Cesarean delivery on maternal request in Israel: Maternity department policies and obstetricians' perspectives.

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

Obstetric and Neonatal Outcomes following COVID-19 Vaccination in Pregnancy.

COVID-19 infection imposes a risk for pregnant individuals and may lead to adverse maternal and obstetric outcomes. This is a retrospective cohort study of all women giving birth between March and July 2021 at a single tertiary center. Obstetric and neonatal outcomes were compared between vaccinated and non-vaccinated pregnant women with singleton pregnancies. Women with prior COVID-19 infection, multiple gestations and stillbirth were excluded from the study. Of 4708 women who delivered during the study period, 3700 met the eligibility criteria, of whom 3240 were vaccinated during pregnancy. Compared with the non-vaccinated group, the vaccinated group was characterized by a lower rate of smoking (3.70% vs. 6.67%, p = 0.0028), whereasother maternal characteristics were not significantly different. Multivariable analysis demonstrated that COVID-19 mRNA vaccination was not significantly associated with increased risk of preterm birth as well as other adverse obstetric outcomes including hypertensive diseases of pregnancy, cesarean delivery and small for gestational age. However, a significantly lower risk for meconium-stained amniotic fluid was observed among the vaccinated group (adjusted odds ratio 0.63; 95% confidence interval, 0.46-0.86, p = 0.0039). Moreover, the vaccine was not significantly associated with increased risk of neonatal adverse outcomes including respiratory complications and NICU hospitalization. In conclusion, BNT162b2 messenger RNA vaccination during pregnancy was not associated with an increased rate of adverse obstetric and neonatal outcomes. Therefore, in view of its safety on one hand, and the risk associated with COVID-19 disease in pregnancy on the other hand, BNT 162b2 COVID-19 vaccine should be recommended for pregnant women.

Oncology Treatments during the COVID-19 Pandemic in Israel: the ONCOR Study.

BACKGROUND: The increased susceptibility of cancer patients to coronavirus disease-2019 (COVID-19) infections and complications calls for special precautions while treating cancer patients during COVID-19 pandemics. Thus, oncology departments have had to implement a wide array of prevention measures. OBJECTIVES: To address issues associated with cancer care during the COVID-19 pandemic and to assess the implementation of measures aimed at containment of COVID-19 diffusion while allowing continuation of quality cancer care. METHODS: A national survey among oncology departments in Israel was conducted between 12 April 2020 and 14 April 2020. Eighteen heads of hospital-based oncology departments completed a self-report questionnaire regarding their institute's preparedness for treatment of cancer patients during the COVID-19 pandemic. RESULTS: In this national survey, prevention measures against COVID-19 spread were taken prior to patients' arrival and at arrival or while staying in the departments. Most participants (78-89%) reported using a quick triage of patients and caregivers prior to their entrance to the oncology units, limiting the entrance of caregivers, and reducing unnecessary visits to the clinic. Switching to oral therapies rather than intravenous ones when possible was considered by 82% and shortage in personal protective equipment was reported by five (28%) heads of oncology departments. Some differences between large and small/medium sized medical centers were observed regarding issues related to COVID-19 containment measures and changes in treatment. CONCLUSIONS: Oncology departments in Israel were able to prepare and adapt their services to guidelines and requirements related to the COVID-19 pandemic with little harm to their treatment capacity.

Cancer in IVF patients treated at age 40 years and older: long term follow-up.

RESEARCH QUESTION: Current knowledge of cancer risk among women who undergo IVF is based mainly on studies of women treated in their thirties, frequently with short follow-up periods. Therefore, information about cancer risk among infertile menopausal women is limited. We aimed to evaluate the risk of cancer among IVF patients treated at age 40 years and older, followed up for an extended period. DESIGN: Historical cohort study of all IVF patients treated at the age of 40 years or older at two university-affiliated IVF units in Jerusalem, Israel, between 1994 and 2002. Data were cross-linked with the Israel National Cancer Registry to 2016. Standardized incidence ratios (SIR) and 95% confidence intervals were computed by comparing the observed number of cancer cases with the expected cancer rate in the general Israeli population adjusted for age and year of birth. In addition, Kaplan-Meier analysis was conducted to account for the length of follow-up. RESULTS: A total of 501 patients were included in the analysis, with mean follow-up of 16.7 ± 3.7 years (range 2-22 years). Mean age at first IVF cycle was 42.3 years (±2.1). Mean number of IVF cycles was 3.2 ± 2.6 (range 1-15). Thirty-six women (7.2%) developed invasive cancer, compared with 47.2 expected cases; SIR 0.76 (95% CI 0.53 to 1.06); 22 women were diagnosed with invasive breast cancer, compared with 19.84 expected; SIR 1.11 (95% CI 0.69 to 1.68). CONCLUSIONS: Older women undergoing IVF treatment were not significantly associated with an excess risk of cancer at long-term follow up. Further studies, however, are needed to confirm these findings.

A case-control study of caesarean delivery on maternal request: who and why?

OBJECTIVE: The current study aimed to evaluate the profile of women who are most likely to undergo caesarean delivery on maternal request (CDMR) and clarify their reasons for this decision. METHODS: For this multicentre case-control study, data were collected from 429 women who underwent CDMR and 429 matched controls who delivered vaginally from June, 2008 through February, 2009. Participants were interviewed by telephone regarding sociodemographic variables, health and lifestyle. RESULTS: CDMR predictors were as follows: increasing age (OR = 1.09/year; 95%CI: 1.05-1.14), family status (unmarried without a steady partner versus married - OR = 3.60; 95%CI: 1.08-11.97), decreasing level of religiosity (secular versus ultra-orthodox - OR = 11.82; 95%CI: 3.75-37.21), and never having engaged, or ceasing sports activity during pregnancy (OR = 1.79; 95%CI: 1.09-2.91 and 2.38; 95%CI: 1.28-4.43, respectively). Above average income reduced the probability of CDMR (OR = 0.56; 95%CI: 0.33-0.94). The most frequent reasons for choosing CDMR were concern for pain (21.9%), concern for their own or baby's health (20.4% and 16.5%, respectively) and emotional aspects (10.0%). CONCLUSIONS: Older, unmarried and/or secular women had increased probability of CDMR. Addressing specific concerns regarding vaginal delivery may provide the basis for a patient-oriented intervention for preventing unnecessary surgery.

Association between BRCA1 and BRCA2 mutations and survival in women with invasive epithelial ovarian cancer.

CONTEXT: Approximately 10% of women with invasive epithelial ovarian cancer (EOC) carry deleterious germline mutations in BRCA1 or BRCA2. A recent article suggested that BRCA2-related EOC was associated with an improved prognosis, but the effect of BRCA1 remains unclear. OBJECTIVE: To characterize the survival of BRCA carriers with EOC compared with noncarriers and to determine whether BRCA1 and BRCA2 carriers show similar survival patterns. DESIGN, SETTING, AND PARTICIPANTS: A pooled analysis of 26 observational studies on the survival of women with ovarian cancer, which included data from 1213 EOC cases with pathogenic germline mutations in BRCA1 (n = 909) or BRCA2 (n = 304) and from 2666 noncarriers recruited and followed up at variable times between 1987 and 2010 (the median year of diagnosis was 1998). MAIN OUTCOME MEASURE: Five-year overall mortality. RESULTS: The 5-year overall survival was 36% (95% CI, 34%-38%) for noncarriers, 44% (95% CI, 40%-48%) for BRCA1 carriers, and 52% (95% CI, 46%-58%) for BRCA2 carriers. After adjusting for study and year of diagnosis, BRCA1 and BRCA2 mutation carriers showed a more favorable survival than noncarriers (for BRCA1: hazard ratio [HR], 0.78; 95% CI, 0.68-0.89; P < .001; and for BRCA2: HR, 0.61; 95% CI, 0.50-0.76; P < .001). These survival differences remained after additional adjustment for stage, grade, histology, and age at diagnosis (for BRCA1: HR, 0.73; 95% CI, 0.64-0.84; P < .001; and for BRCA2: HR, 0.49; 95% CI, 0.39-0.61; P < .001). The BRCA1 HR estimate was significantly different from the HR estimated in the adjusted model (P for heterogeneity = .003). CONCLUSION: Among patients with invasive EOC, having a germline mutation in BRCA1 or BRCA2 was associated with improved 5-year overall survival. BRCA2 carriers had the best prognosis.

Effect of BRCA1/2 mutations on long-term survival of patients with invasive ovarian cancer: the national Israeli study of ovarian cancer.

PURPOSE: To evaluate the long-term survival of ovarian cancer (OvC) patients in total and by BRCA1/2 mutation status. PATIENTS AND METHODS: In a nationwide case-control study on OvC conducted in Israel between 1994 and 1999, 779 Jewish women with epithelial invasive OvC were tested for the three Ashkenazi Jewish founder mutations in BRCA1 (185delAG; 5382insC) and BRCA2 (6174delT) genes and followed for survival up to 2003. Of the 605 women of Ashkenazi origin, 213 (35.2%) carried a mutation in the BRCA1/2 genes. Clinical characteristics were abstracted from the patients' medical records. The Kaplan-Meier method, log-rank tests, and stepwise Cox regression model were used for survival analyses. RESULTS: The 5-year survival rate for the entire group was 39%. Median survival for carriers was significantly longer than for noncarriers (53.7 v 37.9 months, respectively; P = .002). This differential survival was pronounced among women diagnosed at stages III to IV (5-year survival rates of 38.1% and 24.5% for carriers and noncarriers, respectively; P < .001) and for women with poor grade (45.4% v 31.5%, for carriers and noncarriers, respectively; P < .001). These results remained significant after controlling for age at diagnosis, grade, and morphology. This benefit in prognosis was seen for both BRCA1 and BRCA2 carriers compared with noncarriers. During the study period (median follow-up, 6.2 years), being a BRCA1/2 mutation carrier decreased the mortality rate by 28%. CONCLUSION: This study confirms that, among Ashkenazi OvC patients, BRCA1/2 mutations are associated with improved long-term survival. This may be due to distinct clinical behavior and/or to a better response to chemotherapy.

Nosocomial bloodstream infections in a pediatric intensive care unit: 3-year survey.

BACKGROUND: Bloodstream infections (BSI) represent a major cause of hospital-acquired infections in pediatric intensive care unit (PICU) patients. This study was designed to determine the prevalence, risk factors and outcomes of these infections in one local facility. MATERIAL/METHODS: All patients admitted to one PICU between January 1, 2000 - December 31, 2002 and subsequently developed a nosocomial bloodstream infection (NBSI) were consecutively recruited. The study was a retrospective study. Data retrieved from medical records included demographic information, extrinsic (invasive devices) and intrinsic risk factors, specific pathogens, therapeutic interventions and outcome. RESULTS: There were 95 episodes of NBSIs in 59 patients (63/1711 PICU admissions, yielding an incidence of 56/1000). The crude mortality rate (CMR) in children with NBSIs was 52%, compared with 6% for all other children admitted to the PICU. A higher CMR was associated with hemato-oncology illness, prolonged length of hospitalization (>1 month) mechanical ventilation, dialysis and severity of illness. Most of the patients (95%) had central intravascular devices, and 73% of the episodes were catheter-related infections. The most frequent pathogens were coagulase-negative staphylococci (24%), Klebsiella pneumonia (16%), Candida spp. (15%), Pseudomonas aeruginosa (7%) and Staphylococcus aureus (6%). Thirty-three percent of the Staphylococcus aureus were methicillin resistant (MRSA) and 30% of the Klebsiella pneumonia were extended - spectrum beta-lactamase - producing (ESBL) strains. CONCLUSIONS: The overall incidence of NBSIs was 56 episodes per 1000 admissions. The major risk factors were hemato-oncology illness, prolonged length of hospitalization, mechanical ventilation, dialysis and severity of illness. Children with NBSI had a poor outcome when compared with children without NBSI.

Demographic and genetic characteristics of patients with borderline ovarian tumors as compared to early stage invasive ovarian cancer.

OBJECTIVE: Evaluation whether Jewish founder mutations in BRCA predispose to borderline tumors as they do to early invasive ovarian cancers. METHODS: All Jewish women with borderline or invasive ovarian tumors, diagnosed over a 5-year period (1994-1999), were identified in the frame of a nationwide epidemiological study on ovarian cancer in Israel. Out of a total of 1489 patients, 1269 were interviewed; of them 256 (20.2%) patients were identified with stage I and II invasive epithelial ovarian tumors, and 233 (18.3%) patients were identified with borderline tumors. All patients underwent interviews, and blood or tissue samples from 117 borderline tumors and 161 early stage invasive tumors were analyzed for the presence of the 185delAG and 5382insC BRCA1, and the 6174delT BRCA2 Jewish founder mutations. RESULTS: Patients with borderline tumors were younger at diagnosis, and more frequently of the serous type (P < 0.001) as compared to patients with early stage ovarian cancer. Prevalence of Jewish founder mutations in BRCA1 and BRCA2 was only 4.3% of patients with borderline tumors as compared to 24.2% of patients with early stage ovarian cancer (P = 0.001). CONCLUSIONS: This nationwide study comparing patients with early stage borderline and invasive epithelial tumors of the ovary confirms our previous pilot study that showed a lower incidence of BRCA mutations in patients with borderline tumors. Our results suggest that the genetic predisposition and the molecular mechanisms underlying tumor initiation differ between invasive and borderline tumors of the ovary.