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Silibum marianum (Milk thistle) contains high amount of phenolic compounds with antioxidant properties. The aim of this work was to evaluate the antioxidant activity of phenolic compounds included in Milk thistle. The antioxidant properties of the leaves and seeds of milk thistle were examined by determining its ability to scavenge the 2,2-diphenyl-1-picrylhydrazyl (DPPH) free radical. The results obtained from DPPH assay confirm that Milk thistle extracts have high antioxidative activity.DOI: http://doi.dx.org/10.5564/mjc.v15i0.323 Mongolian Journal of Chemistry 15 (41), 2014, p53-55

Background:  Social media networks have been found to provide emotional, instrumental, and social support, which may contribute to improved adherence to postbariatric surgery care recommendations., Objectives:  This study aimed to evaluate the impact of an online social media-based, health care professional-led, educational and support program on patients' long-term engagement with and adherence to follow-up guidelines, self-care recommendations, and weight management after bariatric surgery., Methods:  An observational cohort study, employing mixed methods, accompanied a 12-week interactive, structured, social media psychoeducational intervention program delivered on Facebook. Program participants, who had undergone one bariatric surgery within the past 1 to 7 years and were at least 18 years old at the time of surgery, were invited to join the program via posts online. Interested individuals were provided information about the program and the accompanying evaluation study, and those who met requirements completed study questionnaires before and after the program. Questionnaires included demographic and anthropometric information; postoperative recommendations received and their clarity and implementation; attitudes toward recommendation adherence; and well-being. Daily system data on program engagement were collected from the Facebook website., Results:  Of the 214 participants enrolled in the program, 101 (80.2% female, mean age 43.8 ± 9.1 years and mean body mass index 30.2 ± 6.8 kg/m 2 , 1-7 years after bariatric surgery) completed both baseline and end-of-program questionnaires and were included in the analysis. Following the program, improvements were observed in most aspects of participants' adherence to postoperative recommendations and well-being. Close to half of the participants (44.6%) reported reaching their postoperative target weight at the end of the program or maintaining it throughout the program. Video posts drew higher participant engagement than other media, and content about proteins received the highest number of reactions. However, participants' active engagement gradually declined over time., Conclusion:  Interactive health support on social media can positively enhance patient engagement, adherence to treatment recommendations, health outcomes, and overall well-being., Competing Interests: None declared., (Thieme. All rights reserved.)

Aims: With advances in cloud-based technologies, there has been a rise in remote T1D care. We hypothesized that transitioning T1DM care to a virtual, multidisciplinary clinic could improve measures beyond HbA1c., Methods: To assess the impact of transitioning from standard to virtual T1DM care, we evaluated glycemic measures and patient reported outcomes., Results: Sixty-one adults with T1DM were included, with mean age 40.2 ± 13.5 years and diabetes duration 16.9 ± 9.0 years. Most patients were treated with insulin pumps and CGM. The number of annual diabetes care encounters rose from 2.1 ± 4.2 to 12.8 ± 5.5. Baseline HbA1c was 7.9 ± 1.6 %(63 ± 16.9 mmol/mol), declining to 7.3 ± 1.1 %(56 ± 8.5 mmol/mol) and 7.1 ± 1.0 %(54 ± 7.7 mmol/mol) at 6 and 12 months respectively (p < 0.001 for both). In parallel, TIR improved from 63.1 ± 19.3 % to 69.2 ± 13.8 % (p < 0.001) and 67.5 ± 19.4 % (p = 0.03) at 6 and 12 months respectively, while TBR declined. Scores from validated diabetes treatment and self-management questionnaires rose significantly and these rises were associated with a reduction in HbA1c, the latter score was also associated with increased TIR. There was a trend toward a correlation between encounter frequency and improvement in HbA1c and TIR., Conclusions: Transitioning from standard to virtual, coordinated, multidisciplinary T1DM care is associated with increased visit frequency, improving glycemic control, treatment satisfaction and self-care behaviors., Competing Interests: Declaration of competing interest 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., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: In 2019, 1 mg subcutaneous semaglutide was registered for the treatment of diabetes in Israel. Recognition of its effect on weight has led to its use as a treatment for obesity., Objectives: To explore physicians' pre-therapy considerations, therapy practices, and attitudes regarding subcutaneous semaglutide for weight loss., Methods: A 22-item questionnaire was disseminated to physicians who prescribed semaglutide 1-mg for weight loss using an authorized off-label path., Results: In total, 127 physicians completed the questionnaire. As for pretreatment requirements, in the absence of diabetes, 30% requested a minimal body mass index of 30 kg/m2. Additional requirements were documented lifestyle-change effort (67%) and prior weight loss medication use (13%). Half of the physicians regarded calorie restriction, and 23% considered physical activity as necessary for weight loss while on therapy. As for dose, most physicians (78%) started with a 0.25-mg weekly injection, 57% doubled the dose monthly, and all others recommended doubling when side effects subsided. Regarding weight loss goal, 43% of the physicians set a personal goal with each patient while 26% limited the goal to 10% of initial weight. Fewer than 50% of physicians discussed treatment duration with their patients, and 52% of patients discontinued therapy in the first 3 months. The main reasons for discontinuation were price, lack of effect, and fear of long-term side effects., Conclusions: The diverse approaches regarding off-label use of semaglutide for weight reduction highlight the necessity to guide physicians and standardize treatment regimen.

Objectives: To assess the attitudes and perceived knowledge of health professionals regarding the food product judgemental-labelling reform that began in January 2020 in Israel., Design: Cross-sectional survey., Settings: An online survey among health professionals working in the Israeli health system., Participants: 456 participants (118 physicians, 207 nurses, 131 nutritionists)., Results: Most respondents (89·9 %) were women, 36 % had over 20 years of professional experience. All nutritionists, 96·6 % of physicians and 94·7 % of nurses reported hearing about the reform, and most (88·9 % of nurses, 76·3 % of physicians and 75·6 % of nutritionists) claimed supporting the reform to a great or very great extent. Most respondents believe they should discuss issues related to healthy eating with their patients (91·8 % of nurses, 94·9 % of physicians and all nutritionists), but only about half (47·5 % of physicians and 57·0 % of nurses) reported that they have sufficient knowledge in this field, particularly about food labelling. Almost two-thirds of nutritionists (60·3 %) reported instructing patients to change their food intake according to labelling v . 40·1 % and 34·7 % of nurses and physicians, respectively. Only some respondents felt that they could influence their patients' nutrition habits. Most participants believe that additional regulatory measures should also be used to promote healthy nutrition., Conclusions: There is a gap between the desire of physicians and nurses to provide nutritional guidance to the public and their actual knowledge about the labels' meaning as well as their competencies in providing nutrition counselling. When formulating a reform, policymakers should provide clear guidelines about the expectations of implementing it in therapeutic practice.

Background: The ever-increasing burden of diabetes and the limited resources highlight the need for prioritization of national action goals for diabetes management. The Israeli National Diabetes Council (INDC) initiated a prioritization process aiming to set a top list of diabetes related goals, as suggested by decision makers and health professionals., Methods: A 2-step prioritization process, including a small (n = 32) circle of key opinion leaders of the INDC and a larger (n = 195) nationwide circle of diabetes health professionals consisting of physicians, nurses, and dieticians working in diabetes care centers, hospitals and family practice clinics, was established. An online questionnaire presenting 45 different action areas in diabetes prevention and care was distributed to the INDC members who ranked the 3 top diabetes priorities based on their individual interpretation of importance and applicability. The 7 highest ranking priorities were later presented to hospital-based and community diabetes health professionals. These professionals selected the 3 top priorities, based on their perceived importance., Results: Council members opted mostly for action areas regarding specific populations, such as clinics for adult type-1 diabetes patients, diabetic foot, and pediatric and adolescent patients, while the health professionals' top priorities were mostly in the general field of prevention, namely high-risk prediabetes population, prevention of obesity, and promotion of healthy life-style. In addition, priorities differed between hospital and community health professionals as well as between different professional groups., Conclusions: A national prioritization process of action areas in diabetes prevention and care is attainable. The resulting item list is affected by professional considerations. These priorities may direct efforts in the implementation of interventions to improve national-level diabetes management., (© 2022. The Author(s).)

Aims: To explore and compare key determinants of COVID-19 vaccine acceptance and willingness to get vaccinated among people with diabetes and the general population., Methods: A cross-sectional survey study of 807 Israeli adults with and without diabetes was conducted prior to the first vaccination campaign in Israel in December 2020. Data was analyzed by population group and gender. A multinomial logistic regression determined the association between acceptance factors and willingness to get vaccinated., Results: Diabetes patients had more anxiety about COVID-19, higher levels of confidence in vaccine safety, and greater willingness to get vaccinated than the general population. In both groups, women reported higher levels of anxiety toward COVID-19 but lower levels of confidence in vaccine safety and less willingness to get vaccinated than men. Vaccine safety had the largest contribution to diabetes patients' willingness to get vaccinated. For participants without diabetes, the perception that more than 50% of Israelis would get vaccinated had the largest contribution. Participants in both groups who had vaccinated against seasonal influenza were more likely to get vaccinated against COVID-19., Conclusion: Policies aimed at improving vaccine acceptance should target vulnerable populations, particularly female diabetes patients, whose concerns must be addressed to increase their vaccination rates., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Introduction: The integration and involvement of patients in shaping research, processes and policies in the health care system is a new trend, which is gaining momentum in many countries around the world. Although participatory processes have existed for many years, systematic and organized mechanisms have only begun maturing in recent years. The first expression of this trend is in aspects related to research, including: accessibility to information about experiments; patient participation in research as research subjects; participation in the design and management of research. The second area in which patients are involved is priority setting in research, drug approval processes and policy making. The third subject of patient involvement is the formation of therapeutic practices in healthcare quality improvement, healthcare routine, and the development of assessment tools. In this article, we review participatory processes, which are initiated by the authorities via mandatory standardization or participatory practices embedding, and also by patient organizations and public representatives working alongside, or as part of healthcare organizations. We present the global picture and then present examples from the Israeli context.

Introduction: The Israel National Program for Diabetes Prevention and Care was established in 2014 and endorsed by the Minister of Health in 2016. The ultimate goal of the program is to ensure that all people with diabetes, or at high risk of developing diabetes, will live well and have access to high-quality services that meet their individual needs. The aim of this paper is to describe the program's scope, main components and foremost achievements. In addition, we review national programs in selected countries worldwide, and highlight current and future trends that will affect diabetes management and care.

Introduction: Coping with COVID-19, as well as with measures taken to prevent its spread, poses many challenges for people with diabetes, who seek information and support on the web. Understanding the issues and needs expressed in online discussions can be valuable for improving the support provided in times of crisis., Aims: To map and characterize online Hebrew discourse about diabetes during the first period of the COVID-19 outbreak and the preceding period., Methods: Data about frequency and distribution of posts in social-networks and online-forums were gathered, analysed and compared with respect to these two periods of time. Qualitative text analysis was manually performed on a sample of the posts., Results: Our findings show a growth in the extent of discourse during the first wave of the pandemic. A substantial difference was found between the two periods in informative discourse about the association between COVID-19 and diabetes (rose from 6% to 39%). A decrease had occurred in the perception of unhealthy-diet and lack of physical-activity as causes of diabetes (from 27% to 17% and from 6% to none, respectively). A new theme, concerns about coping with diabetes during the epidemic, has emerged., Conclusions: There is room for an elaborative explication on social-media about the causes of diabetes, recommended conduct, and possible means to communicate with health professionals, all in times of routine and crisis., Discussion: Social-media plays an important role in coping with the coronavirus pandemic. Internet may become a fertile ground for disinformation and dissemination of anxieties, but, also, may be a platform for addressing information needs and emotional support.

Diabetes mellitus poses major public health and economic challenges which necessitate national-level intervention. The ultimate goal of the Israel National Diabetes Program is to ensure that all people with diabetes, or at high risk of developing diabetes, will live well and have access to high-quality services that meet their individual needs. The integrated National Diabetes Program in Israel was established in 2014. Prevailing needs were identified and working groups assigned to delineate deficiencies and propose mode of action. Program leaders summarized and prioritized the needs, and identified main targets of action for the preliminary years. The program was achieved by a combined approach: top-bottom, having the Director General of the Ministry of Health (MoH) personally involved, and bottom-up, by routine meetings with representatives of the health organizations, clinical experts, patient representatives and other stakeholders. Main achievements during the first five years of the program included setting up a novel funding mechanism for diabetes prevention, substantiating the field of diabetes education in Israel, designing the infrastructure of diabetic foot care in Israel, updating the national health-budget allocation formula with incentives to improve provision of services, and promoting a mandatory system for judgemental labelling of food products. The program is in progress with ongoing monitoring, evaluation and improvement with particular emphasis on translational learning. Although there is much to be done, diabetes care in Israel has taken an enormous step forward in the past five years., (© 2020 John Wiley & Sons Ltd.)

Background: Delivering patient-centered care (PCC) is essential to our healthcare system. Patient dignity and respect are foundational elements of PCC. Understanding patients' and their care partner's perspectives on the meaning of dignity and respect within a clinical care environment is critical to achieving our goal of PCC., Objective: The aim of the study was to understand how patients and their care partners define, describe, and experience dignity and respect during hospitalization., Methods: We conducted a qualitative study with 22 patients and care partners hospitalized in high-acuity patient care areas in 1 academic medical center. Data collected from semistructured interviews were analyzed using grounded theory open coding in Atlas Ti software., Results: Our data provide a definition of dignity and respect during hospitalization from the patient and care partner perspective and a conceptual model of the factors needed to enhance patients' and care partners' experience of dignity and respect in the hospital setting. Dignity was felt to be intrinsic to personhood including the recognition of that person's value by others. Respect was characterized as the behavioral or social norms that acknowledge dignity. Determinants of dignity and respect were categorized at the organizational (macro) level and within the microsystem between clinicians, patients, and their care partners., Conclusions: The definition of dignity and respect and the conceptual model presented here represent an important supplement to our understanding of dignity and respect during hospitalization. Healthcare organizations should focus on the key factors found in this study to create a culture that treats patients with dignity and respect., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.)

Aims: In 2011 the central district of Leumit Health Services (LHS) (a health maintenance organization in Israel) implemented a chronic care program to improve diabetes care in general practice: MESSAGE program (Motivation, Education, Skills and Supervision to Achieve better diabetes care in General practice Environment), included training phase and ongoing time allocation for diabetes care., Methods: A population-based retrospective analysis of LHS Electronic Medical Records of all patients with diabetes in LHS between 1 June 2015 and 31 May 2018. Data was processed according to the definitions of the Israeli national program for quality indicators in community healthcare. ~442,000 adults were included, ~49,000 in MESSAGE engaged clinics., Results: The prevalence of diabetes in LHS was ~9.7-9.31% during study period. Over 3 years follow up, the prevalence of patients with A1C ≥ 9% declined in all districts of LHS but to a significantly greater extent in MESSAGE clinics [2015: MESSAGE 12.4%, LHS-combined 13.09%; OR 0.92 (0.83-1.01) p = 0.075; 2018: MESSAGE 8.51%, LHS-combined 10.85%; 0.76 (0.69-0.85) p < 0.001]. Other indicators of diabetes care did not change., Conclusion: The MESSAGE intervention program resulted in improved glycemic control. It is currently being modified to address all aspects of diabetes care and is implemented across all districts of LHS in Israel., Competing Interests: Declaration of Competing Interest 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., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objectives: To evaluate the effect of monetary grants on young physicians' choice of remote or rural hospital-based practice., Background: In late 2011, The Israeli Ministry of Health attempted to address a severe physician maldistribution, which involved severe shortages in remotely-located institutions (RLI). The policy intervention included offering monetary grants to residents who chose a residency program in a RLI., Methods: A total of 222 residents from various disciplines were recruited; 114 residents from RLI and 108 residents from central-located institutions (CLI), who began their residency during 2012-2014. Participants were surveyed on demographic, academic and professional data, and on considerations in the choice of residency location., Results: Residents in RLI attributed significantly more importance to the grant in their decision-making process than did residents from CLI. This effect remained significant in a multivariate model (OR 1.65, 95% CI 1.20-2.27, p = 0.002). The only parameter significantly associated with attributing importance to the grant was older age (OR 1.09, 95% CI 1.00-1.19, p = 0.049)., Conclusion: The choice of a RLI for residency may be influenced by monetary grants. This is consistent with real-life data showing an increase in medical staffing in these areas during the program's duration. Further studies are needed to determine causality and physical practicality of such programs.

Background: Health-related quality of life (QoL) is a comprehensive, multidimensional construct encompassing physical and psychosocial wellbeing. Physicians frequently assess QoL as part of their decision making process without specifically asking their patients. This study examined the degree and predictors of concordance between physician and patient assessments of QoL among patients with diabetes in primary care and in multi-disciplinary diabetes clinics., Methods: Patients completed a questionnaire regarding overall and diabetes-specific QoL before entering their physician's office. After the visit, the physician completed the same questionnaire in order to evaluate how he/she perceived that patient's QoL. In addition, medical data relating to the patient's health status were collected from the medical records. The concordance between patient-reported QoL and physician-estimated QoL was evaluated. Stepwise regression analysis was conducted to determine which factors contributed to the difference between physicians' and patients' assessment of QoL., Results: A total of 136 patients and 39 treating physicians were surveyed. Patients' response rate was 95%. A strong concordance was found between patients' and physicians' ratings of current health status (r = 0.79, p < 0. 01); however, physicians perceived their patients' QoL as worse than the QoL assessed by the patients themselves. Primary care physicians were better at assessing their patients' overall wellbeing while diabetes-specialists were better at assessing their patients' diabetes-specific QoL. In addition, the longer the duration of diabetes, the more difficult is was for the physicians to accurately assess QoL. When entered in the regression analysis, familiarity did not explain physicians' ability to assess health-related QoL or diabetes-specific QoL., Conclusions: Physicians make reasonable assessments of their patients' QoL, however as the patients' disease progresses, it becomes harder for physicians to assess QoL. Primary care physicians are better at assessing overall well-being whereas diabetes specialists are better at assessing diabetes-specific QoL., Trial Registration Number: Not registered. Assuta Medical Center institutional review board approval number 2009103.

Background: Adverse drug events (ADEs) are a major cause of morbidity and mortality worldwide. Hence, identifying and monitoring ADEs is of utmost importance. The Trigger Tool introduced by the Institute of Healthcare Improvement in the United States has been used in various countries worldwide, but has yet to be validated in Israel., Objectives: To validate the international Trigger Tool in Israel and to compare the results with those generated in various countries., Methods: A retrospective descriptive correlative analysis surveying four general hospitals in Israel from different geographical regions was conducted. Patient medical charts (n=960) were screened for 17 established triggers and confirmed for the presence of an ADE. Trigger incidence was compared to the actual ADE rate. Further comparison among countries was conducted using published literature describing Trigger Tool validation in various countries., Results: A total of 421 triggers in 279 hospitalizations were identified, of which 75 ADEs in 72 hospitalizations (7.5%) were confirmed. In addition, two ADEs were identified by chart review only. Mean positive predictive value was 17.81% and overall sensitivity was 97%. We found 1.54 ADEs for every 100 hospitalization days, 7.8 ADEs per 100 admissions, and 1.81 ADEs for every 1000 doses of medication. Of the 77 ADEs identified, 22.7% were defined as preventable., Conclusions: Our results support the Trigger Tool validity in Israel as a standardized method. Further studies should evaluate between hospital and region differences in ADE rate, in particular for the preventable events.

Background: Fiscal policies to fight obesity such as taxation of unhealthy foods or sugar-sweetened beverages (SSBs) have gained considerable attention in recent years. Many studies modelling the impact of various magnitudes of taxes on SSB purchasing and their potential effects on various health outcomes have been published; however, legislation and implementation of such taxes have encountered many obstacles in the countries that have implemented them to date. We investigated the perceptions and views of key opinion leaders, policy makers and various other Israeli stakeholders on taxation of SSBs and unhealthy snacks. We also evaluated the challenges and barriers that may be expected for initiating such a policy., Methods: A qualitative study based on 39 in-depth interviews with Israeli stakeholders in the fields of health, nutrition, economics, public advocacy and policymaking., Results: All stakeholders viewed obesity as a combined societal and personal issue that should be under government responsibility. Only stakeholders from economic sectors thought that taxation of SSBs and unhealthy snacks would reduce their consumption, while the prevailing notion among non-economists was that such a tax would not be acceptable because the higher price would not decrease consumption. Concerns were raised that the tax would mostly affect individuals from low socioeconomic backgrounds. Some of the stakeholders indicated that they would support such a tax only if its revenue would be directed to specific causes such as health-promoting plans. Potential barriers to taxation include: opposition of various sectors, technical and bureaucratic obstacles impeding tax implementation, difficulties in defining which products to tax, and opposition of the treasury to earmark tax revenue for health education., Conclusions: Taxation should be a part of a multipronged strategy rather than a sole measure for fighting obesity. Dedicating tax revenues to specific predefined causes should be considered, particularly towards health promotion activities, obesity treatment and prevention, education, and subsidies of healthy food.

Background: Quality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness., Method: We searched Medline, Embase, CINAHL, PsycINFO and the Cochrane Library databases from January 1995 to December 2014. Studies were included if they met the criteria for a QIC intervention and the Cochrane Effective Practice and Organisation of Care (EPOC) minimum study design characteristics for inclusion in a review. We assessed study bias using the EPOC checklist and the quality of the reported intervention using a subset of SQUIRE 1.0 standards., Results: Of the 220 studies meeting QIC criteria, 64 met EPOC study design standards for inclusion. There were 10 cluster randomised controlled trials, 24 controlled before-after studies and 30 interrupted time series studies. QICs encompassed a broad range of clinical settings, topics and populations ranging from neonates to the elderly. Few reports fully described QIC implementation and methods, intensity of activities, degree of site engagement and important contextual factors. By care setting, an improvement was reported for one or more of the study's primary effect measures in 83% of the studies (32/39 (82%) hospital based, 17/20 (85%) ambulatory care, 3/4 nursing home and a sole ambulance QIC). Eight studies described persistence of the intervention effect 6 months to 2 years after the end of the collaborative. Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline., Conclusions: QICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely., Competing Interests: Competing interests: SW reports grants from The Stevenson Foundation, during the conduct of the study; grants from Health Research Council of New Zealand, grants from Roche Diagnostics Ltd, grants from National Heart Foundation of New Zealand, outside the submitted work; JG reports grants from Stevenson Foundation, during the conduct of the study.OT, MB, DN and DG no competing interests, (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: In an attempt to address severe medical manpower shortages in several medical disciplines, the Israeli Ministry of Health offered grants to residents who chose one of these fields., Methods: A total of 220 residents from various disciplines were surveyed on demographic, academic, and professional data, and asked to rank considerations in the choice of their field of residency., Results: Residents in targeted fields attributed significantly more importance to the grant in their decision-making process (U = 3704.5, p < 0.001). This effect remained significant in a multivariate model (OR 1.67, 95%CI 1.32-2.10, p < 0.001). Higher age (OR 1.15, 95%CI 1.01-1.31, p = 0.031) and attribution of significance to the working conditions compared to other residency fields (OR 1.69, 95%CI 1.23-2.32, p = 0.001) were significantly associated with receptivity toward the grant in a multivariate analysis., Discussion: Receptivity toward the offered grants correlated with real-life data shows a rise in physician in these fields, and the weak association between such receptivity and most variables tested may suggest that the grants were perceived as a property of the specific choice rather than a special bonus., Conclusions: Grants may be useful in diverting medical manpower. Further analysis and modeling are required to determine causal relationship and budgetary feasibility.

Background: There is a debate about the effects of pro-anorexia (colloquially referred to as pro-ana) websites. Research suggests that the effect of these websites is not straightforward. Indeed, the actual function of these sites is disputed, with studies indicating both negative and positive effects., Aim: This is the first study which systematically examined the differences between pro-anorexia web communities in four main aspects: web language used (posts); web interests/search behaviors (queries); users' self-reported weight status and weight goals; and associated self-reported mood/pathology., Methods: We collected three primary sources of data, including messages posed on three pro-ana websites, a survey completed by over 1000 participants of a pro-ana website, and the searches made on the Bing search engine of pro-anorexia users. These data were analyzed for content, reported demographics and pathology, and behavior over time., Results: Although members of the main pro-ana website investigated appear to be depressed, with high rates of self-harm and suicide attempts, users are significantly more interested in treatment, have wishes of procreation and reported the highest goal weights among the investigated sites. In contrast, users of other pro-ana websites investigated, are more interested in morbid themes including depression, self-harm and suicide. The percentage of severely malnourished website users, in general, appears to be small (20%)., Conclusions: Our results indicate that a new strategy is required to facilitate the communication between mental health specialists and pro-ana web users, recognizing the differences in harm associated with different websites., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Importance: Health care-associated infections (HAIs) account for a large proportion of the harms caused by health care and are associated with high costs. Better evaluation of the costs of these infections could help providers and payers to justify investing in prevention., Objective: To estimate costs associated with the most significant and targetable HAIs., Data Sources: For estimation of attributable costs, we conducted a systematic review of the literature using PubMed for the years 1986 through April 2013. For HAI incidence estimates, we used the National Healthcare Safety Network of the Centers for Disease Control and Prevention (CDC)., Study Selection: Studies performed outside the United States were excluded. Inclusion criteria included a robust method of comparison using a matched control group or an appropriate regression strategy, generalizable populations typical of inpatient wards and critical care units, methodologic consistency with CDC definitions, and soundness of handling economic outcomes., Data Extraction and Synthesis: Three review cycles were completed, with the final iteration carried out from July 2011 to April 2013. Selected publications underwent a secondary review by the research team., Main Outcomes and Measures: Costs, inflated to 2012 US dollars., Results: Using Monte Carlo simulation, we generated point estimates and 95% CIs for attributable costs and length of hospital stay. On a per-case basis, central line-associated bloodstream infections were found to be the most costly HAIs at $45,814 (95% CI, $30,919-$65,245), followed by ventilator-associated pneumonia at $40,144 (95% CI, $36,286-$44,220), surgical site infections at $20,785 (95% CI, $18,902-$22,667), Clostridium difficile infection at $11,285 (95% CI, $9118-$13,574), and catheter-associated urinary tract infections at $896 (95% CI, $603-$1189). The total annual costs for the 5 major infections were $9.8 billion (95% CI, $8.3-$11.5 billion), with surgical site infections contributing the most to overall costs (33.7% of the total), followed by ventilator-associated pneumonia (31.6%), central line-associated bloodstream infections (18.9%), C difficile infections (15.4%), and catheter-associated urinary tract infections (<1%)., Conclusions and Relevance: While quality improvement initiatives have decreased HAI incidence and costs, much more remains to be done. As hospitals realize savings from prevention of these complications under payment reforms, they may be more likely to invest in such strategies.

Background: Clinical evidence points to patient-perceived difficulties and compliance problems in implementing early insulin therapy. Therefore, individual treatment aims are necessary to optimize diabetes therapy, as currently acknowledged by the new ADA/EASD guidelines. Better characterization of patient-perceived difficulties in the implementation of early insulin treatment may contribute to improved compliance and optimal tailoring of treatment regimens for the individual patient., Objectives: To assess differences in quality of life (QoL) and patient-perceived difficulties in health care with every addition of oral hypoglycemic agents (OHAs) and insulin therapy., Methods: The analysis was conducted on a cross-sectional sample of 714 diabetic patients treated with OHAs or with insulin once or twice daily. Differences in diabetes-specific QoL, overall QoL, and perception of difficulties associated with specific diabetes treatment attributes were evaluated using trend analysis and comparisons between groups. The contribution of each diabetes treatment attribute to QoL measures and glycemic control was also assessed., Results: No significant differences were found in QoL measures among patients treated exclusively with OHAs when these patients were assessed by the number of oral agents, irrespective of the degree of glycemic control. Better controlled patients treated with 2 OHAs, compared with poorly controlled patients treated with a single OHA, had a lower perception of difficulties associated with diabetes treatment attributes. Poorly controlled patients treated with 2 OHAs and better controlled patients treated with 3 OHAs had similar QoL and perceived difficulties with care. However, the insulin-based alternative was consistently associated with a significantly higher perception of pain and lower overall QoL when compared with the oral regimens. Multivariate models accounted for 52% and 32% of the variance in QoL measures., Conclusions: From the patients' perspective, oral therapy is the preferred strategy for attaining the treatment goals since the addition of OHAs was not associated with lower QoL or patient-perceived difficulties with care. If early insulin treatment is considered, physicians should address specific diabetes treatment characteristics, mainly the issue of pain, to promote improved QoL and disease control.

Objective: The objective of this study is to describe the design and validation of a newly developed brief, treatment-focused scale for use with type 1 and type 2-diabetes, exploring patient-perceived difficulties that are associated with treatment., Methods: The content of the construct was derived from consultation with experts, from existing instruments and the literature, as well as from diabetic patients. The original draft was comprised of 11 attributes. Based on an interim analysis, an additional 12th attribute was added. The final scale was tested on 988 diabetic patients from 25 practices in Israel. Respondents also completed a diabetes-specific quality of life (QoL) questionnaire and indicated their current perceived overall health status., Results: The patient-perceived difficulty of diabetes treatment (PDDT) scale contains 12 items reflecting diabetes-treatment characteristics: adherence to self-monitoring of glucose schedule, frequency of self-monitoring of glucose, adherence to medication administration schedule, frequency of medication administration, multiple number of medications, synchronization between meals and medications, dependence on the medications, pain associated with treatment, diet restrictions, self-care, multiple healthcare providers, and costs of treatment. Response rate to all attributes was very high. Construct validity was shown by significant correlations between PDDT attributes and diabetes-specific quality of life (r = 0.31-0.46) and self-report adherence to recommended treatment (r = 0.14-0.28), as well as between overall perceived difficulty and diabetes-specific quality of life (r = 0.60). Furthermore, the PDDT items showed discriminant capabilities with respect to known groups of patients., Conclusions: The PDDT scale is a simple and valid instrument that may assist in identifying potential barriers in adherence to recommended treatments and to new treatment options., (Copyright © 2011 John Wiley & Sons, Ltd.)

A counterfeit drug is one which is deliberately and fraudulently mislabeled with respect to identity and/or source. Counterfeit drugs can be found worldwide, both in deveLoped and developing countries, and their dissemination is a major threat to public health and safety, and has major economic effects on the consumers, the pharmaceutical industry, and society at Large. One of the first measures in confronting this problem is bringing it to the awareness of medical staff and public. This review aims to describe the extent of the problem, to discuss its negative effect, and to present actual and possible consequences.

Counterfeit drugs are a major threat to public health and safety around the world. This review describes the various distribution methods and channels of counterfeit drugs, including the growing use of the internet. National, regional and international efforts to confront this problem are presented, as well as a wide range of technologies that may assist in detection and enforcement. Finally, the Israeli perspective and actions are illustrated.

Objectives: The aim of this study was to describe the history and present situation with health technology assessment (HTA) in Israel., Methods: The method used in this study was a historical analysis based mainly on the knowledge of the authors, but supplemented by the published literature., Results: HTA originated in Israel as a centralized function conducted under the auspice of research, developing into an active multidisciplinary center. Throughout the expansion of the field, HTA was performed in affiliation with several local and international bodies, while providing direct and indirect support at the national level. Today, mainly as a result of vigorous dissemination of the principles, methodology and tools for HTA by the Israeli Center for Technology Assessment in Health Care (ICTAHC), this discipline is increasingly a decentralized activity conducted by a great variety of institutions. Israeli health policy decisions are increasingly based on the results of HTA., Conclusions: ICTAHC's role and functioning has expanded since its beginnings. HTA has become an important part of health care in Israel.

The Israeli Center for Technology Assessment in Health Care (ICTAHC) was established in 1998 at the Gertner Institute for Epidemiology and Health Policy Research, on foundations set in 1992 by the Medical Technology Assessment Unit. The Center is defined as an independent multidisciplinary research center, whose main aims are to assist in developing processes for the adoption of new technologies, identify and propose health priorities, and serve as an educational center for all stakeholders. Moreover, the Center promotes working relations with overseas counterparts as an essential component for expansion and advancement of the field of health technology assessment. Throughout the years, ICTAHC had contributed significantly to the development of the discipline of health technology assessment in Israel and to actual decision making in the health care system. The Center had outlined the principles, guidelines and overall framework for technology assessment in the country, as well as substantiating the discipline through various research areas, which materialized into a variety of technology-related policy accomplishments. Today, the Center serves as a national focal point in the health care system in Israel, as well as maintaining an active position in the international milieu. It has been a decade since the establishment of ICTAHC. This paper reviews the evolution of the center, describes changes in the HTA field in Israel, identifies areas of focus and main research accomplishments, and illustrates the breadth of potential research scope and projections for the future.

End-of-life care can be delivered in a variety of settings, whereby the majority of terminally-ill cancer patients prefer to die at home. The aim of our study is to evaluate health services utilisation during the last year of life, and to compare terminally ill patients who have received home-specialised palliative care services (HSPCS) with patients who died receiving home non-specialised palliative care services. The study included 120 and 515 patients, respectively, who died between 1999-2000. Age and gender distribution were similar in both groups. During the last year of life, mean health services cost per person among the HSPCS group was lower by more then 30% (P < 0.005). The median cost per patient was as low as one-fifth in the last month. Men and the older age group of 65 and above, cost significantly less compared with women and younger patients, respectively, regardless of provider setting. The main differences in health services utilisation were in hospitalisations and oncology treatments (P < 0.01 and P < 0.05, respectively).

Background: Until three decades ago coronary heart disease and stroke were considered rare in the Israeli Bedouin population. Today, this population shows increasing high prevalence compared to the Jewish population., Objectives: To evaluate the prevalence of diagnosed cardiovascular risk factors among Bedouins (hypertension, diabetes mellitus, dyslipidemia), and to assess compliance with follow-up tests and drug treatment., Methods: The study included all listed patients aged 20 years and older in eight clinics in major Bedouin towns, and in two large teaching clinics in Beer Sheva (Jewish population). Risk factor data were extracted from the clinics' computerized databases. For those diagnosed with hypertension, diabetes or dyslipidemia, drug purchasing data were collected from the pharmacy database to determine compliance with treatment, and from the central laboratory mainframe (HbAlc and low density lipoprotein-cholesterol) to evaluate follow-up and control., Results: A significantly higher prevalence of diabetes in all age groups was found in the Bedouin population compared to the Jewish population; age-adjusted results show a prevalence of 12% vs. 8% respectively (P < 0.001). The prevalence of dyslipidemia and age-adjusted hypertension was lower among Bedouins (5.8% vs. 18.2%, P < 0.01 and 17% vs. 21%, P < 0.001 respectively). Two-thirds of hypertensive Bedouin patients and 72.9% of diabetic Bedouin patients were not compliant with treatment. For dyslipidemia only 10.4% of the Bedouins were compliant compared with 28.2% in the Jewish population (P < 0.001)., Conclusions: Compliance with drug therapy and follow-up tests was found to be a major problem in the Bedouin population.

Ramalina maciformis and Ramalina lacera were exposed to different solutions and UV-B to seek for alterations in the PSII photosynthetic quantum yield (F(v)/F(m)), in response to chemicals and radiation. For R. maciformis, significant alterations of the F(v)/F(m) ratio occurred only in response to different bisulphite solutions. The F(v)/F(m) ratio decreased most in R. maciformis and R. lacera following exposure to 5 and 1 mM bisulphite, respectively. Significant differences in F(v)/F(m) ratios were observed for R. lacera in response to different solutions and light at different wavelengths, this being synergistic. The PSII system was unaffected by simulated acid rain in both lichens. R. maciformis, in particular, may survive limited acid rain exposure owing to high Ca oxalate accumulation. The F(v)/F(m) ratio decreased most in R. lacera following short-term exposures to CuSO(4), suggesting that this species is more sensitive to Cu ions under acidic conditions.

In Israel, updating of the National List of Health Services is performed on a yearly basis by means of a systematic and structured mechanism for almost a decade. The existence of such a mechanism is vital for keeping medicine up to date, since many innovative and breakthrough medical technologies continuously and frequently evolve. The 2006 update is unique in several aspects, relating both to the mechanism and to the decision-making process. In this article we describe notable issues that arose during the current process: modifications to the update mechanism, the four-phase increase in allocated resources to fund the addition of new medical technologies (including the addition of finances at the expense of the 2007 planned budget), and public funding for high-cost therapies. Finally, we discuss the impact of medical advances on healthcare costs and a suggested constant annual addition to the budget.

The rapidly rising health care expenditures, attributed mainly to the high cost of prescription drugs, have led governments around the world to look to generics as a means of containing costs in the pharmaceutical market. Generic drugs provide a less expensive alternative to brand name drugs due to the elimination of the need to perform lengthy and costly clinical trials, as required for innovative drugs. Essentially, generic substitution of drugs may be performed only after showing unequivocally that the generic formulation is identical in its active ingredients, strength, and route of administration as its innovative counterpart, and that they are bioequivalent to each other. Although the two are in essence the same, generic substitution is occasionally a controversial matter.

Protecting intellectual property rights encourages creativity and innovation, which are key measures for research and development of new drugs and also promotes the introduction of drugs to new markets. Over the past years, many countries have enacted laws implementing the protection of data in drug registration files. Until recently, Israel has not provided any form of data protection. Current moves focus on new legislation granting exclusivity in the marketing of innovative drugs. Although controversial, this legislation aims to secure balance in Israel between the innovative pharmaceutical companies and the public's interest in competitive generic drugs.

Primary congenital glaucoma (PCG) is a rare genetic disease usually diagnosed during the first year of life. It occurs because of developmental anomalies of the chamber angle that prevents drainage of aqueous humor, thereby elevating intraocular pressure. Its incidence is 1 in 10,000 live newborns in Western societies and 1 in 1,200 live newborns in the Arab-Bedouin population of the Negev region in Israel. Most cases of PCG appear to be sporadic. The cytochrome P4501B1 gene located within the GLC3A locus on chromosome 2p21 is mutated in individuals with PCG. The triad of epiphora, photophobia, and blepharospasm is classical for PCG. General anesthesia is usually required for an adequate examination of intraocular pressure, corneal diameter, optic disc, and axial length in young children. Congenital glaucoma is almost always managed surgically, with medical therapy being used only as a temporizing measure before surgery or when surgical intervention has repeatedly failed. At least 50% of eyes with PCG presenting at birth will become legally blind (visual acuity < 6/60). Patients with PCG require follow-up examinations throughout their lives.

Clinical trials are a dynamic and complex research domain. Being the backbone of the clinical practice, clinical trials present a wide range of aspects. This overview deals with selected topics related to clinical trials, such as: factors influencing the choice of research issues, reasons for early termination of clinical trials, participating patients' access to experimental treatments following clinical trials, economic implications of clinical trials and the existence of publication bias in clinical research.

Medical research is a broad discipline in which clinical trials bridge between research and practice. During the 20th century, modern concerns regarding the ethical and clinical aspects of clinical trials led to the development of international standards and regulatory procedures that guide research in clinical trials. The rapid development of pharmaceuticals, biological products and medical devices facilitates an increase in the number and magnitude of the clinical trials that are performed worldwide. This overview surveys the historical and regulatory basics of clinical trials, and provides data on the extent and costs of clinical trials conducted throughout the past years, with a special emphasis on Israel.

The present study used the epilithic fruticose lichen Ramalina maciformis to investigate the occurrence of mineral elements, including heavy metals, at a distance of up to 50 km from the industrial region in Ramat Hovav in the Negev Desert, Israel. The major objective of this study was an analytical comparison of elemental content and physiological parameters of lichen vitality, apart from a test of the applicability of this specific lichen in investigations of air pollution. The Ca, Cr, Cu, K, Mg, Na, Pb, S, Sr, and Zn content of thalli from the unpolluted Tellalim site collected in August 1997, transferred to 24 biomonitoring sites, and retrieved in April 1998 was analyzed in comparison with the following parameters: The potential quantum yield of photosystem 11 (PSII), and the integrity of cell membranes. Transplanted thalli in several sites at Ramat Hovav accumulated large amounts of most of the elements. The K content of the transplants located in the polluted sites indicated a leakage of this element, because this content was lower than that of thalli in unpolluted sites. Calcium, Cu, Mn, and Na showed an inverse correlation with the K content of the lichen. Calcium, Cu, and Sr showed an inverse correlation with the Fv/Fm ratio expressing the potential quantum yield of PSII. Calcium, Cr, Cu, Mg, Na, S, and Sr showed a positive correlation with the electrical conductivity corresponding with cell-membrane disintegration. The present study demonstrated a meaningful connection between enlarged concentrations of certain elements and physiological phenomena. The capability of the lichen to detect air pollution was found to be satisfactory. The dispersion of airborne heavy metals was found, however, to be local and limited to a few hundred meters from the source of pollution.

The major objective of the present study was to identify the relationship of physiologial parameters of the photosynthetic system with the elemental content of the lichen Ramalina lacera (With.) J.R. Laund. Thalli of R. lacera were collected in an unpolluted site and transplanted in a national park and an industrial region in Israel for 8 mo. Analyses of photosynthetic activity, chlorophyll integrity, spectral reflectance, and amount of 11 metals were performed after this period of exposure. The normalized difference vegetation index (NDVI), indicative of the spectral reflectance response of the thallus, correlated with photosynthetic rate and chlorophyll and K content and correlated inversely with amounts of Ba, Cr, Cu, and Ni. The NDVI appears to enable the detection of early signs of pollutant-induced stress before changes in other physiological parameters become apparent. Elevated amounts of Cr, Cu, Fe, Mn, Ni, and Zn in lichens transplanted to an industrial area and the correlation of Mn and Ni, Mn and V, Ni and V, Fe and Mn, Fe and V, and Fe and Zn point for the greater part to metal processing in a steel smelter. Correlations of Cr and Ni, Cu and Ni, Zn and Cu, Cu and Mn, and Zn and Ni could be related to metal processing in the industrial area but indicate also vehicular activity as a possible originator.

Obturator hernia is rare and is usually discovered by chance at operation or autopsy. In certain cases obturator hernia may cause sliding and strangulation of abdominal viscera inside the hernial sac, presenting clinically as bowel obstruction. An 83-year-old woman with signs of bowel obstruction was operated after 48 hours of conservative treatment and a small bowel loop was found strangulated inside the sac of an obturator hernia.