of statistical significance., Conclusion: High serum concentrations of CD40L were not associated with increased risk of ischemic stroke or coronary events in patients with chronic coronary heart disease.

Objective: Data regarding the possible contribution of cigarette smoking to development of type 2 diabetes are scarce and inconclusive. Patients with impaired functional capacity and diminished physical activity are prone to develop new diabetes. However, the role of smoking on diabetes incidence among these patients has not been specifically investigated. The present study was aimed to evaluate the association between cigarette smoking and development of type 2 diabetes in patients with coronary artery disease and decreased functional capacity over a 6.2-year follow-up period., Methods: The study sample comprised 630 nondiabetic patients aged 45-74 years, with a fasting blood glucose of <126 mg/dl and with impaired functional capacity (New York Heart Association functional class II and III). The sample was classified into two groups: 1) non smokers (never and past smokers pooled together)--552 patients and 2) current smokers--78 patients., Results: Smokers were younger but they had a relatively unfavorable lipid profile (with respect to apolipoproteins A, triglyceride and HDL-cholesterol levels). No significant differences between the groups were found for weight, body mass index, total cholesterol and blood pressure. During the follow-up, development of new diabetes was recorded in 98 patients: in 80 (14.5%) non smokers and in 18 (23.1%) smokers, p=0.05. Among the non smokers, there were no significant differences in diabetes incidence between 357 past smokers and 195 never smokers: respectively, 48 (13.4%) and 32 (16.4%), p=0.34. In addition, all-cause mortality among the smokers (23.1%) was significantly higher than in non smokers (12.7%), p=0.01. Multivariate analysis identified current smoking as an independent predictor of increased risk of new diabetes development with a hazard ratio of 1.94 (95% confidence interval 1.16-3.25)., Conclusions: Current smoking was associated with an independent two-fold increased risk for development of type 2 diabetes in patients with impaired functional capacity.

Hypothesis: The survival of severe trauma patients is affected by the implementation of a national trauma system, which brought about developments both at the hospital and prehospital levels during the past decade., Design: A retrospective cohort study of all severely injured patients (Injury Severity Score >16) recorded in the Israeli National Trauma Registry at all level I trauma centers in Israel from January 1, 1997, to December 31, 2001. Inpatient death rates were examined overall and by subgroups., Setting: The National Trauma Registry includes trauma (International Statistical Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes 800-959) hospitalizations, patients who were transferred to or from other hospitals, and those who died in the emergency department. It excludes patients who were dead on arrival, discharged following treatment in the emergency department, and patients who do not fall into the definition of trauma. Main Outcome Measure Inpatient death., Results: Seven thousand four hundred twenty-three severe trauma patients were recorded. Inpatient death rates decreased significantly from 21.6% in 1997 to 14.7% in 2001. The odds ratios of mortality in 1998 through 2001 vs 1997, adjusted for year, age, sex, penetrating injury, and severity of injury (Injury Severity Score >25), were 0.92, 0.89, 0.70, and 0.65, respectively, confirming the downward trend., Conclusions: A steady significant reduction in the inpatient death rate of severe trauma patients hospitalized at all level I trauma centers in Israel between 1997 and 2001 was observed. Although a single factor that explains the reduction was not identified, it is evident that the establishment of the trauma system brought about a significant decrease in mortality. We believe that integrated cooperation of various components of the national trauma system in Israel across the years may explain the reduction.

In a nationwide survey conducted in all 26 hospitals in Israel during February and March 2000, data were collected on 2133 consecutive acute coronary syndrome patients. The patients were divided into three age subgroups: <65 years (n=974), 65-74 years (n=500), and > or =75 years (n=639). The frequency of no anginal pain/atypical symptoms on presentation increased with age for all acute coronary syndrome patients (14%, 21%, and 32%, in the three age subgroups, respectively; p for trend <0.0001). The frequency of ST-elevation on admission electrocardiogram decreased with advancing age (59%, 46%, and 42%, in the three age subgroups, respectively; p for trend <0.0001), whereas ST-depression gradually increased (14%, 24%, and 28%, respectively; p for trend <0.0001). In multivariate analysis, variables associated with no anginal pain/atypical symptoms on presentation (in decreasing order) were: history of heart failure, age, lack of past angina, diabetes, and nonsmoking. ST-elevation was inversely associated with no anginal pain/atypical symptoms on admission (odds ratio, 0.48; 95% confidence interval, 0.37-0.63). The use of acute reperfusion therapy significantly declined with advancing age. Seven-day, 30-day, and 1-year mortality increased with advancing age. No anginal pain/atypical symptoms on presentation were associated with an increased early and late mortality in all three age subgroups.

Some prospective randomized trials have established the superiority of primary percutaneous coronary intervention (PCI) over fibrinolytic treatment in patients with acute myocardial infarction (MI). These excellent PCI results are not duplicated in smaller hospitals where there may be delays in getting the cardiac catheterization team to the laboratory. This study aimed to compare the outcome of patients with anterior wall MI, without cardiogenic shock on admission, treated with primary PCI or thrombolytic therapy, in everyday practice. The data of all patients with MI hospitalized in all coronary care units operating in Israel during three consecutive national surveys was analyzed. A total of 1,038 patients with anterior wall MI were treated by reperfusion (886 received thrombolytic therapy, 152 primary PCI). Overall, the outcome of patients treated using primary PCI was better compared to patients treated with thrombolysis, with 68% relative risk reduction of 30-day mortality (mortality at 30 days: 2% vs. 6.3%; P = 0.04). A subanalysis of patients according to age showed that the beneficial effect of primary PCI on mortality was mainly clustered among the younger. In our study, patients (especially younger than 75 years) with anterior wall MI allocated to primary PCI have a better clinical outcome., (Copyright 2004 Wiley-Liss, Inc.)

A positive family history (FH) of coronary artery disease (CAD) is considered an independent risk factor for developing CAD. However, the natural history, coronary angiographic findings and prognosis of patients with a positive FH developing first acute myocardial infarction (AMI) are not well defined. A cohort of 2,690 consecutive patients with first AMI from two prospective nationwide surveys conducted during 1996 and 1998 in all coronary care units operating in Israel was studied. Baseline characteristics, hospital course, management and outcome of 405 patients with first AMI and a positive FH were compared with 2,285 controls without a positive FH. Coronary angiograms of patients with and without a positive FH were reviewed and compared. Patients with a positive FH were younger (53 vs. 64 years), more often male, current smokers and patients with hyperlipidemia, but less often patients with diabetes or hypertension than patients without a positive FH. Patients with a positive FH developed heart failure during hospital stay less frequently. Thrombolytic therapy was similarly administered to both groups. During the hospital stay, coronary angiography, percutaneous coronary intervention or coronary artery bypass grafting were more frequently performed in patients with a positive FH. The coronary anatomy and the extent of the CAD were similar in patients with and without a positive FH. Crude and covariate-adjusted mortality rates were significantly lower in patients with a positive FH than in patients without a positive FH on day 30 (2.2 vs. 9.6%, p < 0.001; odds ratio 0.50, 95% confidence interval 0.22-0.99) and at 1 year (3.5 vs. 14%, p < 0.001; hazard ratio 0.58, 95% confidence interval 0.42-0.80). Patients with a positive FH developed their first AMI more than 1 decade earlier in comparison to those without such a history. The extent of their coronary disease is similar to the older patients without a positive FH. The better prognosis of patients with a positive FH is mostly explained by their younger age.

Mortality and morbidity after acute myocardial infarction (AMI) is higher in diabetic than in nondiabetic patients. Angiotensin-converting enzyme (ACE) inhibitors have been shown to exert a beneficial effect after AMI. We sought to evaluate the association between treatment with ACE inhibitors and 1-year outcome after AMI in diabetic and nondiabetic patients in a national survey. The study population was drawn from a national survey conducted in all coronary care units operating in Israel during a 5-month period in 1996, and included 2,179 patients with AMI: 533 diabetics (24%), 322 of whom received ACE inhibitors (60%) and 211 who did not; and 1,646 nondiabetics, 805 of whom received ACE inhibitors and 841 who did not. In both groups of patients, those treated with ACE inhibitors were older, included more women, more had a history of AMI, anterior wall AMI, or hypertension, and more had worse Killip class on admission. Diabetic patients treated with ACE inhibitors experienced lower 1-year mortality rates than diabetics not treated with ACE inhibitors (16.2% vs 18.8%, respectively; covariate adjusted hazard ratio 0.47, 95% confidence interval 0.30 to 0.74). In nondiabetic patients, however, ACE inhibitor treatment was not associated with a better outcome (10.2% vs 7.3%, respectively; covariate adjusted hazard ratio 0.80; 95% confidence interval 0.56 to 1.15). Thus, treatment with ACE inhibitors after AMI appears to be particularly beneficial in diabetic patients. The beneficial effect observed supports the widespread use of ACE inhibitors in diabetic patients after AMI.

Hypertension (HT) and diabetes mellitus (DM) lead to structural and functional cardiac impairment and worsen the prognosis after myocardial infarction (MI). However, the prognosis of male or female patients with the coexistence of HT and DM after MI has not been clearly demonstrated. The study sample comprised 4317 consecutive patients with an acute MI from a prospective nationwide survey conducted in 1992, 1994 and 1996 in all 25 coronary care units operating in Israel. The in-hospital, 30-day and 1-year outcome of diabetic hypertensive patients (n=546) was compared with that of diabetic normotensive patients (n=547) and with that of nondiabetic hypertensive patients (n=1192) and nondiabetic normotensive subjects (n=2032). The crude in-hospital, 30-day and 1-year mortality rates of diabetic hypertensive patients (11.7, 16.5 and 27.6%, respectively) were significantly higher than those of the diabetic normotensive patients (9.5, 15.4 and 22.9%, respectively) and nondiabetic hypertensive patients (7.1, 11.6 and 17.6%, respectively). Kaplan-Meier survival curves showed increased mortality rates during the 1-year follow-up in diabetic hypertensive patients. Adjusted risk for 1-year mortality was increased in diabetic patients. However, the risk was similar in diabetic hypertensive and normotensive patients (hazard ratio (HR) 1.55, 95% confidence interval (CI) 1.25-1.93, and 1.62, 95% CI 1.29-2.04, respectively). Adjusted Kaplan-Meier survival curves of diabetic hypertensive patients converged with those of the diabetic normotensives. The existence of DM increases the 1-year mortality after MI by about 60%. However, controlled hypertension did not worsen the outcome of diabetic male or female patients after MI.

Background and Purpose: Substantial evidence is accumulating suggesting that hyperhomocysteinemia may be a risk factor for ischemic stroke. Results of prospective studies are, however, conflicting, and the role of hyperhomocysteinemia in patients with preexisting atherosclerotic vascular disease is not clear. Our aim was to assess prospectively the risk of incident ischemic stroke conferred by serum total homocysteine among patients with preexisting stable coronary heart disease (CHD)., Methods: We obtained baseline fasting serum samples from patients with chronic CHD enrolled in the Bezafibrate Infarction Prevention (n=3090) secondary prevention study cohort. With a nested case-control design, we measured baseline total homocysteine concentration by a high-performance liquid chromatography-based method in sera (n=160) of matched case-control pairs: patients who developed ischemic stroke during a mean follow-up of 8.2 years (cases) and age- and sex-matched controls without subsequent cardiovascular events., Results: An increase of 1 natural log unit in homocysteine concentration was associated with a >3-fold increase in relative odds of incident ischemic stroke (3.3; 95% CI, 1.2 to 10.2). Homocysteine concentrations at the highest quartile (>17.4 micromol/L) were associated with significantly higher odds of ischemic stroke compared with the lowest quartile in matched-pair analysis (3.1; 95% CI, 1.1 to 9.8) and after multivariable adjustments (4.6; 95% CI, 1.3 to 18.9). Adding fibrinogen or soluble intercellular adhesion molecule-1 concentrations, markers of inflammation, to the model did not attenuate this association. The linear trends across the quartiles were significant for all models (P<0.05)., Conclusions: Serum total homocysteine concentration is a strong predictor for incident ischemic stroke among patients at increased risk because of chronic CHD. The graded association observed is independent of traditional risk factors or inflammatory markers and indicates the importance of serum homocysteine levels in patients with preexisting vascular disease.

Background: Some patients developing heart failure and functional capacity impairment have no history of myocardial infarction (MI), and stable angina pectoris is their principal clinical manifestation of coronary artery disease (CAD). The present study was aimed to evaluate the outcome of CAD-related functional capacity impairment in patients with and without a history of MI over a 7.7-year follow-up., Methods: The study sample comprised 14,283 coronary patients aged 45-74 years, screened for participation in the Bezafibrate Infarction Prevention study. The presence of NYHA functional class II was defined as mild functional capacity impairment and the presence of NYHA functional class III-IV was defined as advanced functional capacity impairment., Results: The patients were divided in two groups: (1) those with a history of MI, 10,307 patients, who formed three subgroups: NYHA I 7,551 patients (73.3%); NYHA II 2,176 patients (21.1%); NYHA III + IV 580 patients (5.6%), and (2) those without a history of MI, 3,976 patients, who also formed three subgroups: NYHA I 2,744 patients (69.0%); NYHA 981 patients (24.7%); NYHA III + IV 251 patients (6.3%). Multivariate analysis identified a history of MI as a consistent predictor of increased all-cause and cardiac mortality for patients with NYHA I, II and III + IV subgroups with escalating significance for patients with advanced functional capacity impairment: hazard ratios of 1.55 (95% CI 1.36-1.75), 1.56 (95% CI 1.30-1.86) and 1.72 (95% CI 1.24-2.40) for all-cause and 1.93 (95% CI 1.60-2.33), 1.73 (95% 1.35-2.20) and 3.22 (95% CI 1.87-5.54) for cardiac mortality, respectively., Conclusions: The prevalence of low functional capacity is similar among coronary patients with and without a history of MI, but their long-term survival differs substantially in favor of the latter. Therefore, two different types of CAD-related advanced functional capacity impairments (post-MI and non-post-MI) can be distinguished., (Copyright 2003 S. Karger AG, Basel)

Background and Purpose: Inflammation is considered to be involved in the pathogenesis of ischemic stroke. Our purpose was to assess the role of soluble intercellular adhesion molecule-1 (sICAM-1) concentration, a marker of inflammation, in predicting future ischemic stroke among patients at risk because of chronic coronary heart disease., Methods: We obtained baseline serum samples from patients with chronic coronary heart disease enrolled in the Bezafibrate Infarction Prevention trial (n=3090), which assessed the efficacy of bezafibrate in secondary prevention. Using a prospective nested case-control design, we measured baseline sICAM-1 concentration in sera of patients who developed ischemic stroke during a mean follow-up of 8.2 years (cases, n=134) and in age- and sex-matched controls without any subsequent cardiovascular events (n=134)., Results: Baseline serum concentrations of sICAM-1 were significantly higher in cases compared with controls (379 versus 350 ng/mL, P<0.05). sICAM-1 concentration at the highest quartile (>394 ng/mL) was associated with significantly higher relative odds of ischemic stroke compared with the lower concentrations after adjustment for potential confounding variables (relative odds, 2.1; 95% CI, 1.1 to 4.3). After fibrinogen and total white blood cell count were added to the multivariable model, the relative odds were 2.1 (95% CI, 1.1 to 4.2) and 2.2 (95% CI, 1.1 to 4.8), respectively. The risk associated with raised concentrations of sICAM-1 seemed to be highest for large disabling strokes of cardioembolic origin., Conclusions: Elevated concentrations of sICAM-1, a marker of inflammation, are associated with increased risk of ischemic stroke, independent of other traditional cerebrovascular risk factors and of plasma fibrinogen, among patients at increased risk because of manifest coronary heart disease.

Background: Clinical studies showing an association between immigration and increased prevalence of coronary risk factors or mortality rate in patients with coronary artery disease are scarce., Objectives: To compare the risk profile and mortality of coronary patients born in Israel with those who immigrated to Israel, and to determine whether recent immigration is associated with greater risk among immigrants from the Soviet Union., Methods: Demographic, clinical, and laboratory data were collected on chronic coronary artery disease patients from 18 Israeli medical centers during the screening period of the Bezafibrate Infarction Prevention Study in the early 1990s. Data on mortality after a mean 7.7 year follow-up were obtained from the Israel Population Registry., Results: While significant differences in mortality (14.7% vs. 18.5%, P < 0.001) were observed between Israeli-born patients and immigrants respectively, the mortality in these groups was similar when compared within specific age groups. Immigrants suffered more from hypertension and angina pectoris, and their New York Heart Association functional limitation class was higher, as compared to their Israeli-born counterparts. A multivariate analysis of mortality comparing patients from the Soviet Union who immigrated after 1970 with those who immigrated before 1970 showed an increased risk for newer immigrants, with a hazard ratio of 1.69 (95% confidence interval 1.19-2.40) for those immigrating between 1970 and 1984, and 1.68 (95% CI 1.01-2.28) for those immigrating between 1985 and 1991., Conclusion: The worse profile and prognosis observed among patients who recently emigrated from the Soviet Union cannot be explained by traditional risk factors for CAD such as smoking, diabetes, hypertension, and lipid disorders. Further investigation, including variables such as psychological stress to which immigrants are more exposed than others, is needed.