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Health Exercise Nutrition for the Really Young (HENRY) is a UK community–based early childhood obesity prevention intervention that was adopted and implemented in Israel between 2013 and 2018. The aim of this study was to explore the implementation process in Israel and compare it with that of the 'parent' programme in the UK, in order to throw light on the challenges of introducing complex interventions into different countries and cultures. Published reports from HENRY and Haifa University's evaluation of the Israeli implementation were reviewed and comparisons between the UK and Israel were carried out utilizing the RE-AIM framework. In both countries, the intention was to implement in lower SES communities. When comparing the individual items, Reach and Effectiveness, we found a difference in the Reach although Effectiveness was similar: Reach was proportionally lower in Israel, but parent and professional changes in behaviour were positive in both countries. For the organizational items Adoption, Implementation and Maintenance, we found large differences between the countries. Major challenges identified in Israel included: failing to take adequate account when planning and implementing the intervention of the different ways social and health services are organized and how local authorities are structured and provide services. In addition, differences in culture beyond language and professional variations were challenges, when trying to transfer the intervention with high fidelity from the UK to Israel. Lessons learnt may benefit others in attempting cross-country implementation of complex interventions [ABSTRACT FROM AUTHOR]

Transgender and gender non‐conforming people (TGNC), individuals whose gender identity differs from the sex they were assigned at birth, experience unique stressors, discrimination, and barriers to health and wellbeing. TGNC People of Colour (POC) navigate the nexus of racism, cisgenderism (and often homophobia) in their daily lives, resulting in uniquely intersecting forms of discrimination, and pronounced disparities in their health and well‐being. In order to examine the current state of knowledge about the health and wellbeing of TGNC POC, we conducted a systematic search and review of peer‐reviewed journal articles published between 1 January 2010 and 1 May 2020 that focused on this population. A systematic search identified (3,575) papers, with 76 of those meeting full inclusion criteria. In our review, we were able to identify physical health and psychological wellbeing (which included resilience), as core clusters of research focused on TGNC POC. We identified specific factors that hindered physical and psychological health (what we call "push" factors) as well as those that promoted it (what we call "pull" factors). Leveraging these findings, we offer ways forward for best practice in clinical work and carrying out research with this population. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement. [ABSTRACT FROM AUTHOR]

BACKGROUND: Exposure to heat during pregnancy has been associated with reduced fetal growth. Less is known about associations with cold and the potential for critical time windows of exposure. OBJECTIVES: We aimed to evaluate, in a national retrospective cohort, critical windows of susceptibility during pregnancy to extreme temperatures (low and high) and fetal growth, among 624,940 singleton term births in Israel during the period 2010–2014. METHODS: Temperature exposures were estimated using a spatially refined gridded climate data set with a 1-h and 1-km² resolution. Percentiles of temperature were categorized by climatic zone for the entire pregnancy and by trimesters and weeks. Generalized additive models with the distributed lag nonlinear model framework were used to estimate unadjusted and adjusted associations between percentiles and categories of temperature and fetal growth markers: term [births after 36 weeks of gestational age (GA)] mean birth weight and term low birth weight (tLBW, term infants with birth weight below 2,500 g). RESULTS: After adjustment, extreme temperatures (percentiles) during the entire pregnancy were associated with a lower mean birth weight {≤10th vs. 41st-50th percentile: -56 g [95% confidence interval (CI): -63 g, -50 g)]; >90th vs. 41st-50th percentile: -65 g; 95% CI: -72 g, -58 g}. Similar inverse U-shaped patterns were observed for all trimesters, with stronger associations for heat than for cold and for exposures during the third trimester. For heat, results suggest critical windows between 3-9 and 19-34 GA-weeks, with the strongest association estimated at 3 GA-weeks (temperature >90th vs. 41st-50th percentiles: -3.8 g; 95% CI: -7.1 g, -0.4 g). For cold, there was a consistent trend of null associations early in pregnancy and stronger inverse associations over time, with the strongest association at 36 GA-week (≤10th vs. 41st-50th percentiles: -2.9 g; 95% CI: -6:5 g, 0.7g). For tLBW, U-shape patterns were estimated for the entire pregnancy and third trimester exposures, as well as nonsignificant associations with heat for 29-36 GA-weeks. Generally, the patterns of associations with temperatures during the entire pregnancy were consistent when stratified by urbanicity and geocoding hierarchy, when estimated for daily minimum and maximum temperatures, when exposures were classified based on temperature distributions in 49 natural regions, and when estimated for all live births. DISCUSSION: Findings from our study of term live births in Israel (2010–2014) suggest that exposure to extreme temperatures, especially heat, during specific time windows may result in reduced fetal growth. [ABSTRACT FROM AUTHOR]

Objective: This qualitative study sought to obtain feedback from stakeholder cancer caregivers and bereaved family members on the implementation of bereavement risk screening in oncology. Methods: Semi‐structured interviews were conducted with 38 family members of patients with advanced cancer (n = 12) and bereaved family members (n = 26) on when and how to effectively implement bereavement risk screening. Data were analyzed using thematic analysis. Results: Many participants indicated that they would be open to completing a self‐report screening measure before and after the patient's death. Several suggested screening at multiple timepoints and the importance of follow‐up. Participants viewed screening as an opportunity to connect to psychosocial support. Conclusions: The findings suggest that family members appear supportive of sensitively approached bereavement risk screening before and after a patient's death as an important component of quality psychosocial care. To optimize implementation, bereavement risk screening would involve screening at multiple timepoints and include follow‐up. Findings suggest standardized risk screening using a brief, validated self‐report tool would be a pragmatic approach to increasing access to bereavement care. [ABSTRACT FROM AUTHOR]

The study explored how young adults with cancer create a cancer identity across the illness trajectory. Young adults with hematological cancers (n = 53, ages 20–39) completed a semi-structured interview and brief questionnaire. Deductive thematic analysis was used to code interviews. Four identity categories (Acceptance, Enrichment, Engulfment, and Rejection) were coded and linked to the cancer stage (pre-treatment, active treatment, post-treatment). Pre-treatment, there was minimal expression about identity. Acceptance during active treatment involved identity work around disclosure and the integration of pre-cancer identity with the treatment experience. Post-treatment, acceptance involved actively making sense of the cancer experience and its long-term impact; Enrichment was more frequent post-treatment. Engulfment was expressed most during treatment. Individuals who remained engulfed post-treatment expressed difficulties moving beyond the patient’s identity. Rejection of a cancer identity was rarely expressed. Understanding how young adults integrate the cancer experience into their identity may suggest intervention strategies. [ABSTRACT FROM AUTHOR]

Background The Stockholm Convention on Persistent Organic Pollutants (POPs) aims to eliminate or restrict the production and use of POPs around the globe. The Ministry of Health, collaborating with the Ministry of Environmental Protection, measured the exposure of the population to POPs as part of the WHO-coordinated exposure study. Human milk, with a relatively high fat content is a preferred matrix for the monitoring of exposure. Methods Donors of breast milk were recruited from three hospitals after signing informed consent forms. Breast milk was collected from 52 primipara women, aged 23-35, living in Israel for the last 10 years who gave birth to singleton full term healthy infants. Samples, collected at 3-17 weeks postpartum, were stored at -20 °C until sent to the WHO Reference Laboratory, State Laboratory for Chemical and Veterinary Analysis of Food (CVUA), in Frieburg, Germany for a single pooled analysis. Mothers were provided with the pooled analysis results. Results Out of over 50 Persistent Organic Pollutants listed in the analysis, 16, including aldrin, endrin, parlar and mirex were not found at detectable levels in the Israeli pooled sample. For the indicator compounds found at detectable levels, most were lower than those reported in European countries. Discussion Since 1982, levels of POPs contamination as measured in breast milk have declined significantly. This is likely due to restrictions on agricultural, industrial, and other uses of many POPs in Israel. Ongoing biomonitoring in Israel and inter-ministerial collaboration supports the elimination of POPs in the environment and human milk. [ABSTRACT FROM AUTHOR]

Background: Statins are the treatment of choice for dyslipidemia, primarily lowering elevated LDL-C levels and reducing the occurrence of major cardiovascular events. In June 2011, the Food and Drug Administration issued a warning regarding the use of high-dose simvastatin 80 mg and its risk of myopathy. Objective: The incidence of myalgia, myopathy, and rhabdomyolysis was analyzed in a veteran population prescribed simvastatin 80 mg. Risk factors for myalgia were examined and compared with the results of recently published studies. Methods: This was a retrospective medical record review of 450 patients who were prescribed simvastatin 80 mg at the Veterans Affairs Western New York Healthcare System between August 1, 2006, and July 31, 2011. Records were examined for evidence of myalgia, myopathy (incipient or definite), and rhabdomyolysis. Variables that may have contributed to the development of myalgia were also collected and analyzed. Results: Myalgia was reported by 50 patients (11.1%), whereas rhabdomyolysis developed in 1 patient (0.22%). No patient fit the criteria for myopathy (incipient or definite). Myalgia was statistically more likely to occur in younger patients, patients with a history of myalgia, and patients with low vitamin D levels. The mean (SD) vitamin D level in patients experiencing myalgia was 26.2 (12.9) versus 36.3 (11.8) ng/mL. The 25-hydroxyvitamin D level in those who reported myalgia was approximately 10 ng/mL lower compared with those who tolerated simvastatin 80 mg (P = 0.0003). There was no statistically significant association between length of therapy and development of myalgia. Conclusion: A lower incidence of adverse muscle events with high-dose simvastatin 80 mg was found in patients with higher vitamin D levels, suggesting that correction of 25-hydroxyvitamin D levels before statin therapy initiation may mitigate one risk factor in the development of statin-related myalgia. Vitamin D insufficiency appears to be a risk factor for the development of myalgia. [ABSTRACT FROM AUTHOR]

Objective The current paper utilizes qualitative methods to better understand the support needs and resources of sexual minority women (SMW) breast cancer patients. Methods Thirteen semi-structured interviews were conducted with SMW, who were recruited from community-based organizations and had undergone mastectomy for treatment of breast cancer. Interviews explored support needs and resources. Data were analyzed using thematic analysis. Results Three key domains emerged: support groups, family of origin support, and partner support. Participants emphasized the value of cancer support groups and resources tailored to SMW while stating that other dimensions of identity or experience, particularly age and cancer stage, were also important. Participants noted the dearth of social support resources for same-sex partners. Family of origin and partners were typically participants' primary sources of tangible and emotional support; participants often engaged in protective buffering to mitigate caregivers' distress. Single women faced the greatest challenges in terms of support needs and resources. Former partners were often key sources of support. Conclusions SMW and their partners have many shared and unique support resources and barriers. Heteronormativity that is implicit in the structure of support resources can serve as a barrier to support for SMW and their partners. Flexibility in relationship roles enabling some SMW to include former partners as significant means of support may be a source of resiliency, particularly for unpartnered SMW cancer patients. Support needs and resources of SMW are best understood through an intersectionality framework that considers sexual orientation, relationship status, cancer stage, age, healthcare access, and other important identities and experiences. Copyright © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Studies have shown that BRCA1/2 mutation carriers are interested in learning about reproductive options such as preimplantation genetic diagnosis (PGD) to prevent passing their risk onto their children. However, attitudes vary widely, and the procedure raises complex ethical and psychosocial issues. This complexity, plus the highly technical nature of PGD, makes it difficult to integrate PGD information into genetic counseling sessions that already cover probabilistic, emotionally charged risk information.Methods: A total of 33 carriers of the BRCA1/2 mutation who were of reproductive age and had previously undergone genetic counseling viewed a tutorial regarding PGD and were interviewed concerning their attitudes toward PGD and preferences about how to include PGD information in genetic counseling.Results: The majority of participants preferred to be briefly informed of the availability of PGD information, and to receive written materials regarding PGD, but with the option of deferring detailed discussion if they already believed themselves to be overloaded or perceived that PGD was not immediately relevant to their risk management and/or childbearing plans. For some individuals, the stress of testing temporarily interfered with information processing, producing states of cognitive avoidance ("in a fog," or "tuning out"). Some preferred to discuss PGD with a physician with whom they had an ongoing relationship (eg, obstetrician/gynecologist, primary care provider, or oncologist).Conclusions: Providers offering cancer genetic testing may consider indicating the availability of PGD information to their patients, while attending to the patients' level of interest and ability to absorb information. Research is needed to link patient responses to information overload with psychosocial outcomes (eg, distress, and quality of decision-making). Continuing medical education is needed to support providers in facilitating informed decisions regarding PGD. [ABSTRACT FROM AUTHOR]

Abstract: Background: In 1993, the Israel Ministry of Health issued a formal recommendation to avoid placing healthy infants to sleep in the prone position in order to prevent sudden infant death. The objective of the study was to study parents'' compliance with this recommendation and to identify characteristics of noncompliant parents of infants aged less than 6 months old. Methods: The study population consisted of 1912 parents of infants aged 0¿12 months who visited the Haifa District primary preventive health centers during the study week and answered the self-administered questionnaire. Results: 15.6% of infants younger than 1 year were placed to sleep in the prone position: 12.4% among infants younger than 3 months, and 17.6% among infants 3¿6 months old. Surprisingly, multiple logistic regression analysis demonstrated that Israeli-born Jewish mothers were more likely to place their babies prone than Israeli-born Arab mothers or mothers born in the former Soviet Union who had immigrated to Israel after 1990. Conclusions: At-risk behaviors are usually associated with minority and immigrant populations. Culture specific and other possible reasons for our unusual findings are discussed. [Copyright &y& Elsevier]

Background: Israel is a regional "hotspot" of plastic pollution, with little discussion of potential adverse health effects from exposure to plastic. This review aims to stimulate discussion and drive policy by focusing on these adverse health effects., Main Body: Plastics are synthetic polymers containing additives which can leach from food- and beverage-contact plastic into our food and beverages, and from plastic textiles onto our skin. Plastics persist in the environment for generations, fragmenting into MNPs: Micro (1 micron-5 mm)-Nano (1 nm-1 micron)-Plastic, which contaminate our atmosphere, water, and food chain. MNP can enter the human body through ingestion, inhalation and touch. MNP < 10 microns can cross epithelial barriers in the respiratory and gastrointestinal systems, and fragments < 100 nm can cross intact skin, enabling entry into body tissues. MNP have been found in multiple organs of the human body. Patients with MNP in atheromas of carotid arteries have increased risk of a combined measure of stroke, cardiovascular disease, and death. Toxic additives to plastics include bisphenols, phthalates, and PFAS, endocrine-disrupting chemicals (EDCs) which cause dysregulation of thyroid function, reproduction, and metabolism, including increased risk of obesity, diabetes, endometriosis, cancer, and decreased fertility, sperm count and quality. Fetal exposure to EDCs is associated with increased rates of miscarriages, prematurity and low birth weight. There is likely no safe level of exposure to EDCs, with increasing evidence of trans-generational and epigenetic effects. There are several existing Israeli laws to reduce plastic use and waste. Taxes on single-use plastic (SUP) were recently cancelled. There are many gaps in regulatory standards for food-, beverage- and child- safe plastic. Existing standards are poorly enforced., Conclusion: Reduction in production and use of plastic, promotion of recycling and reduction of leaching of toxic additives into our food and beverages are essential policy goals. Specific recommendations: Periodic monitoring of MNP in bottled beverages, food, indoor air; Strengthen enforcement of standards for food-, beverage-, and child-safe plastic; Renew tax on SUPs; National ban on SUP at public beaches, nature reserves and parks; Ban products manufactured with MNP; Increase research on sources and health outcomes of exposure to MNP and EDCs., (© 2024. The Author(s).)

This review provides an overview of patient experiences of endometriosis, endometriosis-related types and sources of stigma pertaining to menstruation, chronic pain, and infertility, and their impact on patients' mental health with particular implications for patient care. Because endometriosis is a complex disease with multifactorial etiology, complicated pathophysiology, and a spectrum of clinical features, diagnosis of endometriosis is typically a lengthy process, and many patients experience initial misdiagnosis. A hallmark symptom is severe menstrual pain with other symptoms including chronic pelvic pain, dysmenorrhea, and infertility. Prior research documents that the diagnostic odyssey, complex management, disabling and unpredictable nature of the disease, and painful symptom profile affect multiple life domains of patients, resulting in poor physical, social, and psychological functioning and clinically-significant rates of anxiety and depression for many. More recently, stigma has been recognized as a potent contributor to poor mental health in endometriosis patients, but existing research is limited and largely atheoretical. We identify major sources of stigma related to endometriosis, including menstrual stigma, chronic pain stigma, and infertility stigma, and their likely impact on patients and health care provision. An integrative theoretical approach is described to facilitate research on the prevalence and effects of endometriosis stigma and their explanatory mechanisms, highlighting specific well-validated psychological instruments to assess stigma. Implications for patient care are emphasized. Better understanding of stigma and mental health in people with endometriosis will enhance the standard of care for this patient population., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: There are ongoing changes around the world in the training and practice of pediatricians who work in the community. These changes are driven by the understanding that pediatricians are required to provide not only acute primary care but also to address more comprehensive concerns, particularly the 'new morbidities'. The present study examines the professional identity of Israeli pediatricians in the community in light of these changes, the barriers and challenges to their work and professional adaptations in the field., Methods: We used a mixed-methods approach, collecting the perspectives of 137 pediatricians who work in the community through an anonymous online survey, followed by in-depth semi-structured interviews with 11 community pediatricians., Results: The survey results show that community pediatricians in Israel have limited knowledge on a variety of developmental, behavioral and emotional issues; that they lack working relationships with medical or other professionals; and are rarely engaged with other community services. Three main themes arose from the interviews that support and deepen the survey results: perceptions of the profession (pediatrics in the community vs. community pediatrics), the stature of pediatricians in the community (during residency, the choice to work in the community, their daily work) and barriers and change in community pediatrics (isolation, limited resources and challenges arising from the nature of community work)., Conclusions: The present study sheds light on the professional identity and the day-to-day challenges and successes of pediatricians working in the community. Continuing medical education, providing a supportive framework and professional community, better resources, more time with patients, and tools and opportunities for professional development would help pediatricians who work in the community to overcome some of these challenges. The research findings reinforce the need for policy change in the field of community pediatrics with a specific community training curriculum, provision of more resources and ongoing support for pediatricians. This requires partnership between the HMOs, the Ministry of Health, the Scientific Council (Israel Medical Association, professional organizations) and NGOs in order to turn individual-level solutions into system-level and policy-changing solutions., (© 2023. The Author(s).)

Background: Resource trade-off theory suggests that increased performance on a given trait comes at the cost of decreased performance on other traits., Methods: Growth data from 1889 subjects (996 girls) were used from the GrowUp1974 Gothenburg study. Energy Trade-Off (ETO) between height and weight for individuals with extreme body types was characterized using a novel ETO-Score (ETOS). Four extreme body types were defined based on height and ETOI at early adulthood: tall-slender, short-stout, short-slender, and tall-stout; their growth trajectories assessed from ages 0.5-17.5 years.A GWAS using UK BioBank data was conducted to identify gene variants associated with height, BMI, and for the first time with ETOS., Results: Height and ETOS trajectories show a two-hit pattern with profound changes during early infancy and at puberty for tall-slender and short-stout body types. Several loci (including FTO, ADCY3, GDF5, ) and pathways were identified by GWAS as being highly associated with ETOS. The most strongly associated pathways were related to "extracellular matrix," "signal transduction," "chromatin organization," and "energy metabolism.", Conclusions: ETOS represents a novel anthropometric trait with utility in describing body types. We discovered the multiple genomic loci and pathways probably involved in energy trade-off., Competing Interests: Conflict of Interest The authors have declared that no conflict of interest exists., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Birthweight is often used as an indicator of fetal health. Categorization of infants as small or large for gestational age has clinical significance. Due to growth differences between countries, it is important to have local reference data. The aim of the study was to describe an Israel population-based reference of birthweight by gestational age stratified for singletons/multiple births and gender., Methods: Data on birthweight and gestational age were obtained for the years 2010-2019 from the Ministry of Health Birth Registry. Implausible birthweight and gestational age values were excluded in a two step process. First, overtly implausible values were excluded using visual mapping. Then, infants whose birthweight was below or above the fifth interquartile range for each completed week were excluded., Results: During the 10-year period there were 1,761,884 infants delivered in Israel; 1,689,696 were included in the analysis. 4.4% of the live born infants were from multiple births. The mean birthweight of singletons (3251 g) was 947 ± 4 g higher than that of multiples (2304 g). The birthweight of the male multiple births began to differ from that of the singletons at 30 weeks; female multiple births began to deviate at 31 weeks. The increase in birthweight of singletons leveled after 42 weeks and those born after 43 weeks weighed less than infants born earlier. Comparison of the curves for singletons from the present study to those reported for the years 1993-2001 reveal a similar median but significant differences in the distribution of lower and higher percentiles., Conclusions: Improved data collection and validation permitted inclusion of 96% of births for analysis. Use of interquartile range distribution to exclude values of birthweight/gestational age that were implausible improved validity. Compared to curves reported previously, changes were found in the distribution of birthweights for the upper and lower percentiles. Periodic updates of growth curve references are important., (© 2022 Lisa Rubin et al., published by De Gruyter, Berlin/Boston.)

Background: Data on growth of Israeli school children show that children from Jewish ultra-orthodox Haredi and Bedouin Arab families have a higher prevalence of stature below the 3rd percentile. While these populations are usually from lower socioeconomic strata, they also have larger families. This study aimed to evaluate if family structure and the timing of a child's infancy-childhood transition (ICT) are central to variations in stature., Study Design: We analyzed the association between family size, birth order and inter-birth interval with child growth and the age at ICT in 3 groups of children, 148 high birth order children from large families (LF ≥ 6), 118 low birth order children from large families (LF ≤ 3) and 150 children from small families (SF)., Results: High birth order children from large families were shorter in childhood than children from small families with a difference of 0.5 SDS in length. We found that birth length and birth order explained 35% of the total variance in infancy length whereas ICT age and infancy length explained 72% of the total variance in childhood length., Conclusion: Infancy and childhood length are compromised in children from large families. As the family grows larger the younger children tend to be shorter. Reduced length gain in the period between infancy to childhood is when growth is most affected., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 German, Rubin, Raisin and Hochberg.)

Objective: To analyze psychometric properties of two novel instruments assessing decisional distress and uncertainty experienced by individuals considering preimplantation genetic testing (PGT)., Methods: The new PGT Decisional Distress instrument (22 items) assesses negative/positive emotions. The new PGT Decisional Uncertainty instrument assesses Clarity about test benefits/disadvantages (5 items) and Certainty of having adequate information/support to make a good decision (7 items). Scales ranged from 0 to 4. Psychometrics (central tendencies, internal consistency reliability, and discriminant validity) were evaluated. Stratified analysis by decision stage was conducted. All participants had considered or used PGT in the previous 6 months., Results: N = 106 females (mean age 36.5 ± 4.8 years; 16% non-Caucasian; 9% Hispanic) across 16 US states completed an online anonymous questionnaire. On average, respondents reported minimal distress (mean 0.96), high clarity (mean 3.26), and high certainty (mean 3.06), particularly those who had already decided compared to undecided women (P ≤ .02). Instruments had excellent internal consistency (Cronbach's α's 0.92-0.94) and displayed sufficient inter-individual variability (SD's 0.75-0.89). Correlations confirmed expected patterns of association between instruments (P's < .01), indicating discriminant validity., Conclusion: We document initial reliability and validity of new instruments to measure emotional distress and uncertainty in female patients who have recently considered PGT for single-gene or chromosomal disorders., (© 2020 John Wiley & Sons, Ltd.)

Increasing numbers of children with developmental, emotional, and psychosocial issues require adaptation of the services provided by pediatricians in the community. An international workshop that took place in Israel on June 3-4, 2019, addressed this need. Local policy makers and international experts discussed the following topics: (1) the future of training in community pediatrics; (2) enhancing the prestige of the community pediatrician; (3) development of management and research skills; (4) academic advancement within community pediatrics; (5) the future content of community pediatric practice; (6) visit length and community pediatricians' reimbursement; (7) developing the collaborative model of care in community pediatrics and (8) integrating child healthcare. The meeting provided a venue to understand the challenges and to formulate recommendations to policymakers. A key target highlighted was the increased exposure of all pediatric residents to community pediatrics. This gained the support of the Chief Executive Officers of all four Health Funds in Israel. This document provides a synopsis of the topics addressed and suggested recommendations.

Background: The Israeli Newborn Hearing Screening Program (NHSP) began operating nationally in January 2010. The program includes the Otoacoustic Emissions (OAE) test for all newborns and Automated Auditory Brainstem Response (A-ABR) test for failed OAE and infants at risk for auditory neuropathy spectrum disorders. NHSP targets are diagnosis of hearing impairment by age three months and initiation of habilitation by six months., Objectives: (1) Review NHSP coverage; (2) Assess NHSP impact on age at diagnosis for hearing impairment and age at initiation of habilitation; (3) Identify contributing factors and barriers to NHSP success., Methods: (1) Analysis of screening coverage and referral rates for the NHSP; (2) Analysis of demographic data, results of coverage, age at diagnosis and initiation of habilitation for hearing impaired infants pre-implementation and post-implementation of NHSP from 10 habilitation centers; (3) Telephone interviews with parents whose infants failed the screening and were referred for further testing., Results: The NHSP coverage was 98.7% (95.1 to 100%) for approximately 179,000 live births per year for 2014-2016 and average referral rates were under 3%. After three years of program implementation, median age at diagnosis was 3.7 months compared to 9.5 months prior to NHSP. The median age at initiation of habilitation after three years of NHSP was 9.4 months compared to 19.0 prior to NHSP. Parents (84% of 483 sampled) with infants aged 4-6 months participated in the telephone survey. While 84% of parents reported receiving a verbal explanation of the screening results, more than half of the parents reported not receiving written material. Parental report of understanding the test results and a heightened level of concern over the failed screen were associated with timely follow-up., Conclusions: The findings indicate high screening coverage. The program reduced ages at diagnosis and initiation of habilitation for hearing impaired infants. Further steps needed to streamline the NHSP are improving communication among caregivers to parents to reduce anxiety; increasing efficiency in transferring information between service providers using advanced technology while ensuring continuum of care; reducing wait time for follow-up testing in order to meet program objectives. Establishment of a routine monitoring system is underway.

Israel is home to a child-oriented society that values strong family ties, universal child benefits, and free education for all children from 3 years of age to school grade 12. Alongside the universal health-care services that are guaranteed by the National Health Insurance Law and strong, community-based primary and preventive care services, these values have resulted in good maternal and child health. In 2015, infant and maternal mortality (3·1 deaths per 1000 livebirths and 2·0 deaths per 100 000 livebirths, respectively) were lower than the mean infant and maternal mortality of countries within the Organisation for Economic Co-operation and Development. Israel has already exceeded the developed regions' Sustainable Development Goal 2030 targets for maternal mortality, neonatal mortality, and mortality in children younger than 5 years in all population groups. Yet these accomplishments are marred by Israel's high prevalence of child poverty (more than 30%), particularly among Arabs (63%) and ultra-Orthodox Jews (67%). Although infant mortality has improved in all subpopulations since Israel was founded in 1948, infant mortality among Arabs is still more than twice as high as among Jews. To address these disparities in health, the Israeli Ministry of Health has created a special division and has funded an intervention programme to reduce the infant mortality among Bedouin Arabs. Other interventions include targeted and culturally appropriate health-care programmes and services for communities with a high number of at-risk children and young adults, dental health service for all children up to 15 years, and improved collaboration between health, education, and welfare services. The challenges faced by the Israeli health-care system include a growing trend towards medicalisation of prenatal care, ensuring staff are trained to treat developmental, behavioural, and psychosocial issues in children and their families, securing sustainable funding for health promotion and injury prevention programmes, expanding and improving the coordination of services for children with special needs or who are at risk, and programme assessment. Ensuring adequate funding for dedicated, preventive paediatric care and taking action on a nationwide scale to reduce child poverty are essential for maintaining health gains in children. In this Series paper, we describe the health indices, highlight disparities, and discuss the challenges in delivering and maintaining maternal and child health care in Israel., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Despite a growing body of research examining the psychosocial issues involved in oocyte donation, few studies have examined the role of information in the process of donor selection. The aim of this interview-based qualitative study was to understand how donor oocyte recipients relate to information provided about potential oocyte donors, how they use this information to select donors and their preferences for, and reactions to, various types of information provided to them. Donor oocyte recipients who underwent treatment between 1995 and 2011 were recruited for participation from an academic centre for reproductive medicine. Twenty-two oocyte donor recipients participated. Findings indicate that recipients use information to select donors who they believe would enable them to fulfill their priorities: having a healthy child and 'passing' as genetically related. Obtaining more specific information prompted a focus on donor imperfections and presented a burden of choosing. Moreover, for participants preferring distance, having more information created dilemmas by making the donors less abstract. Although more information and options are often desired by oocyte donor recipients, increased choice can also present psychological dilemmas and emotional costs. Further research is needed to investigate the influence of information-related conflicts on patient decision-making, post-treatment emotional adjustment and disclosure decisions., (Copyright © 2014 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Prior studies raise concern about gender bias in cancer research, including insufficient inclusion of women or men, or studying women and men differently. The 1993 National Institutes of Health Revitalization Act aimed to eliminate gender bias in medicine. To examine changes in medical and psychological literature, this study reviews gender representation in biomedical treatment studies and psychosocial survivorship studies published in a single year., Methods: Research published in Cancer in 2007, and all empirical psychological studies about cancer published that year, provided a 15-year update to findings reported by Meyerowitz and Hart. The gender distribution and context of included articles were coded and compared with findings from 1983 and 1992., Results: Across biomedical studies, 34.3% of subjects were women (vs 47% of new cancers and 48% of cancer deaths). Among men, 41.3% had sex-specific cancers (vs 12.5% [1983] and 12.3% [1992]). Among women, 46.1% had sex-specific cancers (vs 69.1% [1983] and 64.6% [1992]). Fewer women (36.8%) were represented in sex-nonspecific cancer studies (vs 41.4% [1983] and 42.5% [1992]); however, fewer studies had a significant (>20%) gender disparity. Across psychosocial studies, representation of men increased to 47.9% (vs 30.4% [1983] and 29.9% [1992]). The proportion of men in studies of feelings/relationships increased to 47% (vs 22.9% [1992]); the proportion of women in studies assessing physical/functional ability increased to 58.3% (vs 45.4%)., Conclusions: Women remain under-represented in sex-nonspecific biomedical research, whereas men's representation in sex-specific research increased substantially. Psychosocial research trends suggest movement from research questions supporting traditional stereotypes that women feel and men act., (Copyright © 2012 American Cancer Society.)

Deleterious mutations in the BRCA1/BRCA2 genes elevate lifetime risk of breast and ovarian cancer. Each child of a mutation-positive parent has a 50% chance of inheriting it. Preimplantation genetic diagnosis (PGD) permits prospective parents to avoid the birth of a BRCA-mutation-positive child, introducing predictability into a process historically defined by chance. This investigation explored how BRCA1/2 mutation carriers understand genetic inheritance and consider a child's inheritance of a BRCA1/2 mutation, given the opportunities that exist to pursue PGD. Thirty-nine female and male BRCA1/2 mutation carriers of reproductive age were recruited from urban cancer and reproductive medical centers. Participants completed a standardized educational presentation on PGD and prenatal diagnosis, with pre- and posttest assessments. An interdisciplinary team of qualitative researchers analyzed data using grounded theory techniques. Participants expressed the belief that reproduction yields children with unique genetic strengths and challenges, including the BRCA1/2 mutation, family traits for which predictive tests do not exist, and hypothetical genetic risks. Participants expressed preference for biologically related children, yet stated their genetically "well" partner's lineage would be marred through reproductive merger, requiring the well partner to assume the burden of the BRCA1/2 mutation via their children. Participants expressed diverse views of genetically "well" partners' participation in family planning and risk management decisions. Pressure to use reprogenetic technology may grow as genetic susceptibility testing becomes more widely available. Work with individuals and couples across the disease spectrum must be attuned to the ways beliefs about genetic inheritance play into reproductive decision-making.

Objective: To investigate relationships between institutional mistrust (systematic discrimination, organizational suspicion, and conspiracy beliefs), HIV risk behaviors, and HIV testing in a multiethnic sample of men who have sex with men (MSM), and to test whether perceived susceptibility to HIV mediates these relationships for White and ethnic minority MSM., Method: Participants were 394 MSM residing in Central Arizona (M age = 37 years). Three dimensions of mistrust were examined, including organizational suspicion, conspiracy beliefs, and systematic discrimination. Assessments of sexual risk behavior, HIV testing, and perceived susceptibility to HIV were made at study entry (T1) and again 6 months later (T2)., Results: There were no main effects of institutional mistrust dimensions or ethnic minority status on T2 risk behavior, but the interaction of systematic discrimination and conspiracy beliefs with minority status was significant such that higher levels of systematic discrimination and more conspiracy beliefs were associated with increased risk only among ethnic minority MSM. Higher levels of systematic discrimination were significantly related to lower likelihood for HIV testing, and the interaction of organizational suspicion with minority status was significant such that greater levels of organizational suspicion were related to less likelihood of having been tested for HIV among ethnic minority MSM. Perceived susceptibility did not mediate these relationships., Conclusion: Findings suggest that it is important to look further into the differential effects of institutional mistrust across marginalized groups, including sexual and ethnic minorities. Aspects of mistrust should be addressed in HIV prevention and counseling efforts.

The goal of postmastectomy breast reconstruction is to restore a woman's body image and to satisfy her personal expectations regarding the results of surgery. Studies in other surgical areas have shown that unrecognized or unfulfilled expectations may predict dissatisfaction more strongly than even the technical success of the surgery. Patient expectations play an especially critical role in elective procedures, such as cancer reconstruction, where the patient's primary motivation is improved health-related quality of life. In breast reconstruction, assessment of patient expectations is therefore vital to optimal patient care. This report summarizes the existing literature on patient expectations regarding breast reconstruction, and provides a viewpoint on how this field can evolve. Specifically, we consider how systematic measurement and management of patient expectations may improve patient education, shared medical decision-making and patient perception of outcomes.

Purpose: The case of a patient who was successfully treated with i.v. phenytoin for an acute exacerbation of refractory trigeminal neuralgia (TN) is reported., Summary: A 77-year-old, 87-kg Caucasian man with a 12-year history of right-sided, classical TN was admitted for an acute exacerbation of TN refractory to pharmacologic treatment with carbamazepine, baclofen, hydrocodone-acetaminophen, tramadol, hydromorphone, and gabapentin. His medical history included atrial fibrillation, peripheral vascular disease, benign prostatic hyperplasia, and chronic ataxia secondary to antibiotic therapy in the 1970s. His outpatient medications included carbamazepine, warfarin, ergocalciferol, and saw palmetto. A 15-mg/kg dose of i.v. phenytoin sodium (1300 mg on the basis of total body weight) was recommended by neurology consultants. Because of potential adverse reactions related to high serum phenytoin concentrations and rapid infusion rates (e.g., hypotension, ataxia, nausea, vomiting, apnea, nystagmus), the patient's age, the baseline presence of atrial fibrillation and ataxia, and the fact that seizures were not being treated, the clinical pharmacist recommended dividing the 1300-mg dose into two 650-mg doses separated by four hours, with each infused at 25 mg/min; this suggestion was accepted. The patient's pain score dropped from a self-rated 12/10 to 2/10 after the first infusion and to 1/10 after completion of the second infusion. The patient's blood pressure and heart rate were monitored via telemetry every five minutes during both infusions. No adverse events were noted., Conclusion: Phenytoin sodium 15 mg/kg i.v. divided into two doses separated by four hours was safe and effective in treating an acute exacerbation of refractory TN.

Aim: We aimed to study the association between day care attendance and changes in the height, weight and weight/height ratio over a 6-month period., Methods: Data were retrieved from three maternal and child health care centres. Parents were asked to fill a short questionnaire regarding the infant/toddler life style, the day care facilities and the family demographic information., Results: One hundred and seventy infants participated in the study. The research group consisted of 85 infants that had placed in day care centre prior to the age of 18 months. The control group consisted of 85 infants who had placed in day care at a later age. The research group had significantly shorter stature 3 months after day care enrolment (mean height percentiles of 56.9 versus 66.3, respectively, p = 0.024,). This trend was more pronounced after 6 months (mean height percentiles of 52.3 versus 63.7, p = 0.022). We could not, however, demonstrate a concomitant significant deceleration in weight or weight/height percentiles., Conclusions: The explanation for this rather dramatic finding remains speculative. Possible mechanisms are stress-related growth hormone suppression. Our findings reinforce the importance of monitoring infant/toddler weight and height growth velocities, especially when he/she is introduced to day care., (© 2010 The Author(s)/Acta Paediatrica © 2010 Foundation Acta Paediatrica.)

Background & Aims: We aimed to study the personal compliance of physicians and nurses with recommendations for the administration of iron supplements for their own children and their compliance with the routine child and maternal health care surveillance recommended during the first year of life., Methods: Five hundred physicians and nurses from Haifa and Tel Aviv area working in hospitals and the community were asked to answer a self administered questionnaire. The questionnaire included questions assessing their compliance (using a 100 mm analogue visual scale) with iron and vitamin A + D supplementation, immunizations and routine examinations at the child and maternal health care center for their children., Results: One hundred and forty one physicians and 135 nurses (55.2%) cooperated and returned the questionnaire. We found that 41.2% of medical personnel graded their compliance with iron supplementations as 6 or less, in a scale of 0-10. Significant differences were found between the different professions. Nurses were significantly more compliant compared to physicians (54.9% of nurses reported full compliance compared to only 32.4% of physicians, (p = 0.001)). The degree of seniority also affected compliance. Specialists were significantly less compliant compared to interns (22% vs. 38.8% respectively). Certified nurses were also less compliant compared to uncertified nurses (52.9% vs. 61.5% respectively). Significant differences between physicians and nurses were also noted in A + D administration and routine health visits. Although nurses demonstrated more compliance with vaccinations these differences were not significant (p = 0.076)., Conclusions: The compliance of medical staff for iron and A + D administration to their own children is poor especially among physicians., (Copyright © 2010 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: The rate and duration of breastfeeding in Ethiopia is very high. Factors that could affect breastfeeding among women emigrating to Israel include the desire to adopt "modern" behaviors, the availability of infant formulas, and the greater awareness of AIDS and fear of transmission via breast milk., Objectives: To examine the rate and duration of breastfeeding among recent Ethiopian immigrants to Israel., Methods: Using a structured questionnaire we interviewed 93 Ethiopian born mothers of children aged 2 months to 5 years living in northern Israel., Results: Ninety-two percent of the children born in Ethiopia were exclusively breastfed as compared to 76.3% of the Israeli born children, in whom the rate of mixed feeding was 18.3%. Although the duration of breastfeeding of the youngest child was significantly shorter than that of the firstborn (20.1 vs. 24.8 months), it remains much longer than the average duration for native Israeli mothers. No association was seen between breastfeeding rate or duration and the years since immigration, work outside the home or exposure to formula. The women's attitude towards breastfeeding was positive despite the lack of specific knowledge concerning breast milk and infant formulas., Conclusions: Breastfeeding patterns among Ethiopian women have changed since their immigration to Israel. These changes probably reflect the cultural and societal pressures to acculturate to the mores of the adopted society. Reinforcing traditional family and peer support for these women is important to preserve breastfeeding in this population. This should be done within the context of changes that support breastfeeding in Israeli society.

Background: Ultrasound examination of the fetus enables diagnosis of many major malformations during pregnancy, providing the possibility to consider termination of the pregnancy. As a result, in many cases the incidence of malformations at birth does not represent their true incidence., Objectives: To determine the impact of prenatal diagnosis and pregnancy termination on the relative incidence of malformations at birth among Jews and Muslim Arabs in Israel., Methods: Data on selected major malformations in 2000-2003 were collected from the two large central databases of the Ministry of Health and the Central Bureau of Statistics which contain information regarding births, stillbirths and terminations of pregnancies., Results: For many malformations the total incidence was much higher than the incidence at birth. For almost all of the malformations studied, the total incidence was higher in Muslims than in Jews and the differences were further accentuated among the liveborn because of the differences in the rate of pregnancy terminations., Conclusions: In order to detect possible influences of environmental or genetic factors on major malformations in Israel, it is critical to look at data including pregnancy terminations, stillbirths and live births.

Background: An outbreak of pertussis occurred in a daycare center with 87.5% vaccination coverage., Objectives: To assess the effectiveness of the acellular pertussis vaccine and prevention of pertussis after chemoprophylaxis with azithromycin., Methods: We studied 31 daycare children aged 3-5.5 years exposed to a child with pertussis. Nasopharyngeal swabs were obtained for Bordetella pertussis culture and polymerase chain reaction initially, and at days 21 and 60 of follow-up, in cases exhibiting symptoms., Results: Of the 31 daycare children 6 (19%) tested positive for 8. pertussis by PCR, 4 of whom had not been vaccinated against the disease. Of the two vaccinated children who contracted pertussis, one had milder symptoms and the other was asymptomatic. The incidence of pertussis was significantly lower in the vaccinated group (2/27) than in the unvaccinated group (4/4) (P = 0.000), with efficacy of the vaccine calculated to be 92.5%. Azithromycin chemoprophylaxis was taken only by 14 of the 25 exposed children (56%). On day 21 follow-up, there was no further laboratory-diagnosed B. pertussis cases in any of the exposed children, regardless of whether or not chemoprophylaxis was taken., Conclusions: Based o the children's clinical manifestations and PCR findings a pertussis outbreak had occurred in the daycare center studied. Our findings support the importance of pertussis vaccination since all the unvaccinated children in the daycare center contracted the infection.

Objective: The aim was to measure patient satisfaction with the Pharmacy Specialty Immunization Clinic (PSIC), a pharmacist-run vaccination clinic., Methods: Patient satisfaction was measured using a non-validated instrument containing 10 items with a five-point Likert scale (strongly agree, agree, not sure, disagree and strongly disagree). Patients who were seen at the PSIC and who received at least one vaccination were eligible to take part in the patient satisfaction survey. Priority index, a method used to identify areas where limited resources can be used to maximize patient satisfaction, was calculated for the different items of the instrument to determine areas for quality improvement. This study was conducted at the Veterans Affairs San Diego Healthcare System (VASDHS)., Key Findings: A total of 188 (55.1%) out of 341 patients who received at least one vaccine in the PSIC completed the survey. Prior to any encounter with the PSIC, patients perceived that the VASDHS was doing a good job providing vaccinations (92.5% answered agree or strongly agree). This perception continued when asked about overall satisfaction after receiving vaccination through the PSIC (86.9% answered agree or strongly agree). When asked about the time the pharmacist spent with the patient, nearly all answered that the pharmacist spent as much time as necessary (97.8% answered agree or strongly agree). Patient satisfaction with pharmacist counselling was equally well received and reflected good communication between patient and pharmacist (97.8% answered agree or strongly agree). In regard to pharmacist competency, 98.9% (n = 184) of patients agreed that pharmacists in the PSIC administered vaccinations appropriately. Priority index identified access to the vaccine as an area where performance-improvement efforts should be committed to improve patient satisfaction., Conclusions: Patients perceived good overall satisfaction with the pharmacist-run immunization clinic in terms of professionalism and access to vaccination. Priority index identified access to vaccination as a focus for future quality improvement.

This study was designed to measure the magnitude and duration of inhibition of platelet aggregation following doses of aspirin or ibuprofen alone or taken in combination in a group of healthy volunteers. Ten normal volunteer subjects underwent 3 randomized treatment sessions: aspirin 325 mg alone, ibuprofen 400 mg alone, and ibuprofen 400 mg, followed by dosing with aspirin 325 mg 2 hours thereafter. In addition, a confirmatory study was performed in patients. Over 27 months, a cohort of patients treated with aspirin for secondary stroke prophylaxis while concomitantly taking a nonsteroidal anti-inflammatory drug (NSAID) was identified. A significant reduction was found in both the magnitude and duration of aspirin's inhibitory effect on platelet aggregation when ibuprofen was given prior to aspirin administration in normal volunteer subjects. During a 27-month period, a cohort of 28 patients took regular daily doses of ibuprofen or naproxen. Of these 28 patients, 18 returned for follow-up testing in the absence of this pharmacodynamic interaction. None of these 18 patients demonstrated inhibition of platelet aggregation while on both NSAID and aspirin; however, all showed inhibition of aggregation following discontinuation of the NSAID. Notably, 13 of these 18 patients (72%) had experienced a recurrent ischemic episode while taking aspirin and NSAIDs concomitantly. These data suggest that ibuprofen prevents the irreversible inhibition of platelet aggregation produced by aspirin needed for secondary stroke prophylaxis, and this interaction can have clinical consequences for patients taking aspirin.

We describe 6 cases of meningitis after spinal anesthesia associated with a single anesthesiologist over the course of 5 years. The earliest case occurred in 2000, and the other 5 cases occurred over the course of 14 months in 2004-2005. The case identified in 2000 was culture-positive for Streptococcus salivarius. The other 5 cases were culture-negative for this organism but in 2 cases, the cerebrospinal fluid was found to be positive for bacterial DNA that was identified as belonging to S. salivarius by sequencing of the 16S rRNA gene. The association with a single anesthesiologist and a single hospital during a relatively short interval, however, lead us to believe that these occurrences are part of a series associated with possible violations of aseptic technique.

Objectives: To describe trends in sexually transmitted disease morbidity in the Haifa District during the years 2001-2004 according to subdistrict, age, gender and nationality., Methods: Epidemiological data were taken from notifications on gonorrhea, chlamydia, syphilis, HIV carriers and AIDS patients. Reports are sent by physicians and diagnostic laboratories of hospitals and Health Maintenance Organizations ("Kupot") in the Haifa District. Denominators for calculating specific incidence rates were based on the data from the Central Bureau of Statistics. Time trends were calculated using Haifa District Health Office's former epidemiological reports., Results: A total of 74 chlamydia trachomatis patients were notified during 2004, an incidence rate of 8.8/100,000, of whom 71 were notified from the Haifa subdistrict (13.4/ 100,000). In the Hadera subdistrict only 3 patients were reported (0.96/100,000). Notification of 57 gonorrhea patients was sent to the Health District (incidence rate 6.8/100,000) including 42 from Haifa subdistrict (7.9/100,000) and 15 from Hadera subdistrict (4.8/100,000). Only 6 patients with primary or secondary syphilis were notified (0.7/100,000): 3 from the Haifa subdistrict and 3 from the Hadera subdistrict. Thirty new HIV carriers were reported and 2 AIDS patients (3.8/100,000), 23 from the Haifa subdistrict (4.3/100,000) and 7 carriers from the Hadera subdistrict (2.2/100,000). Most of the STD patients were Jewish males (2-3 times more than the number of women or Arab patients). Age specific rates were highest among persons 25-44 years old. During the last 4 years a decline was noted in the incidence of all reportable STD's with the exception of chlamydia., Conclusions: The main indices that reflect the population's present sexual behavior are incidence rates of gonorrhea and primary and secondary syphilis. These indices demonstrate a decline during the years 2001-2004. Reports of new HIV carriers to the Health district also declined. For the first time, chlamydia became the leading notified STD in Haifa District in 2004. Therefore, it is apparent that a true decline in STD's incidence rates has occurred during the last few years in the Haifa District especially in the Haifa subdistrict. This may be attributed to a reduction in the availability of paid sexual services. The increase in chlamydia incidence is most probably related to better diagnostic procedures.

Objective: This study aimed to assess the association between the health markers of vaccination coverage, birth weight, hemoglobin levels and nutritional status with the ethnic origin and the mother's educational status among all infants born in 1995 and toddlers born in 1994 in the Haifa subdistrict., Methods: The data on vaccination coverage rates and other different measures was collected from the Mother and Child Health (MCH) centers in the Haifa subdistrict. MCH centers were categorized into 4 levels of mother educational status (MES) using the distribution of the average number of years of schooling of the registered children's mothers., Results: (1) More than half of the Arab sector in this study were classified in the lowest level of MES, while only 3% of the Jewish sector in this study were classified in this level. (2) No significant association between vaccine coverage rate and MES or ethnicity was found. (3) The percentage of low birth weight was higher among Jews. (4) No consistent association between birth weight and MES. (5) The rate of children with anemia was higher in Arabs (18%) than in Jews (10%). (6) No significant association between anemia and MES in both sectors., Conclusions: Differences in health measures were found to be associated with ethnicity but not with mother educational status. Arabs were found to be at higher risk for anemia and probable improper nutrition habits than Jews. Thus appropriate health promotion programs should be targeted towards this group, especially programs to improve the hemoglobin levels.

Background: Whereas the diagnosis of classical pertussis has traditionally been based on clinical criteria, increasing numbers of atypical presentations suggest the need for an extensive laboratory-based approach., Objectives: To assess the relative efficacy of clinical and laboratory methods in the diagnosis of Bordetella pertussis by patient age and immunization status., Methods: We compared the clinical and laboratory diagnosis of B. pertussis in 87 pre-vaccinated, 78 recently vaccinated, and 75 post-vaccinated children with suspected pertussis. Serum and nasopharyngeal swabs were obtained for serology, culture and polymerase chain reaction., Results: PCR and culture identified 41% and 7% of patients with B. pertussis, respectively (P < 0.001). All positive cultures were PCR-positive. Positive PCR was less common among those recently vaccinated than among those in the pre- (P < 0.001) and post-vaccinated groups (P < 0.05). Positive culture was more common among those pre-vaccinated than among those recently vaccinated (P < 0.01). Positive tests for immunoglobulin M and A were more common among the post-vaccinated than the pre- and recently vaccinated (P < 0.001), respectively. Logistic regression analyses revealed that clinical criteria have no significant association with infection in recently and post-vaccinated children. Among the pre-vaccinated children, whoop and cough duration were associated with a positive PCR (odds ratio 7.66 and 0.5, P < 0.001). Seventy-six percent of pre-vaccinated, 39% of recently vaccinated and 40% of post-vaccinated children with positive PCR did not meet the U.S. Centers for Disease Control diagnostic criteria for B. pertussis., Conclusions: PCR is a useful tool for pertussis diagnosis, particularly in pre-vaccinated infants. The yield of culture and serology is limited, especially among pre- and recently vaccinated children. In pre-vaccinated infants with whoop and less than 2 weeks of cough, PCR testing should be implemented promptly.

Background: The incidence rate of Norovirus gastroenteritis is unknown since diagnostic tests are less readily available than for other agents. This pathogen is identified in less than 10% of acute gastrointestinal illness, despite the fact that recent reports from the United States attribute more than 50% of outbreaks to Noroviruses., Objectives: This article describes three outbreaks of gastroenteritis caused by Noroviruses in three of Haifa's chronic care hospitals in order to raise awareness of its main role as a common agent in such outbreaks, and thereby include it in the differential diagnosis of outbreak investigations., Methods: Methods employed included epidemiological investigation of the outbreaks, sanitary inspection, personal interviews of hospital staff members, data collection from medical files and laboratory diagnosis by electron microscopy and RT-PCR of stool and vomitus for Noroviruses., Results: Noroviruses were identified in faeces and vomitus of patients in 2 outbreaks in chronic care hospitals in Haifa. Attack rates were high (20-41%). Proximity in time to these 2 outbreaks, and clinical and epidemiological findings lead us to attribute another outbreak in a third hospital to norovirus as well., Conclusions: Physicians in institutions and the community should include Noroviruses in the differential diagnosis of outbreaks of gastroenteritis, particularly in cases where no other pathogens have been isolated. Timely requests for identification of Noroviruses are essential. The institution of good hygienic practices is important to prevent spread of this highly infectious agent.

Ethnicity-specific differences in body aesthetic ideals and body satisfaction have been cited as a potential explanation for interethnic differences in the prevalence and presentation of eating disorders. It has been widely hypothesized that such ethnically based differences in aesthetic body ideals mitigate cultural pressures that contribute to body disparagement and disordered eating among white women. However, mechanisms by which a cultural milieu may be protective against the development of disordered eating remain poorly understood. This study investigated relationships among ethnicity, self-representation, and body aesthetic ideals among 18 college-educated black and Latina women through analysis of focus group discussion data. Rather than confirming body aesthetic ideals different from those of white culture, study respondents reframed the discussion about body aesthetics to one of body ethics. That is, study subjects both contested ideologies defining thinness and whiteness as inherently beautiful and espoused a body ethic of self-acceptance and nurturance that rejects mainstream cultural pressures to reshape bodies to approximate aesthetic ideals promulgated in the media. We conclude that understanding body image concerns from the standpoint of body ethics, rather than body aesthetics, may be a more productive and inclusive approach to the study of ethnically diverse women's embodied experience. Ultimately it is anticipated that this will better illuminate the complex relationships among ethnicity, culture, and risk for body image and eating disorders.

We report on an outbreak of Campylobacter jejuni (C. jejuni) gastroenteritis among children residing in Haifa subdistrict after a farm visit. This incident emphasizes the importance of this issue and our report suggests preventive measures to reduce the risk of transmission of enteric pathogens in such situations.