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Purpose: Estimate the reliability of the E-chart as used with Israeli school children. Design: Cross-sectional, population-based study conducted among 751 Israeli students of the Northern District, aged 6- and 7-year-olds and 13- and 14- years-old in 30 schools in 2003. Methods: Each student was screened separately by two public health nurses using the illiterate E-chart. Collected data included the students' vision and demographic characteristics, the nurses' professional background, and whether they referred students for medical testing. The reliabilities of vision testing and of the recommendations were determined using total, positive, and negative percentages of agreement and Kappa coefficients. Findings: Total percentage of agreement on vision (combined findings for both eyes) was 78.2% (Kappa 0.47, 95% CI 0.41--0.53). Logistic regression models to predict agreement on vision abnormality showed a higher percentage of agreement among females and 13- and 14-year-old students than among males and 6- and 7-year old students. Total agreement of 85.8% was found in referral recommendations (Kappa 0.58, 95% CI 0.51--0.65). Significant relationships were noted with student age, ethnicity, subdistrict of residence, nurse seniority, and agreement on vision findings. Conclusions: Improvement in school vision-screening reliability is needed, especially among 6- and 7-year-old students. To this end, the determinants of fair reliability should be investigated and training programs planned. Reasons for differences in the reliability of nurses' recommendations detected among subdistricts must be further studied, together with careful supervision, to ensure better performance and adherence to PHS guidelines. Implications for nurses and nursing should be considered. Clinical Relevance: Demographic characteristics were found to predict reliability, which can guide nurses in selecting students who need more careful attention or closer supervision during vision testing. [ABSTRACT FROM AUTHOR]

The study reports a gradient in adhering to a recommended health behavior-mammography screening. Data were collected on 951 Israeli women, aged 50-74, who were mailed an invitation to a prescheduled mammography screening appointment and were later phone interviewed about their background, their other health behaviors and their health perceptions related to cancer, mammography and self-rated health. The main finding that emerged was a gradient consisting of three groups defined by their adherence to mammography screening: women who declined the invitation to undergo screening (nonattenders, 32%), women who attended a screening upon encouragement (attenders, 45%) and women who initiated the test on their own (self-screenees, 23%). This gradient was shown to be related to structural/background variables (e.g. SES, age, education, ethnicity), other health behaviors and perceptual variables related to health in general and to cancer. For example, self-screenees were of a higher SES, engaged in more health behaviors and were closer to other women who performed a mammography. An analysis carried out to discern where the difference between the three groups lied showed that it was more apparent between the self-screenees and attenders, and that the attenders and nonattenders were more similar to each other. These findings are discussed in terms of health behavior as a discrete phenomenon vs. reflecting a lifestyle. Suggestions for intervention possibilities are presented in light of the finer ranking proposed above (as opposed to the dichotomy of engaging/not engaging in a health behavior). [ABSTRACT FROM AUTHOR]

Dealing with the outbreak of the new coronavirus has generated unprecedented challenges around the world, including in Israel. Women of childbearing age may be forced to live under particularly difficult circumstances during the pandemic. The current study among Israeli women of childbearing age has three main objectives related to the specific period of the COVID-19 pandemic: to study the prevalence and predictors of intimate partner violence (IPV); to investigate the prevalence and predictors of depression; to examine whether IPV mediates the association between general stress, fear of COVID-19 and depression as an outcome. In a cross-sectional study, 722 married women, Jewish and Arab residents of Israel, were recruited to answer an online self-completion questionnaire during the first wave of the COVID-19 pandemic. The questionnaire included an assessment of their degree of general stress and depression, fear of COVID-19, experiences of IPV and demographic variables. The results of the current study show that a high percentage of women reported IPV (with Muslim women reporting higher IPV than Jewish women), perceived stress (PSS), perceived COVID-19 stress and depression. The findings also show that IPV and its three dimensions mediate the relationship between COVID-19 stress and depression, such that higher stress was related to higher IPV, raising the odds for depression. Moreover, the total scores for IPV and emotional violence were found to mediate the relationship between stress and depression. That is, domestic violence explains part of the association between stress and depression during the COVID-19 pandemic. Indeed, the current pandemic has resulted in an increase in IPV and depression, and especially in the specific stress associated with the disease itself. Based on the findings of the current study, preventing violence will reduce stress-related depression. The Muslim population, and especially those who are more religious, is in particular need of intervention.

Background: Almost 90% of patients with dementia suffer from some type of neurobehavioral symptom, and there are no approved medications to address these symptoms., Objective: To evaluate the safety and efficacy of the medical cannabis oil "Avidekel" for the reduction of behavioral disturbances among patients with dementia., Materials and Methods: In this randomized, double-blind, single-cite, placebo-controlled trial conducted in Israel (ClinicalTrials.gov: NCT03328676), patients aged at least 60, with a diagnosis of major neurocognitive disorder and associated behavioral disturbances were randomized 2:1 to receive either "Avidekel," a broad-spectrum cannabis oil (30% cannabidiol and 1% tetrahydrocannabinol: 295 mg and 12.5 mg per ml, respectively; n = 40) or a placebo oil ( n = 20) three times a day for 16 weeks. The primary outcome was a decrease, as compared to baseline, of four or more points on the Cohen-Mansfield Agitation Inventory score by week 16., Results: From 60 randomized patients [mean age, 79.4 years; 36 women (60.0%)], 52 (86.7%) completed the trial (all eight patients who discontinued treatment were from the investigational group). There was a statistically significant difference in the proportion of subjects who had a Cohen-Mansfield Agitation Inventory score reduction of ≥ 4 points at week 16: 24/40 (60.0%) and 6/20 (30.0%) for investigational and control groups, respectively (χ 2 = 4.80, P = 0.03). There was a statistically significant difference in the proportion of subjects who had a Cohen-Mansfield Agitation Inventory score reduction of ≥ 8 points at week 16: 20/40 (50%) and 3/20 (15%), respectively (χ 2 = 6.42, P = 0.011). The ANOVA repeated measures analysis demonstrated significantly more improvement in the investigational group compared to the control group at weeks 14 and 16 ( F = 3.18, P = 0.02). Treatment was mostly safe, with no significant differences in the occurrence of adverse events between the two groups., Conclusion: In this randomized controlled trial, 'Avidekel' oil significantly reduced agitation over placebo in patients suffering from behavioral disturbances related to dementia, with non-serious side-effects. Further research is required with a larger sample size., Competing Interests: LB-L and VL report employment at Tikun-Olam Cannbit Pharmaceuticals Ltd., with stock options in the company. LB-L reports consulting role with TO Pharmaceuticals LLC. As a consultant of the company, LB-L was registered as an inventor on a patent on the investigational product for behavioral disturbance in patients with dementia. The remaining 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 Hermush, Ore, Stern, Mizrahi, Fried, Krivoshey, Staghon, Lederman and Bar-Lev Schleider.)

While nurses strive to provide optimal patient-centered care, this is not always straightforward, as some cases are more emotionally charged than others - depending on the patient's mental, emotional, and physical state, and on the nurses themselves. Therefore, in order to provide accurate therapeutic responses while maintaining their own personal well-being, nurses must develop strong mentalization capabilities. We present a unique program for nursing students, specifically targeted at enhancing their mentalization abilities as part of their communication skills for dealing with emotionally charged situations. In the program, he students first learn to identify what leads them to experience increased emotional loads and how this affects their mentalization processes. Next, they learn alternative coping patterns for their benefit, enabling their own emotional regulation while providing optimal care for their patients. Conducted in small groups, this holistic four-year program is led by experienced clinical nurses and psychologists; the learning is based on actual experiences encountered by the students during their clinical experience., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Oral mucosal Langerhans cells (LC) are likely to play important roles in host defense against infection by human cytomegalovirus (CMV). We previously showed that in vitro-differentiated immature LC (iLC) populations contain smaller amounts of infected cells but produce higher yields than mature LC (mLC) cultures, obtained by iLC stimulation with fetal bovine serum (FBS), CD40 ligand (CD40L) and lipopolysaccharide (LPS). Here, we sought to determine if exposure to select stimuli can improve LC permissiveness to infection, if specific components of the mLC cocktail are responsible for lowering viral yields, if this is due to defects in progeny production or release, and if these restrictions are also effective against reactivated virus. None of the stimuli tested extended the proportion of infected cells to 100%, suggesting that the block to infection onset cannot be fully removed. While CD40L and FBS exerted positive effects on viral progeny production per cell, stimulation with LPS alone or in combination with CD40L was detrimental. Reductions in viral titers were not due to defects in progeny release, and the permissive or restrictive intracellular environment established upon exposure to each stimulus appeared to act in a somewhat similar way toward lytic and latent infections.

Background: The detection and correction of refractive errors is one of the priorities of the World Health Organization Initiative Vision 2020., Objectives: To determine the factors related to ocular abnormalities (poor vision, refractive error or other abnormality) among schoolchildren in northern Israel., Methods: A cross-sectional population-based study was conducted among 2113 students aged 6-7 and 13-14 years old in 70 schools in northern Israel. Medical examination included vision history, clinical eye examination and vision testing. If a parent's informed consent was available, eye drops (cycloplegia) were delivered for fundus and retinoscopy testing. An ophthalmologist was asked to determine the need for the child's referral for further diagnostic procedures, treatment and/or follow-up. Multivariate analysis was limited to 1708 children, using data pertaining to the ophthalmologist's decision regarding referral, as well as vision and retinoscopy results., Results: Vision and/or ocular abnormality was prevalent in 21.5% (95% confidence interval 17.4-26.6%), predominantly among 13-14 year olds and Jewish children. Abnormal clinical findings were found in 5.7% of the students. Retinoscopy showed a higher prevalence of hypermetropia among 6-7 year olds and a higher prevalence of myopia and astigmatism among the 13-14 year olds. The multivariate analysis suggests an independent effect of retinoscopy abnormality (odds ratio = 3.85), vision abnormality (OR = 2.42), Jewish ethnicity (OR = 1.62) and 13-14 year old age group (OR = 1.26) on the ophthalmologist's referral decision., Conclusions: Vision and/or ocular abnormality is an important health problem among schoolchildren in northern Israel. The independent effect of ethnicity and age on the ophthalmologist's referral decision should be further explored.

Background: Atherosclerotic cardiovascular disease (CVD) is the most common cause of morbidity and mortality among hemodialysis (HD) patients. It has been attributed, among other causes, to hypertension and dyslipidemia. The aim of the present study was to investigate the effect of a year-long consumption of Pomegranate juice (PJ), on two traditional cardiovascular (CV) risk factors: hypertension and lipid profile, as well as on cardiovascular events., Methods: 101 HD patients were randomized to receive 100 cc of PJ (0.7 mM polyphenols) or matching placebo juice, three times a week for one year. The primary endpoints were traditional CV risk factors; blood pressure and lipid profile. Systolic, diastolic and pulse pressure, plasma levels of triglycerides (TG), high density lipoprotein (HDL), low density lipoprotein (LDL) and total cholesterol were monitored quarterly during the study year. Secondary endpoint was incidence of cardiovascular events., Results: PJ consumption yielded a significant time response improvement in systolic blood pressure, pulse pressure, triglycerides and HDL level; an improvement that was not observed in the placebo intake group. These beneficial outcomes were more pronounced among patients with hypertension, high level of triglycerides and low levels of HDL., Conclusion: Regular PJ consumption by HD patients reduced systolic blood pressure and improved lipid profile. These favorable changes may reduce the accelerated atherosclerosis and high incidence of CVD among HD patients., Trial Registration: ClinicalTrials.gov registry, Identifier number: NCT00727519.

Background: Since the incidence of TB has decreased in the developed countries, the diagnosis and treatment of latent TB infection (LTBI) has assumed increasing importance. It is estimated that 5-10% of persons with LTBI go on to develop TB; therefore, the crucial role of LTBI treatment in eliminating TB is well recognized. However, levels of adherence are found to be consistently low, and noncompliance constitutes the major barrier for achieving the full benefits of LTBI treatment., Objective: 1. To estimate rates of treatment completion with an outreach - directly observed preventive treatment (DOPT), a program among Ethiopian immigrants (El) at absorption centers treated for LTBI. 2. To determine if follow-up visits by a physician at their place of residence, vs. management at a TB Clinic (TBC), would further enhance the patient's adherence., Methodology: Quasi experiment, retrospective cohort analysis of 495 medical records for all El at absorption centers in Zefat who had started DOPT for LTBI and were followed up at absorption centers (2005-2006, study group - SG), compared to patients followed up at a TBC (2008-2010, comparison group - CG). Free transportation to the TBC was provided for the CG., Findings: Altogether 495 Els were included (263 in the SG and 232 in the CG group). Both groups had high completion rates (SG: 96.2% vs. CG: 93.1%, p=0.14). While demographic factors did not predict treatment completion, side effects were significantly associated with non-completion., Conclusion: High treatment completion rates among El were achieved when DOPT outreach and cultural case management strategies were combined. In these circumstances, the physician follow-up location had no significant impact on treatment completion rates.

The hemodialysis (HD) procedure induces oxidative stress (OS), which is further aggravated by intravenous (IV) iron administration, aimed at correcting anemia of patients with HD. We have recently shown that 1 year of pomegranate juice (PJ) intake attenuated OS and inflammation in patients with HD. In the current study, we hypothesized that a single dose of PJ can attenuate the enhanced OS and inflammation induced by both the dialysis procedure and IV iron administration during HD session. Twenty-seven patients with HD were randomized to receive PJ or placebo during 1 dialysis session with IV iron. Blood samples were drawn before and after the session to asses OS biomarkers such as advanced oxidation protein products and myeloperoxidase (MPO), whereas polymorphonuclear leukocyte (PMNL) counts served as an indirect measure of inflammation. At the end of the dialysis session, an increase in advanced oxidation protein products and MPO levels as well as a decrease in PMNLs counts were observed in the placebo group, whereas no significant changes occurred in the PJ group. The postdialysis increase in MPO levels in the placebo group is a direct result of PMNL degranulation, associated with postdialysis decrease in PMNL counts. Degranulation of PMNLs leads to the release of other cell moieties, such as inflammatory mediators and proteases that enhance inflammation. We conclude that PJ intake attenuated the increase in systemic OS and inflammation induced by IV iron administration during the dialysis session. These beneficial effects illuminate the previously observed attenuation in OS and inflammation in patients with HD on prolonged PJ intake., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Identifying patients who benefit from hyperoxygenation therapy is important, because treatment is time-consuming and involves high costs and complications (minor). Our objective was to develop a model for predicting therapy outcome based on population of patients with and without diabetes. A retrospective cohort study was carried out in a major hospital in Israel. All 385 patients treated between 1/1/1998 and 1/1/2007 for ischemic nonhealing lower extremities wounds were included. Data on medical history, demographic, transcutaneous oximetry, wounds, treatment, and outcome characteristics were collected. Eight factors were identified to optimally predict wound healing: (1) number of hyperbaric oxygenation treatments (odds ratio [OR] = 1.034, p < 0.001), (2) transcutaneous oximetry values at hyperbaric conditions (OR = 1.001, p = 0.019), (3) wound duration (OR = 0.988, p = 0.022), (4) absence of heart disease (OR = 3.304, p < 0.001), (5) being employed (OR = 3.16, p = 0.008), (6) low socioeconomic status (OR = 2.50, p = 0.004), (7a) good/partial granulation wound appearance (OR = 2.73, p = 0.022), (7b) wounds covered with fibrin (OR = 3.16, p = 0.015), and (8) absence of anemia (OR = 2.13, p = 0.016). The model's sensitivity is 78.7%, specificity is 62.9%, and accuracy is 71.8%. We suggest using our model as an adjunct to patients' clinical evaluation. Also, we recommend initiating hyperoxygenation therapy no later than 2 months after wound appearance., (© 2013 by the Wound Healing Society.)

The objective of our study was to assess factors associated with iatrogenic events in Neonatal Intensive Care Units (NICUs). This was a retrospective analysis based on a cohort of patients who participated in our previous prospective study (Pediatrics 122:550-555, 2008), conducted in four tertiary university-affiliated NICUs in Israel, that included all consecutive infants (n = 615) hospitalized during the study period. Ongoing monitoring of iatrogenic events was performed by designated "iatrogenesis advocates." The main outcome measures were the association of individual infant characteristics and NICUs' environmental characteristics with iatrogenic events assessed by univariate and multiple logistic regression analysis. We found that four infant characteristics were significantly (p < 0.001) associated with iatrogenic events in a univariate analysis: gestational age, birth weight, severity of initial illness as assessed by the Score for Neonatal Acute Physiology and Perinatal Extension (SNAPPE II), and length of stay (LOS). All four factors demonstrated a significant (p < 0.001) dose-response relationship with iatrogenic events. Univariate analysis for environmental characteristics showed that type of shift, but not nursing workload, was significantly associated with iatrogenic events (p < 0.001). In a multiple logistic regression analysis, only LOS (adjusted OR 1.02 [95 % CI, 1.01-1.03]) and type of shift, morning vs. evening (adjusted OR 3.44 [95 % CI, 2.33-5.08]) and morning vs. night (adjusted OR 6.07 [95 % CI, 3.86-9.56]), remained independently associated with iatrogenic events (p < 0.001). Prolonged LOS and morning shifts were found to be significantly associated with iatrogenic events. Further prospective research is warranted to identify the specific causes for iatrogenic events in order to target active interventions to prevent them.

Increased systemic inflammation and oxidative stress are well established as nontraditional key players in the pathogenesis of atherosclerosis and are also involved in the innate immunity dysregulation in hemodialysis (HD) patients. The study aim was to investigate the effect of 1-year intake of pomegranate juice, an antioxidant source, on oxidative stress, inflammation, and long-term clinical outcomes. A randomized placebo controlled double-blind trial was designed, enrolling 101 chronic HD patients to receive during each dialysis 100 cc of pomegranate juice, or matching placebo, three times a week for 1 year. The primary endpoints were levels of oxidative stress and inflammation biomarkers. Secondary endpoints were hospitalization due to infections and the progression of atherosclerotic process based on a composite of variables of the carotid arteries: intima media thickness (IMT), number, and structure of plaques. Pomegranate juice intake yielded a significant time response reduction in polymorphonuclear leukocyte priming, protein oxidation, lipid oxidation, and inflammation biomarkers levels. These beneficial effects were abolished 3 months postintervention. Pomegranate juice intake resulted in a significantly lower incidence rate of the second hospitalization due to infections. Furthermore, 25% of the patients in the pomegranate juice group had improvement and only 5% progression in the atherosclerotic process, while more than 50% of patients in the placebo group showed progression and none showed any improvement. Prolonged pomegranate juice intake improves nontraditional CV risk factors, attenuates the progression of the atherosclerotic process, strengthens the innate immunity, and thus reduces morbidity among HD patients., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Wounds of the lower extremities are a significant public health problem, being severe and costly to treat. Adjunctive treatment with hyperbaric oxygenation (HBOT) has proven to be a useful and cost-effective means of treating ischemic wounds, mainly in diabetic patients., Objectives: To describe patients with ischemic wounds treated at the Rambam and Elisha Hyperbaric Medical Center and their wound improvement following HBOT., Methods: We conducted a retrospective cohort study of all patients (N = 385) treated in the center during 1998-2007 for ischemic non-healing wounds in the lower extremities., Results: The mean age of the patients was 61.9 years (SD 13.97). Most of them were diabetic (69.6%) and male (68.8%). Half of the subjects had a wound for more than 3 months prior to undergoing pre-HBOT transcutaneous oximetry (TcPO2) testing. Most of the wounds were classified as Wagner degree 1 or 2 (39.1% and 46.2% respectively). The median number of treatments per patient was 29. Only 63.1% of patients had continuous treatments. Approximately 20% of patients experienced mild side effects. An improvement occurred in 282 patients (77.7%) following HBOT: 15.2% fully recovered, 42.7% showed a significant improvement (and were expected to heal spontaneously), and 19.8% a slight improvement., Conclusions: HBOT can benefit the treatment of non-healing ischemic wounds (especially when aided by pretreatment TcPO2 evaluation; data not shown). Our experience shows that this procedure is safe and contributes to wound healing.

Background: The incidence of cutaneous leishmaniasis in northern Israel began to rise in 2000, peaking at 41.0 per 100,000 in the Kinneret subdistrict during the first half of 2003., Objectives: To examine the morbidity rates of CL in northern Israel during the period 1999-2003, which would indicate whether new endemic areas were emerging in this district, and to identify suspicious hosts., Methods: The demographic and epidemiologic data for the reported cases (n=93) were analyzed using the GIS and SPSS software, including mapping habitats of suspicious hosts and localizing sites of infected sand flies., Results: The maximal incidence rate in the district was found in the city Tiberias in 2003: 62.5/100,000 compared to 0-1.5/100,000 in other towns. The cases in Tiberias were concentrated on the peripheral line of two neighborhoods, close to the habitats of the rock hyraxes. Sand flies infected with Leishmania tropica were captured around the residence of those affected. Results of polymerase chain reaction were positive for Leishmania tropica in 14 of 15 tested patients., Conclusions: A new endemic CL area has emerged in Tiberias. The most suspicious reservoir of the disease is the rock hyrax.

Background: The effect of acute kidney injury (AKI) on anemia has been well-documented. However, the effect of 'preexisting' anemia on AKI has been less addressed. The aims of the present study were to investigate (1) the association between anemia at hospital admission and AKI occurrence, and (2) the effect of 'preexisting' anemia on the clinical outcomes of AKI., Methods: A retrospective cohort study was undertaken among patients aged > or =17 years who were admitted to our hospital during the year 2006 (n = 34,802). Anemia at hospital admission and AKI occurrences were determined using the WHO definition and the RIFLE criteria, respectively. A subgroup of patients with an estimated glomerular filtration rate > or =60 ml/min/1.73 m(2) was analyzed separately to control for the effect of chronic kidney disease on anemia., Results: The cumulative incidence of AKI was 11.2% in anemic patients at hospital admission, compared to 5.5% in nonanemic subjects. The association between anemia at admission and AKI occurrence remained statistically significant after controlling for potential confounders (odds ratio 1.5, 95% CI 1.4-1.6). In addition, an association between anemia at hospital admission and clinical outcomes of AKI was observed., Conclusion: Anemia at hospital admission should be recognized as a potential risk factor for in-hospital AKI occurrence., (Copyright 2010 S. Karger AG, Basel.)

Background: Radiological procedures utilizing intravascular contrast media are being widely applied for both diagnostic and therapeutic purposes. This has resulted in the increasing incidence of procedure-related contrast-induced nephropathy. In Israel, data on the incidence of CIN and its consequences are lacking., Objectives: To describe the epidemiology of CIN among hospitalized patients in the Western Galilee Hospital, Nahariya (northern Israel), and to explore the impact of CIN on mortality and length of stay., Methods: The study group was a historical cohort of 1111 patients hospitalized during the year 2006 who underwent contrast procedure and whose serum creatinine level was measured before and after the procedure. Data were electronically extracted from different computerized medical databases and merged into a uniform platform using visual basic application., Results: The occurrence of CIN among hospitalized patients was 4.6%. Different CIN rates were noticed among various high risk subgroups such as patients with renal insufficiency and diabetes mellitus (14.1%-44%). Average in-hospital length of stay was almost twice as long among patients with CIN compared to subjects without this condition. Furthermore, the in-hospital death rate among CIN patients was 10 times higher. A direct association was observed between severity of CIN based on the RIFLE classification and risk of mortality., Conclusions: Low CIN occurrence was demonstrated in general hospitalized patients (4.6%), and high rates (44%) in selected high risk subgroups of patients (with renal insufficiency or diabetes mellitus). Furthermore, prolonged length of stay and high in-hospital mortality were directly related to CIN severity.

Background: Acute kidney injury remains a common significant clinical problem. Yet there are scant data in Israel on the incidence of hospital-acquired AKI and on diagnosis validity., Objectives: To describe the epidemiology of AKI among hospitalized patients in the Western Galilee Hospital, Nahariya, compare discharge summaries to laboratory diagnosis, and investigate the impact of AKI on mortality and length of stay., Methods: Computerized medical and laboratory data of 34,802 hospitalized subjects were collected. AKI was diagnosed according to three different definitions. We calculated the sensitivity and specificity of AKI based on ICD-9 diagnosis compared to patient's laboratory data as the gold standard., Results: The overall AKI annual incidence rate was 1-5.1%, depending on the AKI definition used. The incidence of AKI based on ICD-9 diagnosis was significantly lower compared to the laboratory-based diagnosis. Average in-hospital length of stay was 2.4 times longer among patients with AKI compared to subjects without this condition. Furthermore, the in-hospital death rate among AKI patients was 14 times higher than among non-AKI hospitalized subjects, with a positive association between AKI severity and risk of death., Conclusions: Using AKI laboratory diagnosis as the gold standard revealed ICD-9 diagnosis to be 9.1% sensitive and 99.4% specific. Hospital-acquired AKI is a major contributor to prolonged length of stay and high mortality rates; therefore, interventions to reduce in-hospital disease incidence are required.

Background: Uncorrected refractive error is the leading cause of visual impairment in children. In 2002 a screening project was launched in Israel to provide data on the effectiveness of the illiterate E-chart in identifying Jewish and Arab schoolchildren in need of a comprehensive eye examination., Objectives: To present the aims, design and initial results of the visual screening project and the prevalence of vision abnormality in the study population., Methods: A cross-sectional population-based study was conducted during 2002-2003 among first- and eighth-graders in 70 schools in northern Israel. The nurse's test included use of the illiterate E-chart to measure visual acuity. The medical examination included vision history, clinical eye examination, VA and retinoscopy. The ophthalmologist's evaluation as to whether a child needed a referral for, diagnostic procedures, treatment and/or follow-up was recorded and compared with explicit referral criteria formulated after data collection., Results: Of 1975 schoolchildren, 31% had abnormal VA, defined as VA worse than 6/6 in at least one eye, and a quarter had VA equal or worse than 6/12 in both eyes. The prevalence of vision abnormality among the children was 22.4% when based on the evaluation of the field ophthalmologist and 26.1% when based on two sets of explicit severity scores and referral criteria., Conclusions: Vision abnormality is a significant health problem among northern Israeli schoolchildren. This project is unique in scope and importance, providing evidence to assist policy making with regard to vision screening for schoolchildren (including data on test reliability and validity) and optimal VA cutoff level, and confirming the need for clinical guidelines regarding referral criteria.

Objectives: To evaluate the screening performance of 6/6 and 6/12 vision cut-offs with an illiterate E-chart implemented by a public health nurse to test children for ocular abnormalities and uncorrected refractive error. The gold standard diagnosis is an eye examination performed by an ophthalmologist., Setting: A cross-sectional population-based study was conducted among 2113 students' ages 6-7 and 13-14 years old in 70 Northern District Israeli schools., Methods: Students were tested by nurses and ophthalmologists. A nurse examination was carried out using the illiterate E-chart for vision measurement. The medical examination included vision history, clinical eye examination, vision and retinoscopy testing. The Physician's evaluation of whether students needed a referral for diagnostic procedures, treatment and/or follow-up was recorded. Screening test's performance was determined using ophthalmologist's decision regarding referral as the gold standard. Detection rate (DR), false-positive rate (FPR), odds affected positive result (OAPR), positive predictive value (PPV) and negative predictive value (NPV) were estimated overall and by students' demographic characteristics., Results: For vision >6/6 cut-off in at least one eye (eyes tested separately): DR - 71.9% (95% CI 65.8-78.7%), FPR - 22.8% (95% CI 17.9-28.9%), OAPR - 0.98:1 (95% CI 0.84:1-1.15:1), PPV - 52.7% (95% CI 45.4-61.2%), NPV - 90.9% (95% CI 88.7-93.1%). For 6/12 vision cut-off, namely vision 6/12 or worse in both eyes (tested separately): DR - 58.6 (95% CI 51.8-66.4%), FPR - 15.2% (95% CI 10.9-21.1%), OAPR - 1.13:1 (95% CI 0.94:1-1.35:1), PPV - 61.1% (95% CI 52.9-70.6%), NPV - 87.6% (95% CI 84.9-90.4%)., Conclusions: Vision-screening test performance measures are mild. It is suggested to change vision cut-off level that denotes vision abnormality from current policy of vision not equal 6/6 in both eyes (tested separately) to vision 6/12 or worse in both eyes (tested separately). This change will result in reduction of FPR from 22% to 15%, concomitant with an increase in false-negative rate from 28% to 41%. Students may be equally screened by either a senior or a less experienced nurse.

Purpose: Breast cancer remains the major malignant disease among Israeli women, with about 4,000 new cases diagnosed annually, and a steadily increasing incidence rates. Early in this century investigators noted that nulliparity and a history of never having breastfed were more common in women with breast cancer than without the disease. Epidemiological evidence on those issues remains controversial. The purpose of this study was to clarify those controversial., Methods: A hospital-based case control study was carried out at Nahariya hospital (North of Israel) to assess the risk of breast cancer in relation to breastfeeding history. A total of 256 recent cases of breast cancer (diagnosed between January 1999 and February 2005) and 536 controls were included. Detailed information regarding breastfeeding, menstruation, reproductive factors and confounders was collected. Adjusted odds ratios and 95% confidence intervals were calculated., Results: Short duration of lifetime breastfeeding, late age at first breastfeeding and experience of insufficient milk were found to increase breast cancer risk. When women who had ever breastfed their infants were compared with females who had not, breastfeeding was found to be protective (OR of 0.39; 95% CI 0.26-0.59)., Conclusions: These findings may have significant impact on intervention planning aimed towards breast cancer reduction among Israeli Jewish women.

Background: In the western world, trauma is the leading cause of disability and mortality in the 1-39 years age group. Road accidents constitute the most frequent cause of mortality among children older than 1 year and falls from heights are the most frequent cause of injuries requiring hospitalization., Objectives: To analyze the epidemiology and characteristics of severe pediatric trauma due to falls from a height in northern Israel. This analysis should aid in planning an effective intervention plan., Methods: This observational study included all patients aged 0-14 who died or were admitted to an intensive care unit in northern Israel following a fall from a height. Demographic and clinical data were collected retrospectively for 3 years and prospectively for 1 year., Results: A total of 188 children were severely injured or died following such a fall, with an annual rate of 11.4 per 100,000 children. Over 85% of severe injuries due to falls occurred among non-Jewish children, with an incidence rate 6.36 times higher than among Jewish children (20.17 and 3.17 per 100,000 children, respectively). In the non-Jewish sector 93.7% of the falls occurred at or around the child's home, mainly from staircases, balconies and roofs., Conclusions: A very high incidence of severe trauma due to domestic falls from a height was found among non-Jewish children in northern Israel. Domestic falls represent an important epidemiological problem in the non-Jewish pediatric sector, and an effective prevention plan should include measures to modify parents' attitudes towards safety issues and the creation of a safe domestic environment.

Background: The State of Israel controlled a protective security zone in southern Lebanon from 1982 until May 2000, when the Israel Defense Forces (I.D.F.) evacuated this area within two days. Officers and soldiers of the South Lebanese Army, a local militia, which had formerly cooperated with the I.D.F., chose to come to Israel with their families. The provision for the health needs of this displaced population of over 5,861 persons was coordinated by the Northern Region Health Office of the Ministry of Health., Aim: To describe the deployment and provision of health care for this displaced population and to present the lessons learned., Methods: Data was collected from interviews with the personnel most actively involved in the decisions and execution of the enterprise, as well as from relevant documents., Results: The main health needs of the displaced South Lebanese were related to anxiety, outbreak of chickenpox, dental problems and provision of medical equipment for the disabled., Conclusion: The experience accrued by the Northern Region Health Office over the years in provision of care to displaced populations at short notice was implemented. Cooperation within the health sector and between the health services and the military and defense forces was invaluable and essential to deal successfully with this unusual situation.

Background: Although the preferred management of a patient presenting with an acute myocardial infarction is in a coronary care unit, data based on discharge diagnoses in Israel indicate that many of these patients are treated outside of such units., Objectives: To compare the demographic and clinical characteristics, treatment and mortality of AMI patients treated inside and outside a CCU., Methods: We compiled a registry of all patients admitted to three general hospitals in Haifa, Israel during January, March, May, July, September and November 1996., Results: The non-CCU admission rate was 22%. CCU patients were younger (61.6 vs. 65.5 years), less likely to report a past AMI (18% vs. 34%), and arrived earlier at the emergency room. Non-CCU patients were more likely to present with severe heart failure (30 vs. 11%). Non-CCU patients received less aspirin (81 vs. 95%) and betablockers (62 vs. 80%). Upon discharge, these patients were less frequently prescribed beta-blockers and cardiac rehabilitation programs. CCU-treated patients had lower unadjusted mortality rates at both 30 days (odds ratio = 0.35) and in the long term (hazards ratio = 0.57). These ratios were attenuated after controlling for gender, age, type of AMI, and degree of heart failure (OR = 0.91 and HR = 0.78, respectively)., Conclusions: A relatively high proportion of AMI patients were treated outside a CCU, with older and sicker patients being denied admission to a CCU. The process of evidence-based care by cardiologists was preferable to that of internists both during the hospital stay and at discharge. In Israel a significant proportion of all AMI admissions are initially treated outside a CCU. Emphasis on increasing awareness in internal medicine departments to evidence-based care of AMI is indicated.

Introduction: Depression in the elderly is frequently detected by screening instruments and often accompanied by anxiety. We set out to study if anxiety will affect the ability to detect depression by a screening instrument., Objective: To validate the short Zung depression rating scale in Israeli elderly and to study the affect of anxiety on its validity., Design: The short Zung was validated against a psychiatric evaluation, in a geriatric inpatient and outpatient service. The overall validity was determined, as well as for subgroups of sufferers and non-sufferers of anxiety., Setting: An urban geriatric service in Israel., Patients: 150 medical inpatients and outpatients, aged 70 years and older., Measures: Psychiatric evaluation of modified Anxiety Disorders Interview Schedule for DSM-IV as criterion standard for anxiety and depression and short Zung instrument for depression., Results: By criterion validity, 60% suffered from depression. The overall validity of the short Zung was high (sensitivity 71.1%, specificity 88.3%, PPV 90.1%, NPV 67.1%). The validity for those not suffering from anxiety was good (sensitivity 71.1%, specificity 90.2%, PPV 84.4%, NPV 80.7%). In those with anxiety, sensitivity, specificity and PPV were high (71.2%, 77.8%, 94.9% respectively), although the specificity was less than in non-suffers. However major difference was in the NPV rate being much lower (31.8%)., Conclusion: The short Zung, an easily administered instrument for detecting depression, is also valid in the Israeli elderly. However, anxiety limits the usefulness of this instrument in correctly ruling out depression. The clinician must be aware, therefore, that those suffering from anxiety may score negatively for depression on a screening instrument, such as the short Zung., (Copyright 2002 John Wiley & Sons, Ltd.)

This study attempts to characterize health lifestyles by subgrouping women with similar behavior patterns. Data on background, health behaviors, and perceptions were collected via phone interview from 1,075 Israeli women aged 50 to 74. From a cluster analysis conducted on health behaviors, three clusters emerged: a "health promoting" cluster (44.1%), women adhering to recommended behaviors; an "inactive" cluster (40.3%), women engaging in neither health-promoting nor compromising behaviors; and an "ambivalent" cluster (15.4%), women engaging somewhat in both health-promoting and compromising behaviors. Clustering was cross-tabulated by demographic and perceptual variables, further validating the subgrouping. The cluster solution was also validated by predicting another health behavior (mammography screening) for which there was an external validating source. Findings are discussed in comparison to published cluster solutions, culminating in suggestions for intervention alternatives. The concept of lifestyle was deemed appropriate to summarize the clustering of these behavioral, perceptual, and structural variables.

Introduction: The Short Anxiety Screening Test (SAST), an easily administered rating scale, was developed to standardize the detection of anxiety disorder in the elderly, even, and especially, in the presence of depression. The instrument also included somatic complaints, often the manifestation of anxiety in the elderly. Failure to relate to the anxiety component in depression may result in the initial failure of antidepressant therapy., Objective: To validate the SAST in the elderly, especially in the presence of depression., Design: The SAST was validated against a psychiatric evaluation in consecutive patients attending a geriatric service, both inpatient and outpatient. The initial validity of the SAST was tested in all the sample and subsequently in the subgroups of depressed and non-depressed., Setting: An urban geriatric service in Israel., Patients: One hundred and fifty medical inpatients and outpatients, 95 females, aged 70 years and older., Measures: Psychiatric evaluation of modified Anxiety Disorders Interview Schedule for DSM-IV as criterion standard for anxiety and depression, SAST for anxiety and short Zung Interview-Assisted Depression Rating Scale for depression., Results: By the psychiatrist's evaluation, 40.7% suffered from anxiety. Mean SAST scores in the presence and absence of anxiety were significantly different (25.3 and 20.1; p<0.0005). The overall validity of the SAST was high (sensitivity 75.4%, specificity 78.7%). In the presence of depression, sensitivity was 83.3% and specificity 70.5%., Conclusion: The SAST was valid in detecting anxiety in the elderly, as well as in depressed patients. The study proved the usefulness of the SAST in a geriatric assessment programme., (Copyright 1999 John Wiley & Sons, Ltd.)

Background and Purpose: The Barthel Index for assessing activities of daily living (ADL) was developed particularly for young stroke patients, but it now has a wider application in the geriatric assessment profile. This study tests the validity of the Barthel Index by self-report in the old-old (> or = 75 years). If more than 10% of the studied population assessed themselves incorrectly (> or = 15-point discrepancy), the test may have limitations. We set out to try to quantify and explain this discrepancy., Methods: During a 3-month period, we tested 126 old-old patients, both geriatric medical inpatients and subjects from the community, in a cross-sectional study. Using the Barthel Index, their functional status was assessed by self-report and by observation of performance. A measure of the magnitude of discrepancy between the two methods (discrepancy score) was calculated as the difference between the self-report and performance total scores., Results: Comparing the self-report with actual ADL performance scores, the mean score for self-report was higher (90 vs 88). There was a low Kappa score in all areas of the scale (range 0.103-0.398). Twenty of the 126 patients (15.9%) scored 15 or more points in the discrepancy score. By running a multiple linear regression, we were able to explain only 21% of the variance in the discrepancy score (R2 = .21). Significant explanatory variables were the presence of cognitive impairment, source of patients from acute geriatric ward, and age (very old > or = 85 years)., Conclusion: For the purpose of this study, use of the Barthel Index by self-reporting was found to have its limitations in the old-old (> or = 75 years), particularly with regard to the very old (> or = 85 years) medical geriatric inpatients. Therefore, we suggest that the older people may have to be assessed by the rehabilitation services using a performance-based measure or a different self-report test for documenting their activities of daily living, bearing in mind that self-reported and performance-based measures capture physical abilities differently.

The objectives of this study were to determine the impact of different personal invitations on screening mammography attendance and to clarify the influence of personal characteristics and health-related attitudes and behaviors on compliance. One thousand and five hundred women, aged 50-74 years, were randomly selected in the city of Haifa. Four letters of invitation were used. Actual mammography performance was validated by a national computerized database. All other data was collected via a telephone interview following the mammography. The overall compliance rate amounted to 45%. The major predictors of compliance were having had a clinical breast examination within the previous year (p = 0.0008), having a health professional recommend routine mammography (p = 0.01) and perceiving mammography as efficient in early detection of breast cancer (p = 0.02). Aggressiveness of message details, or a family physician's or higher authority's signature on the letter had no impact on compliance. A letter of invitation for a routine mammogram at a specific time resulted in an overall rate of compliance 3-fold higher than the baseline. Based on the results of this study. Kupat Holim Clalit decided to implement use of personal invitations for screening mammography to israeli women on a regular basis.

The yield of bone scintigraphy was assessed in a general hospital. A random 1:2 sample of the bone studies performed within a year was evaluated. The referral forms were judged to show absent, ambiguous or clear diagnostic questions. The indications for which the study was ordered were matched with the scintigraphic diagnosis, and yield was defined as the proportion of studies with relevant findings on scintigraphy. The overall yield was 23.5%. In cancer patients the yield was 27.2% and in repeat studies 40.2%. In non-cancer patients the yield was 19.8% and when scintigraphy was performed for the evaluation of specific disease entities it was 35.7%. Relatively low-yield indications in non-cancer patients were suspected metastases 11.1%, and evaluation of X-ray abnormalities 11.5%. An association between the clarity of the diagnostic question and the scintigraphic yield was detected in non-cancer patients. When a diagnostic question was absent the yield was 12%, ambiguous 19%, and when it was clear 26%. This correlation is probably attributed to better understanding of this common procedure, and better definition of the diagnostic question in patients with diverse clinical conditions as compared to cancer patients in whom the question always relates to the presence of bone metastases.

Background and Methods: Women with ductal carcinoma in situ have been treated both by lumpectomy and by lumpectomy followed by radiation therapy, but the benefit of combined therapy is uncertain. A group of 818 women with ductal carcinoma in situ were randomly assigned to undergo lumpectomy or lumpectomy followed by breast irradiation (50 Gy). Sufficient tissue was removed that the margins of the resected specimens were histologically tumor-free. The mean duration of follow-up was 43 months (range, 11 to 86). The principal end point of the study was event-free survival, as defined by the presence of no new ipsilateral or contralateral breast cancers, regional or distant metastases, or other cancers and by no deaths from causes other than cancer., Results: Five-year event-free survival was better in the women who received breast irradiation (84.4 percent, vs. 73.8 percent for the women treated by lumpectomy alone; P = 0.001). The improvement was due to a reduction in the occurrence of second ipsilateral breast cancers; the incidence of each of the other events was similar in the two groups. Of 391 women treated by lumpectomy alone, ipsilateral breast cancer developed in 64 (16.4 percent); it was noninvasive in 32 and invasive in the remaining 32. Of 399 women treated with lumpectomy and breast irradiation, ipsilateral breast cancer developed in 28 (7.0 percent) (noninvasive in 20 and invasive in 8). The five-year cumulative incidence of second cancers in the ipsilateral breast was reduced by irradiation from 10.4 percent to 7.5 percent for noninvasive cancers and from 10.5 percent to 2.9 percent for invasive cancers (P = 0.055 and P < 0.001, respectively)., Conclusions: Breast irradiation after lumpectomy is more appropriate than lumpectomy alone for women with localized ductal carcinoma in situ.

Until 1975 in Israel the mortality rates in men greater than or equal to 25 years old were higher in Jews than non-Jews. Since then the relationship has been reversed with higher rates in the non-Jewish group. The three main causes of death in the two groups were heart disease, cancer and cerebrovascular disease (CVA). Death rates from total heart diseases rose in the non-Jewish population during 1970-82, whereas in the Jewish men there were only slight changes. With regard to cancer, death rates were higher in the Jewish group, but from 1970 to 1978 it increased in both groups, the change being relatively higher in non-Jews. Mortality from CVA was higher among Jews at the beginning of the study period, but since 1978 the rates remained higher in the non-Jewish population. Death from heart disease, cancer and CVA can partially explain the reversal in total mortality rates in 1975. A comparison of the data of Israeli men with those of Israeli women shows that the mortality rates of the non-Jewish population of both sexes have changed dramatically over the last decade. These findings have important implications for the planning of further research and for priority determination in health care planning.

Until 1975 in Israel mortality rates in women aged greater than or equal to 25 years old were higher among Jewish women than non-Jewish women. Since then the relationship has been reversed with higher rates in the non-Jewish group. The three main causes of death in the two groups were heart disease, cancer and cerebrovascular disease (CVA). The proportional mortality and death rates from total heart diseases rose in the non-Jewish population during 1970-82, whereas in Jewish women there were only slight changes. With regard to cancer, the proportional mortality and death rates were higher in the Jewish group. However, from 1970 to 1982 cancer mortality in the Jewish population declined continuously, while in the non-Jewish group it rose. Mortality from CVA rose in both Jewish and non-Jewish women until 1974, but then declined. Since then, the rates remained considerably higher in the non-Jewish population. Death from heart disease, cancer and CVA can partially explain the reversal in total mortality rates in 1975.

Salivary flow rate and composition, oral microflora and clinical manifestations of radiation damage were studied in 32 patients treated with external irradiation to head and neck areas. Several parameters were investigated: field arrangement, amount of salivary glands irradiated, clinical manifestations such as dryness of the mouth, taste impairment, dysphagia, salivary secretion and composition, and oral yeast flora. The salivary glands have a greater sensitivity to radiation damage than the gustatory tissues. The decrease in salivary secretion is accompanied by a rise in salivary sodium concentration, and in oral yeast flora. The clinical symptomatology was correlated with the amount of salivary glands irradiated. We found that most of the parotids have to be outside of the treated volume, when the rest of the major salivary glands are irradiated, to prevent severe dryness phenomena.