Emergency Department Admission Rates, Waiting Times, and Mortality: An Observational Study in the Tertiary Center Most Proximal to Gaza During a Military Conflict.

OBJECTIVES: Military conflicts may be ongoing and encompass multiple medical facilities. This study investigated the impact of a military conflict ("Protective Edge" PE) on emergency department (ED) function in a tertiary medical center. METHODS: Visits to the ED during PE (July-August 2014) were compared with ED visits during July-August 2013 and 2015 with regard to admission rates, waiting times and 30-d mortality. Odds ratios (ORs) adjusted for confounders were used for the multivariable regression models. RESULTS: There were 32,343 visits during PE and 74,279 visits during the comparison periods. A 13% decrease in the daily number of visits was noted. During PE, longer waiting times were found, on average 0.25 h longer, controlling for confounders. The difference in waiting times was greater in medicine and surgery. Admission rates were on average 10% higher during PE military conflict, controlling for confounders. This difference decreased to 7% controlling for the daily number of visits. Thirty-day mortality was significantly increased during PE (OR = 1.42; 95% CI: 1.18-1.70). ORs for mortality during PE were significantly higher in medicine (OR = 1.45; 95% CI: 1.15-1.81) and pediatrics (OR = 4.40; 95% CI: 1.33-14.5). CONCLUSIONS: During an ongoing military conflict, waiting times, admission rates, and mortality were statistically significantly increased.

[DIAGNOSTIC ERROR: PREDICTING THE SEVERITY OF HARM].

INTRODUCTION: Many studies report that the most common cause for malpractice claims is "diagnostic error including delayed/ missed/ wrong diagnosis". AIMS: To identify factors associated with severe harm and mortality in malpractice claims due to delayed/wrong diagnosis. METHODS: Review of records of malpractice claims against Clalit Health Services due to delayed/failed diagnosis in 2010-2019. RESULTS: The study included 354 claims (60.9% males, median age: 48). Primary care physicians were involved in a third of cases. The most common correct diagnoses were cardiovascular disease (21%), infection (19%) and cancer (16%). The level of harm was moderate in 38%, and severe in 24%, while 25% died. In a multivariable analysis, factors associated with severe harm were age, cancer or a cardiovascular disease, the department involved (pediatrics, internal medicine or primary care were associated with severe harm) and the physician's specialty (neurology/neurosurgery associated with severe harm). Factors associated with mortality included age, cancer or a cardiovascular disease, involvement of the internal medicine department and the physician's specialty (internal medicine associated with mortality). CONCLUSIONS: About half of malpractice claims involved delayed/failed diagnosis resulting in severe harm or mortality. Factors associated with severe harm and mortality include age, the diagnosis and the medical specialty involved. DISCUSSION: Potential ways to decrease delayed/failed diagnosis are review. It is important to be familiar with delayed/failed diagnosis as a major cause of harm in health services and in malpractice claims.

P16, Ki67, P53, and WT1 Expression in Uterine Smooth Muscle Tumors: An Adjunct in Confirming the Diagnosis of Malignancy in Ambiguous Cases.

The diagnosis of uterine smooth muscle tumors is sometimes difficult, as these tumors may show worrisome features, suspicious for but not diagnostic of malignancy. The recommended immunohistochemical panel in this setting is currently under debate. In this study, we aimed to find a panel of immunohistochemical stains that would be helpful in determining the correct diagnosis in ambiguous uterine smooth muscle tumors, with an emphasis on investigating the possible usefulness of the WT1 antibody. Uterine leiomyomas were found to be immunoreactive with WT1. Since a previous study reported on the lack of immunoreactivity of uterine leiomyosarcomas with WT1, we speculated that WT1 might be useful in this setting. We retrospectively reviewed the medical charts and slides of 91 patients: 22 with leiomyosarcoma, 15 with smooth muscle tumor of uncertain malignant potential, and 54 with leiomyoma. Immunohistochemical stains for WT1, p16, p53, and Ki67 were performed on each case. We found that immunoreactivity with p16 and Ki67 (>40% and >10% of the tumor cells, respectively) and loss of nuclear expression of WT1 (<10% of the tumor cells) were significantly more common in leiomyosarcomas (all P<0.001). Mutated p53 immunohistochemical staining pattern was significantly more prevalent in leiomyosarcomas than in leiomyomas (P<0.001). Thus, in diagnostically challenging uterine smooth muscle tumors, we recommend using an immunohistochemical panel composed of Ki67, p16, p53, and WT1. A positive result in either of the former 2 (p16 >40% and/or Ki67 >10%) has the strongest association with leiomyosarcoma (sensitivity: 95.5%, specificity=88.9%, positive predictive value=77.8%, negative predictive value=98.0%).

Elevated cancer risk in Holocaust survivors residing in Israel: A retrospective cohort study.

BACKGROUND: The purpose of this study was to examine the incidence of malignant diseases among Holocaust survivors in Israel compared with European and American immigrants who did not experience the Holocaust. METHODS: Study subjects included Holocaust survivors born in European countries under Nazi occupation before 1945, who immigrated to Israel after 1945 and were alive as of the year 2000. Living survivors were identified based on recognition criteria in accordance with the Holocaust Survivor Benefits Law. The comparison group consisted of Clalit enrollees who were born before 1945 in European countries not under Nazi occupation and were alive in 2000 or were born in any European country or America, immigrated to Israel before 1939 and were alive in 2000. The incidence of malignant diseases was compared in univariate and Poisson regression models analyses, controlling for age, smoking, obesity, diabetes and place of residence. RESULTS: The study included 294,543 Holocaust survivors, and the mean age at the beginning of follow-up was 74 ± 8.7 years; 43% males. In multivariable analyses, the rate ratio (RR) values for males and females were 1.9 and 1.3 for colon cancer, 1.9 and 1.4 for lung cancer, 1.6 and 1.4 for bladder cancer and 1.2 and 1.3 for melanoma, respectively. For prostate cancer in males, the RR was 1.4, while for breast cancer in females, it was 1.2. CONCLUSIONS: The incidence of malignant diseases among Holocaust survivors residing in Israel was higher than that among non-Holocaust survivors. These associations remained statistically significant in a multivariable analysis and were stronger for males.

Establishing an integrated gastroenterology service between a medical center and the community.

AIM: To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established. METHODS: Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians' knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators. RESULTS: An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient's visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett's esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer. CONCLUSION: Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.

Uterine cervix conization based on Pap smear results: the "see and treat" approach.

BACKGROUND: The "see and treat" approach, proceeding without a biopsy directly to uterine cervix conization in women diagnosed with high grade squamous intraepithelial lesion (HGSIL) on Pap smear, shortens the treatment duration, lessens patient anxiety, and reduces health care costs. OBJECTIVES: To evaluate the level of diagnostic accuracy and the over-treatment rate in the "see and treat" versus conventional management of women diagnosed with HGSIL. METHODS: We retrospectively reviewed all women with HGSIL who had undergone the "see and treat" approach during 2001-2011 at Soroka University Medical Center. Similar cohorts, who were managed conventionally with a cervical biopsy prior to the conization, served as a comparison group. RESULTS: The study population consisted of 403 women: 72 (18%) had undergone the "see and treat" approach and 331 (82%) conventional management. The false positive rate was 11% for the "see and treat" group, compared to 6% for the conventional management group (P = 0.162). Similarly, no statistically significant difference was observed when comparing the positive predictive value (PPV) of high grade dysplasia diagnosed on Pap smear (PPV 88.9%) versus cervical biopsy (PPV 93.8%) (P = 0.204). Moreover, both the false positive rate and PPV remained similar in subgroups of patients, according to age, menopausal status, number of births, and colposcopy findings. CONCLUSIONS: The accuracy level of HGSIL diagnosis on Pap smear is similar to that of high grade dysplasia on a cervical biopsy. We therefore recommend referring patients with HGSIL directly to conization. Skipping the biopsy step was not associated with significant over-treatment or other adverse effects.

Positive margin status in uterine cervix cone specimens is associated with persistent/recurrent high-grade dysplasia.

The frequency of positive cone margins and its significance in cervical intraepithelial neoplasia are under controversy. The purpose of the current study was to identify factors associated with positive cone margin status and to evaluate its clinical significance in high-grade cervical intraepithelial neoplasia. Medical records of women who underwent loop electrosurgical excision procedure at the Soroka Medical Center (January 2001-July 2011) were reviewed retrospectively. Patient age, extent of dysplasia, endocervical glands involvement, positive margin status, type of margin involved, degree of margin involvement, and postcone endocervical curettage results were evaluated as possible factors associated with persistent/recurrent disease. A total of 376 women were included in the study. Cone margin involvement was observed in 33% (endocervical-22%, ectocervical-8%, both margins-3%). Factors significantly associated with cone margin involvement were older age (older than 35 y), widespread dysplasia in the cone specimen (≥4 sections) (P<0.001 for each), and endocervical glands involvement (P=0.003). Fifty patients (13%) had persistent/recurrent disease. Involvement of the cone margins (focal: hazard ratio=17, P<0.001; extensive: hazard ratio=28, P<0.001) and older age (hazard ratio=1.18 for every 5 additional years, P=0.03) were associated with persistent/recurrent disease. We conclude that women older than 35 yr with widespread high-grade dysplasia in the cone specimen and involvement of endocervical glands are more likely to have positive cone margins. Positive cone margins, particularly when extensively involved, and increased patient age are associated with persistent/recurrent disease. These factors should be considered while planning for further management.

Is radical hysterectomy necessary in early cervical cancer?

AIMS: To estimate the prevalence of tumor spread to the parametrium, vagina and uterine corpus in radical hysterectomy specimens and define a subgroup of patients with low-risk of extracervical involvement, who may benefit from less radical surgery. METHODS: We retrospectively reviewed 96 patients with stage IA1-IIA cervical cancer who had undergone radical hysterectomy and pelvic lymphadenectomy. RESULTS: Tumor spread beyond the uterine cervix was evident in 45 (47%) patients. Thirteen (13%) of the 96 patients had parametrial tumor spread, 12 (13%) had vaginal tumor extension, and 23 (24%) had uterine corpus involvement. Tumor size >2 cm, stromal invasion to a depth of ≥8 mm, and lymph vascular space invasion (LVSI) were significantly associated with extracervical invasion. Twenty-five patients had stromal invasion of <8 mm and no LVSI, of which only 1 (4%) had extracervical involvement. On the contrary, extracervical involvement was evident in 44 patients (63%) among those who had stromal invasion of ≥8 mm and/or LVSI (p < 0.001). Among women with LVSI, extracervical tumor spread was seen with any tumor size and any depth of stromal invasion. All patients with stromal invasion to a depth of >15 mm had extracervical invasion. CONCLUSION: Patients with tumor size <2 cm, depth of invasion of <8 mm and no LVSI could be considered for less radical surgery.

Post-conization endocervical curettage for estimating the risk of persistent or recurrent high-grade dysplasia.

OBJECTIVE: To evaluate the association between post-cone endocervical curettage (ECC) results, either alone or with cone margin status, and persistent/recurrent high-grade dysplasia after conization. METHODS: The medical records of 250 women who underwent a loop electrosurgical excision procedure with post-cone ECC at Soroka Medical Center, Be'er Sheva, Israel, between January 2001 and July 2011 were reviewed retrospectively. RESULTS: Thirty-one women (12.4%) had evidence of high-grade dysplasia in the ECC sample. Factors associated with positive ECC were being older than 35 years (P=0.004) and positive margin status (P=0.001). Twenty-nine patients (11.6%) had persistent/recurrent high-grade dysplasia. Both high-grade dysplasia in the ECC sample (hazard ratio, 2.31; P=0.032) and positive cone margins (hazard ratio, 23.4; P<0.001) were associated with persistent/recurrent disease. CONCLUSION: High-grade dysplasia in the ECC sample was associated with positive cone margin status. These 2 factors were both associated with persistent/recurrent disease. Among patients with positive cone margins, a combination of margin status and ECC was superior to margin status alone for estimating the probability of persistent/recurrent disease. For women with negative cone margins, ECC was less useful. Because ECC is valuable for assessing the risk of persistent/recurrent high-grade dysplasia in many cases, post-cone ECC should be performed routinely with conization.

The association between continuity of care in the community and health outcomes: a population-based study.

BACKGROUND: The study goal was to assess indices of continuity of care in the primary care setting and their association with health outcomes and healthcare services utilization, given the reported importance of continuity regarding quality of care and healthcare utilization. METHODS: The study included a random sample of enrollees from Clalit Health Services 19 years-of-age or older who visited their primary care clinic at least three times in 2009. Indices of continuity of care were computed, including the Usual Provider Index (UPC), Modified Modified Continuity Index (MMCI), Continuity of Care Index (COC), and Sequential Continuity (SECON). Quality measures of preventive medicine and healthcare services utilization and their costs were assessed as outcomes. RESULTS: 1,713 randomly sampled patients were included in the study (mean age: 48.9 ± 19.2, 42% males). Continuity of care indices were: UPC: 0.75; MMCI: 0.81; COC: 0.67; SECON: 0.70. After controlling for patient characteristics in a multivariate analysis, a statistically significant association was found between higher values of UPC, COC, and SECON and a decrease in the number and cost of ED visits. Higher MMCI values were associated with a greater number and higher costs of medical consultation visits. Continuity of care indices were associated with BMI measurements, and inversely associated with blood pressure measurements. No association was found with other quality indicators, e.g., screening tests for cancer. CONCLUSIONS: Several continuity of care indices were associated with decreased number and costs of ED visits. There were both positive and negative associations of continuity of care indices with different aspects of healthcare utilization. The relatively small effects of continuity might be due to the consistently high levels of continuity in Clalit Health Services.

Nocturic episodes in patients with benign prostatic enlargement may suggest the presence of obstructive sleep apnea.

BACKGROUND: Nocturia is a common symptom of benign prostatic enlargement (BPE) that is generally attributed to a urologic pathology. This study assessed whether nocturia severity in BPE patients may be related to an underlying sleep disorder. METHODS: Cross-sectional study based in urban community primary care clinics. Study population included men aged 55 to 75 years old. The research group included patients with documented BPE and nocturia of at least once per night versus a comparison group without BPE and with either no or one nocturia episode per night. The presence of symptoms of obstructive sleep apnea (SOSA) was assessed using the Berlin questionnaire. RESULTS: Patients with BPE were significantly more likely to report weight gain (21% vs 10%), loudness of snoring (22.6% vs 4%), daytime sleepiness (35.3% vs 12.0%), and hypertension (61.8% vs 41.0%). Fifty-nine patients (57.8%) in the research group were considered high risk for OSA compared with 31 patients (31.0%) from the comparison group (P < .001). The odds ratio (OR) for SOSA gradually increased from 1.00 in patients reporting no nocturia to 2.44, 5.75, and 12.3 in patients reporting 1, 2 to 3, and >3 episodes of nocturia per night, respectively. CONCLUSION: The odds for SOSA increased log-linearly in correlation with the number of nocturia episodes. We imply that nocturic episodes in patients with BPE may suggest the presence of OSA. Physicians following patients with BPE who report frequent awakenings from sleep to urinate should suspect OSA as a possible comorbidity.

Increased matrix metalloproteinases-1,-9 in the uterosacral ligaments and vaginal tissue from women with pelvic organ prolapse.

OBJECTIVES: To investigate the possible association of increased matrix metalloproteinases (MMPs)-1,-9 with pelvic organ prolapse (POP) and to evaluate whether inflammatory processes contribute to its development. STUDY DESIGN: Forty women who underwent hysterectomy, 20 with POP grade 2 and above, and 20 without POP, participated in the study. Biopsies from the uterosacral ligaments and vaginal mucosa were obtained from each woman. Each biopsy was sectioned and stained for MMP-1 and MMP-9 by immunohistochemical methods and with hematoxylin and eosin (H&E). MMP-1,-9 expressions were evaluated on the immunostained slides. H&E stained sections were examined for possible inflammatory changes. RESULTS: A higher stromal (extra-cellular) expression of MMPs-1,-9 was found in POP cases compared with controls in vaginal biopsies (MMP-1: p=0.004; MMP-9: p=0.042) as well as in uterosacral ligament biopsies (MMP-1: p=0.011; MMP-9: p=0.015). Increased intracellular expression of both MMPs was also demonstrated in fibroblasts in biopsies of women with POP (p<0.001 for all). Most of these differences persisted after controlling for age. The degree of inflammatory changes reflected by the number of lymphocytes, plasma cells and capillary-sized blood vessels per 10 high power fields, was similar in specimens obtained from women with and without POP. CONCLUSIONS: The expression of MMPs-1,-9 appears to be increased in tissues from women with POP. This supports an association, although not a causal relation, between increased MMPs-1,-9 and POP. Inflammation does not seem to play an important role in the pathogenesis of POP.

[The quality indigators program in Clalit Health Services: the first decade].

The quality indicators program in the community has existed in Clalit Health Services for over a decade. As a part of this program, approximately 70 evidence-based quality indicators have been defined, in 11 different domains. The indicators relate to preventive medicine (immunizations, early detection of diseases, e.g. colorectal cancer, breast cancer, hypertension, chronic renal failure), chronic disease management (diabetes, hyperlipidemia, ischemic heart disease, asthma, congestive heart failure), care of the elderly (prevention of repeated hospitalizations) and child care (obesity detection, anemia detection and treatment). The indicators program is founded on one of the worldwide leading information systems, based on a common data warehouse with data regarding sociodemographic factors, purchase of medications, health services utilization, laboratory and imaging data, as well as a unique, validated registry of chronic diseases. The program has led to progress in several domains, including control of diabetes and hyperlipidemia, pneumococcal vaccination and early detection of colorectal cancer. The program narrowed the gaps and reduced inequalities between the Arab and Jewish populations, and between socioeconomic levels. The improvement in quality indicators is based on teamwork of physicians, nurses, other health professionals and administrative staff. The day-to-day work and the major effort invested in Clalit's enrollees are reflected in the continuing improvement in clinical quality.

Psoriasis associated with hepatitis C but not with hepatitis B.

PURPOSE: To investigate the association between psoriasis and viral hepatitis. METHODS: Psoriasis patients were compared to controls regarding the prevalence of viral hepatitis in a case-control study using logistic multivariate models. The study was performed utilizing the medical database of Clalit Health Services. RESULTS: The study included 12,502 psoriasis patients >20 years old and 24,287 age- and sex-matched controls. The prevalence of hepatitis C in patients with psoriasis was increased compared to the prevalence in controls (1.03 vs. 0.56%; p < 0.001). In a multivariate analysis, psoriasis was associated with hepatitis C. An interaction with smoking was noted (smokers: odds ratio, OR = 1.93, 95% confidence interval, CI = 1.30-2.67; nonsmokers: OR = 2.22, 95% CI = 1.63-3.04). The prevalence of hepatitis B in patients with psoriasis was higher than in the controls (0.74 vs. 0.56%; p = 0.043). However, in a multivariate analysis psoriasis was not associated with hepatitis B (OR = 1.22, 95% CI = 0.93-1.60, p = 0.15). CONCLUSION: Our observation supports previous reports of an association between psoriasis and hepatitis C but not with hepatitis B. Physicians who care for patients with psoriasis should be aware of this possible association and consider screening patients with psoriasis for hepatitis C.

Psoriasis and hypertension: a case-control study.

In recent years, numerous reports have demonstrated an association between psoriasis and metabolic syndrome. However, some studies failed to demonstrate an association between psoriasis and hypertension. The aim of the present study was to examine the association between psoriasis and hypertension. Psoriasis patients of a health-maintenance organization were compared with enrollees without psoriasis regarding the prevalence of hypertension in a case-control study. The study included 12,502 psoriasis patients over the age of 20 years and 24,285 age- and sex-frequency-matched controls. The prevalence of hypertension was significantly higher in psoriasis patients than controls (38.8%, 29.1%, respectively, p<0.001). In a multivariate analysis, hypertension was associated with psoriasis after controlling for age, sex, smoking status, obesity, diabetes, non-steroidal anti-inflammatory drugs (NSAIDs) and use of Cox-2 inhibitors (odds ratio: 1.37, 95% confidence interval: 1.29-1.46). The results of this study support the previously noted association between psoriasis and hypertension. We suggest that patients with psoriasis should be routinely screened for the presence of hypertension.

Pregnancy outcome in patients following different types of bariatric surgeries.

BACKGROUND: The objective of this study was to investigate pregnancy outcome of patients following different types of bariatric surgery. METHODS: A population-based study includes all pregnancies of patients with bariatric surgeries delivered during 1988-2008. Pregnancy outcome was compared between the different types of surgeries. RESULTS: This retrospective study included 449 deliveries: 394 deliveries following pure restrictive operations-laparoscopic gastric banding (LAGB; n = 202), silastic ring vertical gastroplasty (SRVG; n = 136), and vertical-banded gastroplasty (VBG; n = 56)-and 55 deliveries following restrictive and malabsorptive Roux-en-Y gastric bypass (RGB). While no significant differences were noted between the groups regarding body mass index (BMI) before the bariatric operations or prepregnancy BMI, patients following LAGB had significantly higher BMI before delivery (36.8 +/- 5.9 kg compared to the SRVG 33.4 +/- 6.0, VBG 34.2 +/- 5.4, and RGB 34.9 +/- 6.8 groups; p < 0.001). Following LAGB, patients had higher weight gain during pregnancy (13.1 +/- 9.6 kg) compared to the SRVG (8.8 +/- 7.4), VBG (8.5 +/- 8.0), and RGB (11.6 +/- 9.6; p < 0.001) groups. The interval between operation and pregnancy was shorter in the LAGB group (22.8 months) compared to the SRVG (41.0) and the VBG (42.1) groups and was significantly higher in the RGB group (57.4; p < 0.001). Birth weight was significantly higher among newborns of patients following RBG (3,332.8 +/- 475.5 g) compared to the restrictive procedures (3,104.3 +/- 578.7 in the LAGB, 3,086.7 +/- 533.1 in the SRVG, and 3,199.2 +/- 427.2 in the VBG groups). No significant differences in low birth weight (<2,500 g) or macrosomia (>4,000 g), or low Apgar scores or perinatal mortality were noted between the groups. CONCLUSION: There is no difference in the affect on pregnancy outcome among the different forms of bariatric surgeries; all procedures have basically comparable perinatal outcome.

Estimation of mortality savings due to a national program for diabetes care.

BACKGROUND: Diabetes-related complications can be reduced by better control of glycemia, lipid abnormalities and blood pressure. In recent years, efforts at improving diabetes care in Israel have been made. This study aims to estimate mortality savings related to a national program for diabetes care in Israel. METHODS: Total population data for Israel was projected to 2020. Current diabetes prevalence and disease management data were obtained from a national program of diabetes care. Projections of the program's effect were based on two models: improvement in glycemic control, reflected in Hb A1c levels, and improvement in overall diabetes care, reflected in the percentage with LDL<100 mg/dl, a proxy for multi-factorial control. Potential years of life lost (PYLL) and quality-adjusted life years (QALYs) saved were calculated. RESULTS: A drop in average Hb A1c values from 8.13% at baseline to 7.36% in 2020 is expected, and as a result 4216 deaths from diabetes will be prevented over the period 2001-2020, saving around 47,773 life years or 34,342 QALYs. Overall diabetes care, reflected in improving the control rate of LDL levels to <100 mg/dl from 36% in 2000 to 58% in 2020, is estimated to prevent around 4803 deaths from diabetes over the period 2001-2020., so the program will save around 47,127 PYLL or 32,862 QALYs. CONCLUSIONS: A nationwide program of diabetes care is estimated to result in significant reductions of overall, as well as CHD-related, mortality.

Physicians' knowledge and attitudes regarding periconceptional folic acid supplementation: a survey in Southern Israel.

BACKGROUND: Pre-conceptional folic acid supplementation is an effective way to reduce the incidence of neural tube defects (NTDs). Primary care providers are an important source of information to promote folic acid intake. This study aimed at evaluating primary care physicians' knowledge and attitudes regarding folic acid supplementation for childbearing women. MATERIAL/METHODS: A questionnaire on physicians' knowledge and attitudes, mostly including multiple-choice questions, was delivered by mail to all physicians (n=370) in a large health provider organization in southern Israel in 2006. Data regarding demographics as well as type of specialty, experience, and place of work were collected. RESULTS: Eighty-seven physicians were included in the study (response rate: 24%). Seventy physicians out of 81 (94%) reported routine recommendation of folic acid for their patients. Most physicians admitted that they needed more information regarding folic acid supplementation. Knowledge about folic acid's role in preventing congenital anomalies was suboptimal, with 2% of the physicians correctly estimating the efficacy of folic acid in decreasing the risk of NTDs and 8% recognizing the association between folic acid supplementation and decreased prevalence of malformations other than NTDs. Knowledge about the correct timing (12%) and dosage (47%) of folic acid preparations for average-risk women was also lacking. CONCLUSIONS: Primary care physicians report that they routinely prescribe folic acid to women in childbearing age in order to prevent congenital anomalies, but their knowledge about folic acid supplementation is insufficient.

Non-Hodgkin lymphoma and pesticide exposure: 25 years of research.

Over the past 40 years, a substantial rise in the incidence of non-Hodgkin lymphoma (NHL) has been observed. Epidemiologic studies aimed at understanding this rise have revealed some association with occupational exposure. NHL is common among farmers, where pesticides have been described as the culprit. The association between pesticides and NHL has been demonstrated mainly in case-control studies, while retrospective cohorts have been less convincing. Pesticides including chlorphenol and phenoxyacetic acid herbicides, organochlorines, and organophosphate insecticides, carbamates, and fungicides have been associated with NHL. Although the causality has not been clearly proven, both genotoxic and nongenotoxic mechanisms for lymphomagenesis have been proposed. The leveling-off of NHL incidence in certain countries may be the result of a favorable change in pesticide usage patterns. Future studies, such as the Agricultural Health Study, may clarify the uncertainties regarding this issue.