The effect of an injectable toltrazuril - gleptoferron (Forceris®) on Cystoisospora suis oocyst excretion and growth of neonatal piglets pre- and post-weaning.

In this study the efficacy of an intramuscular formulation of toltrazuril combined with gleptoferron for the control of porcine cystoisosporosis caused by Cystoisospora suis was investigated. The study was carried out on three Belgian farms with a confirmed history of C. suis infections. As none of the farms implemented a standardized toltrazuril treatment regimen for their piglets, the presence of resistant C. suis strains seems improbable. In total 90 litters, representing 1249 piglets, were included in the study and randomly allocated to either the treatment or control group. Piglets in the treatment group received a single intramuscular injection, containing 45 mg toltrazuril and 200 mg gleptoferron, between 1 and 3 days of age. Piglets in the control group received a single injection with only 200 mg gleptoferron. The effect of treatment on oocyst excretion, expressed in oocysts per gram of feces (OPG), average daily weight gain (ADG) and mortality was determined both pre- and post-weaning. A significant decrease in OPG as well as a decrease in the number of litters (pre-weaning) and pens (post-weaning) that tested positive for cystoisosporosis, was observed in the treated animals compared to the controls. Furthermore, treatment resulted in an increased ADG during the period from day 1 to day 21 (p-value: 0.03881). There was no significant difference in mortality observed between the treatment group to the control group (p-value: 0.2167). To our knowledge, this is the first report on the effect of toltrazuril on oocyst excretion after weaning. This finding highlights the potential long-term benefits of the treatment beyond the initial administration.

Cystoisospora suis in Portugal: an observational study of prevalence, management, and risk factors.

BACKGROUND: Neonatal coccidiosis is a common and important disease of suckling piglets in modern farming caused by Cystoisospora suis. Prevalence rates are high, namely, in Portugal, although no recent data are available. The metaphylactic administration of a single dose of toltrazuril and hygienic measures are the backbone of control strategies on positive farms. However, several studies have shown that these programs are not always effective, underlining the need to revise the risk factors and control strategies currently applied. The present study evaluated C. suis prevalence on Portuguese farms and assessed the risk factors associated with facilities and farm rearing practices. RESULTS: From the 27 tested farms, 23 were positive to Cystoisopora suis (85.2%). In total, 258 litters were sampled (accounting for 516 samples-2 samples per litter), with an average of 59.7% of positive litters per positive farm. Faecal pools from litters, in which liquid faeces predominated had a higher probability of containing oocysts than litter pools with mainly solid (Odds Ratio: 9.87; p < 0.0001) or pasty faeces (OR: 7.05; p = 0.001), and samples obtained from younger animals had higher oocyst counts (coefficient: - 0.0720; 95% CI - 0.125; - 0.019). No significant effect of toltrazuril administration was observed on the positivity rate, and none of the tested farms used disinfectants with official claims against parasites and known anticoccidial effects (e.g., cresol-based products). CONCLUSIONS: The C. suis prevalence on Portuguese swine farms appears to be similar to the prevalence found in other European countries. Repeated sampling of the same litter and the use of autofluorescence microscopy after a modified Ritchie technique seems to have increased sensitivity and consequently the detection rate of positive litters. Finally, despite the common use of oral toltrazuril, C. suis control programs appear to not always be effective (based on the detection of oocysts in faecal samples), suggesting the need to revise the control strategies applied in the field, including management factors and choices of disinfectant products.

Cystoisospora suis infection in suckling piglets in Brazil: Prevalence and associated factors.

Piglet coccidiosis is a parasitic disease caused by the protozoan Cystoisospora suis, which is regarded as the most prevalent gastrointestinal parasite in intensive pig farms. Despite the availability of highly effective chemo-metaphylaxis (toltrazuril), coccidiosis is still prevalent in European and other countries. We conducted a cross-sectional study on swine farms in Brazil, to assess the prevalence of Cystoisospora suis in fecal samples and determined the associated factors. In total, 666 litters from 50 farms were sampled twice within one week between samplings (mean age at sampling: 10.75 and 17.7 days). Of 666 litters, 225 (33.8%) were positive at least once, and the expected within farm prevalence of C. suis oocysts was 32.9% (25.4-41.3%; 95% confidence interval). Oocysts were more prevalent in fecal samples collected from farms with diarrhea (odds ratio = 6.75). The room temperature was also positively associated with oocyst detection; a one-degree increase in room temperature increased the chance of a litter being positive by 23.2%. Up-to-date, this is the most comprehensive technical evidence of factors associated with C. suis infection in Brazilian industrial piglet farms.

Absorption and Distribution of Toltrazuril and Toltrazuril Sulfone in Plasma, Intestinal Tissues and Content of Piglets after Oral or Intramuscular Administration.

Piglet coccidiosis due to Cystoisospora suis is a major cause of diarrhea and poor growth worldwide. It can effectively be controlled by application of toltrazuril (TZ), and oral formulations have been licensed for many years. Recently, the first parenteral formulation containing TZ in combination with iron (gleptoferron) was registered in the EU for the prevention of coccidiosis and iron deficiency anemia, conditions in suckling piglets requiring routine preventive measures. This study evaluated the absorption and distribution of TZ and its main metabolite, toltrazuril sulfone (TZ-SO2), in blood and intestinal tissues after single oral (20 mg/kg) or single intramuscular (45 mg/piglet) application of TZ. Fifty-six piglets were randomly allocated to the two treatment groups. Animals were sacrificed 1-, 5-, 13-, and 24-days post-treatment and TZ and TZ-SO2 levels were determined in blood, jejunal tissue, ileal tissue, and mixed jejunal and ileal content (IC) by high performance liquid chromatography (HPLC). Intramuscular application resulted in significantly higher and more sustained concentrations of both compounds in plasma, intestinal tissue, and IC. Higher concentrations after oral dosing were only observed one day after application of TZ in jejunum and IC. Toltrazuril was quickly metabolized to TZ-SO2 with maximum concentrations on day 13 for both applications. Remarkably, TZ and TZ-SO2 accumulated in the jejunum, the primary predilection site of C. suis, independently of the administration route, which is key to their antiparasitic effect.

Piglet coccidiosis in Belgium and the Netherlands: Prevalence, management and potential risk factors.

Piglet coccidiosis caused by Cystoisospora suis is one of the most important causes of diarrhea in suckling piglets. The parasite has a fast development and multiplies quickly and effectively under the conditions of a farrowing unit. Control measures include cleaning and disinfection and anticoccidial treatment. In Europe, toltrazuril-based products are authorized for this purpose and are applied to piglets on affected farms in the first week of life. To observe the effect of treatment and disinfection on the control of piglet coccidiosis in the field, 23 farms (11 from Belgium, 12 from the Netherlands, mean number of sows = 1413) were sampled twice by litter in the second and third week of life and fecal scores and the presence of C. suis oocysts were determined. A questionnaire was used to collect data on farm sizes, management and hygiene measures as well as treatment (product, dose and piglet age). Thirteen farms regularly treated with toltrazuril (treatment age: 1-6 days, mean 4.3 days) and 19 applied disinfection. Parasite excretion was documented on 60.9% and diarrhea on 78.3% of farms and in 34.3%/15.7% of the litters. Only 2.4% of the litters showed both, so subclinical infection appeared to be common. No significant differences between farms that did not treat against coccidiosis and farms that applied toltrazuril was observed with regard to C. suis oocysts shedding and/or diarrhea. However, in litters that were treated within the first three days of life, oocyst excretion was significantly less often observed than in litters with later treatment (p = 0.033). No significant effect of disinfection could be shown, but most farms applied disinfectants that have no proven effect against coccidia (oxygen-releasing agents or glutaraldehyde + ammonia) while the only farm that used chlorocresols (which are effective against coccidia) did not show oocyst shedding. Current control measures thus appear to be insufficient on most of the examined farms. It is therefore recommended to treat piglets timely and to apply effective disinfectants to reduce C. suis infections. Furthermore, regular evaluation of sustained efficacy of all implemented measures are necessary.

Shifts in the Fecal Microbial Community of Cystoisospora suis Infected Piglets in Response to Toltrazuril.

The protozoan parasite Cystoisospora suis causes diarrhea and reduced weight gain in suckling piglets. Infections occur in the first days of life; it is transient but can lead to dysbiosis, exacerbating disease and increasing mortality. Cystoisosporosis is effectively controlled by toltrazuril treatment; however, alterations of the gut microbial composition upon infection and treatment have not been investigated. This study evaluated the development of fecal microbiota of C. suis infected piglets in response to treatment with toltrazuril. Thirty-eight conventional piglets were infected with C. suis on the first day of life (dol 1). Twenty-six of them received either parenteral or oral toltrazuril 2 days later. Fecal samples were collected pre- and post-weaning (dol 1-15 and 31-38) for microbiota analysis using 16S rRNA amplicon sequencing and during dol 5-18 to determine fecal consistency and parasite excretion. All control animals shed parasites at least once and the majority developed diarrhea, while toltrazuril-treated piglets did not excrete parasites and only had low levels of diarrhea. Age-related shifts in the fecal microbiota composition and increase in diversity and species richness were seen until after weaning. Parasite infection disrupted bacterial maturation 2 weeks after infection. Irrespective of the route of administration, fecal communities of piglets in the treated groups clustered separately and were more diverse compared to that of control piglets during the acute phase of infection on dol 11. Control piglet feces showed higher levels of Fusobacteriaceae and Veillonellaceae, while Ruminococcaceae, Lachnospiraceae, S24-7, Clostridiaceae, and Erysipelotrichaceae were more abundant in feces of treated piglets on dol 11. Thereafter, treatment-related effects on the microbial communities were small and mainly detectable on dol 34 (5 days post-weaning), potentially indicating that the oral toltrazuril treatment might have had long-term effects on host physiological responses post-weaning. Irrespective of the administration route, toltrazuril prevented C. suis-related dysbiosis and maintained species richness and diversity on dol 11. In addition to cystoisosporosis prevention, toltrazuril seems to contribute to the stabilization of the gut microbial development during the suckling phase and thus may reduce the need for antibiotics to control infections with secondary bacterial enteropathogens in C. suis-infected suckling piglets.

Cystoisospora suis Control in Europe Is Not Always Effective.

After introduction of the anticoccidial toltrazuril for the metaphylactic treatment of suckling piglet coccidiosis, only few field evaluations on the effect of treatment against the causative agent, Cystoisospora suis, were performed. In 2018, a field study was conducted to detect the presence of the parasite on pig farms in four different European countries, and to evaluate management parameters possibly associated with infection and disease. A total of 49 farms from Austria, the Czech Republic, Germany and Spain were included. Repeated pooled fecal samples from 603 litters were taken in the 2nd and 3rd week of life. Samples were examined by autofluorescence for the presence of C. suis, and fecal consistency was scored. For each farm a questionnaire was provided to document management and treatment history. Feces scored as diarrhoeic were not significantly more often positive for C. suis than non-diarrhoeic feces but samples from litters with previously reported occurrence of diarrhea were significantly more often positive (p = 0.000). Pasty feces were significantly more often positive than those of other consistency (p = 0.005). Overall, 71.4% of the farms and 50.1% of the litters were positive for C. suis at least once. The prevalence on the farms reached up to 100%. Diarrhea was seen in samples from 53.1% of the farms (9.6% of the litters). Cystoisospora suis was diagnosed on 80.8% of the farms with vs. 60.8% of those without diarrhea. Toltrazuril was applied on 30 farms, and of these 53.3% had diarrhoeic samples and 66.7% were positive for C. suis vs. 19 farms that did not use toltrazuril with 52.6% diarrhoeic and 79.0% C. suis positive samples (p > 0.05). Only on two farms a disinfectant with activity against coccidia was used, and C. suis was not detected there. Current control of C. suis appears to be insufficient on the majority of the examined farms. These findings highlight the importance of correct application of medication, and an effective hygiene management. To maintain effective parasite control, efficacy monitoring of the control measures should be implemented.

Efficacy of injectable toltrazuril-iron combination product and oral toltrazuril against early experimental infection of suckling piglets with Cystoisospora suis.

BACKGROUND: Toltrazuril is frequently administered for the metaphylactic control of piglet cystoisosporosis. In a previous study, the efficacy of parenteral toltrazuril (45 mg/piglet, Group Forceris®) applied on the 2nd day of life (dol), and of oral toltrazuril (20 mg/kg of body weight, Group Baycox®) applied on the 4th dol was evaluated in an experimental model with Cystoisospora suis infection on the 3rd dol (late infection, LI). In a follow-up study, efficacy and safety were evaluated against infections with C. suis on the 1st dol (early infection, EI). Parameters included oocyst excretion and faecal consistency, body weight development, bacteriological examinations and animal health. RESULTS: All control piglets (n = 12) shed oocysts and had diarrhoea, while parasite excretion was completely suppressed in both treatment groups (n = 13 each) and diarrhoea was reduced to a single animal (Forceris® group), resulting in significant differences for these parameters between the treated groups and the controls without significant differences among the treatment groups. No treatment-related adverse events were noted. Body weight gain was reduced in the control group during the acute phase of infection, resulting in significantly lower body weight on the 15th dol. Sows and piglets shed high numbers of Escherichia coli. Clostridium perfringens type A was only detected in low amounts in pooled litter samples. In comparison to the LI study oocyst shedding was more intense in the control animals in EI, while diarrhea was more frequent in LI. In both infection models a high efficacy of toltrazuril in the control of parasitological and clinical outcomes of experimental C. suis infection could be demonstrated. Since in the LI study high numbers of Cl. perfringens type A were detected, it is hypothesized that colonization with these opportunistic pathogens has synergistic effects with C. suis and may explain variable clinical outcomes in untreated animals as well as the sporadic occurrence of diarrhea in toltrazuril-treated piglets. CONCLUSIONS: Parenteral and oral toltrazuril administered on the 2nd or 4th dol is safe and effective against experimental infections with C. suis on the 1st to 3rd dol. The clinical outcome of experimental infections seems influenced by bacterial coinfections.

Efficacy of an injectable toltrazuril - gleptoferron (Forceris®) to control coccidiosis (Cystoisospora suis) in comparison with iron supplemented piglets without anticoccidial treatment.

The efficacy and safety of an injectable combination product containing toltrazuril and gleptoferron (Forceris® - CEVA) for the control of coccidiosis due to Cystoisospora suis was investigated in neonatal piglets. The study was carried out on five European commercial pig farms in France, Germany and Spain and 122 litters consisting of 1508 piglets were selected and randomly allocated to one of two treatment groups. The first group received a single intramuscular injection per piglet of the test product, containing 45 mg toltrazuril and 200 mg iron and this was compared with a control group, which was administered a single intramuscular treatment of iron at 200 mg per piglet only. Body weights, faecal scores and oocysts counts, recorded as oocysts per gram of faeces, (OPG) were observed for 21 days. Only 1138 piglets were actually exposed to coccidiosis and data sets of these animals were selected for statistical analysis. The efficacy of the test product in the control of coccidiosis was shown in higher body weight gains, a lower percentage of animals with diarrhoea, fewer samples with positive oocysts counts as well as a lower excretion peak and a reduced area under the curve of OPG from study day (SD) 4 - SD 21. The combination product of toltrazuril and gleptoferron provided an effective alternative approach to current conventional separate treatment for the prevention of iron deficiency anaemia and coccidiosis in neonatal piglets. It reduced the numbers of potentially stressful interventions and work time.

Efficacy of an injectable toltrazuril - gleptoferron (Forceris®) to control coccidiosis (Cystoisospora suis) in comparison with iron supplemented piglets without anticoccidial treatment.

The efficacy and safety of an injectable combination product containing toltrazuril and gleptoferron (Forceris® - CEVA) for the control of coccidiosis due to Cystoisospora suis was investigated in neonatal piglets. The study was carried out on five European commercial pig farms in France, Germany and Spain and 122 litters consisting of 1508 piglets were selected and randomly allocated to one of two treatment groups. The first group received a single intramuscular injection per piglet of the test product, containing 45 mg toltrazuril and 200 mg iron and this was compared with a control group, which was administered a single intramuscular treatment of iron at 200 mg per piglet only. Body weights, faecal scores and oocysts counts, recorded as oocysts per gram of faeces, (OPG) were observed for 21 days. Only 1138 piglets were actually exposed to coccidiosis and data sets of these animals were selected for statistical analysis. The efficacy of the test product in the control of coccidiosis was shown in higher body weight gains, a lower percentage of animals with diarrhoea, fewer samples with positive oocysts counts as well as a lower excretion peak and a reduced area under the curve of OPG from study day (SD) 4 - SD 21. The combination product of toltrazuril and gleptoferron provided an effective alternative approach to current conventional separate treatment for the prevention of iron deficiency anaemia and coccidiosis in neonatal piglets. It reduced the numbers of potentially stressful interventions and work time.

A neo-institutional analysis of the hidden interaction between the Israeli Supreme Court and the Ministry of Finance: the right to healthcare services.

BACKGROUND: Under structural conditions of non-governability, most players in the policy arena in Israel turn to two main channels that have proven effective in promoting the policies they seek: the submission of petitions to the High Court of Justice and making legislative amendments through the Economic Arrangements Law initiated by the Ministry of Finance. Nevertheless, an analysis of the principal trends emerging from the High Court of Justice rulings and legislative amendments through the Economic Arrangements Law indicates that these channels are open to influence, primarily by forces that are essentially neo-liberal. Little is known about the effects of these trends on the right to healthcare services, which in Israel has not been legislated as an independent constitutional law in Basic Laws. METHODS: We use four major legal cases decided by the Supreme Court of Israel in the past 10 years where the Court reviewed new legislative initiatives proposed by the Economic Arrangements Law in the area of healthcare. We utilize an institutional approach in our analysis. RESULTS: A neo-institutional analysis of the legal cases demonstrates that petitions against the Economic Arrangements Law in the area of healthcare services have been denied, even though the Court uses strong rhetoric against that law and the government more generally in addressing issues that concern access to healthcare services and reforms in the healthcare system. This move strengthens the trend toward a neo-liberal public policy and significantly weakens the legal protection of the right to healthcare services. CONCLUSION: In deciding petitions against the Economic Arrangements Law in the area of healthcare, the Supreme Court allows the Ministry of Finance to be a dominant player in the formation of public policy. In doing so, it may be promoting a goal of strengthening its position as a political institution that aspires to increase the public's trust in the judiciary and especially in the Supreme Court itself, in addition to exercising judicial restraint and allowing more leeway to the executive and legislative branches more generally.

Detection of Cystoisospora suis in faeces of suckling piglets - when and how? A comparison of methods.

BACKGROUND: Cystoisospora suis is the causative agent of porcine neonatal coccidiosis, a diarrheal disease which affects suckling piglets in the first weeks of life. Detection of oocysts in the faeces of infected animals is frequently hampered by the short individual excretion period and the high fat content of faecal samples. We analysed oocyst excretion patterns of infected piglets, evaluated different detection methods for their detection limit and reproducibility, and propose a sampling scheme to improve the diagnosis of C. suis in faecal samples from the field using a protocol for reliable parasite detection. RESULTS: Based on a hypothesized model of the course of infection on a farm, three samplings (days of life 7-14-21 or 10-15-20) should be conducted including individual samples of piglets from each sampled litter. Samples can be examined by a modified McMaster method (lower detection limit: 333 oocysts per gram of faeces, OpG), by examining faecal smears under autofluorescence (lower detection limit: 10 OpG) or after carbol-fuchsin staining (lower detection limit: 100 OpG). Reproducibility and inter-test correlations were high with (R2 > 0.8). A correlation of oocyst excretion with diarrhoea could not be established so samples with different faecal consistencies should be taken. Pooled samples (by litter) should be comprised of several individual samples from different animals. CONCLUSIONS: Since oocyst excretion by C. suis-infected piglets is usually short the right timing and a sufficiently sensitive detection method are important for correct diagnosis. Oocyst detection in faecal smears of samples taken repeatedly is the method of choice to determine extent and intensity of infection on a farm, and autofluorescence microscopy provides by far the lowest detection limit. Other methods for oocyst detection in faeces are less sensitive and/or more labour- and cost intensive and their usefulness is restricted to specific applications.

Comparison of an injectable toltrazuril-gleptoferron (Forceris®) and an oral toltrazuril (Baycox®) + injectable iron dextran for the control of experimentally induced piglet cystoisosporosis.

BACKGROUND: Cystoisospora suis causes diarrhoeal disease and reduced weight gain in suckling piglets, and a toltrazuril-based oral suspension is available for treatment. Recently a combinatorial product with toltrazuril plus iron has been developed for parenteral application. In this study we compared the efficacy of the injectable product with the oral suspension against experimentally induced piglet cystoisosporosis. METHODS: In a randomised controlled study, three groups of piglets (n = 10-13) were treated either with a fixed dose of 45 mg toltrazuril + 200 mg gleptoferron i.m. per piglet (Forceris®) on the second day of life (study day 2; SD 2) or with 20 mg toltrazuril/kg body weight as an oral suspension (Baycox® 5%) on SD 4 or left untreated (Control group). The Baycox® and the Control group received 200 mg of iron dextran/piglet on SD 2. All piglets were infected with 1000 sporulated C. suis oocysts on SD 3. Faecal samples were taken daily from SD 7 to SD 20 to determine faecal consistency, oocyst shedding and other diarrhoeal pathogens. Body weight was recorded on SD 1 and then weekly until SD 29. Animals were observed daily for general health and after treatment for possible adverse events. RESULTS: In the Control group all animals shed oocysts for 3.1 days on average and all animals showed diarrhoea for an average of five days. Excretion peaked on SD 9 (max. 48,618 oocysts per gram of faeces). Treatment with Forceris® completely suppressed oocyst excretion. In the Baycox® group, low levels of excretion could be detected. Diarrhoea was reduced to single piglets in the treated groups. Body weight development was reduced in the Control group compared to the treated groups. Enteropathogenic bacteria (Escherichia coli, Clostridium perfringens) could be detected. All parameters related to oocyst excretion, faecal consistency and weight gain were significantly improved in the treated groups compared to the Control group without significant differences between the treated groups. Both products were safe to use. CONCLUSIONS: Treatment with both the injectable (Forceris®) and the oral (Baycox®) formulation of toltrazuril in the prepatent period were safe and highly effective against experimental infection with C. suis in newborn piglets.

Comparative efficacy of two parenteral iron-containing preparations, iron gleptoferron and iron dextran, for the prevention of anaemia in suckling piglets.

Iron-deficiency anaemia (IDA) is a serious health problem in neonatal piglets and is controlled by routine application of iron in various formulations. The efficacy and safety of two iron-containing products for the prevention of IDA in suckling piglets were compared in a randomised, parallel study. Newborn piglets were treated with 200 mg iron supplied by intramuscular injection in the neck as either Forceris (gleptoferron; n=13) or Uniferon 200 (iron dextran; n=12) 24-48 hours after birth. Blood samples were collected before and after treatment (2nd, 18th and 31st day of life) for complete haematology. The treatments were well tolerated with only mild transient swelling observed in two piglets (Forceris group). Piglets treated with Forceris had significantly higher haemoglobin, haematocrit, mean corpuscular volume and haemoglobin concentration values, as well as significantly higher plasma iron and transferritin saturation and a lower total iron binding capacity than those treated with Uniferon. No animals in the Forceris group but 17 per cent of piglets in the Uniferon group had haemoglobin levels <9 g/dl after treatment, indicating anaemia. These results suggest that both products were safe and effective in the prophylaxis of IDA in piglets, and that Forceris was superior to Uniferon in preventing IDA in piglets.

Complications, Recovery, and Early Functional Outcomes and Oncologic Control Following In-bore Focal Laser Ablation of Prostate Cancer.

UNLABELLED: From April 2013 to July 2014, 25 consecutive men participated in a longitudinal outcomes study following in-bore magnetic resonance imaging (MRI)-guided focal laser ablation (FLA) of prostate cancer (PCa). Eligibility criteria were clinical stage T1c and T2a disease; prostate-specific antigen (PSA) <10 ng/ml; Gleason score <8; and cancer-suspicious regions (CSRs) on multiparametric MRI harboring PCa. CSRs harboring PCa were ablated using a Visualase cooled laser applicator system. Tissue temperature was monitored throughout the ablation cycle by proton resonance frequency shift magnetic resonance thermometry from phase-sensitive images. There were no significant differences between baseline and 3-mo mean American Urological Association Symptom Score or Sexual Health Inventory in Men scores. No man required pads at any time. Overall, the mean PSA decrease between baseline and 3 mo was 2.3 ng/ml (44.2%). Of 28 sites subjected to target biopsy after FLA, 26 (96%) showed no evidence of PCa. Our study provides encouraging evidence that excellent early oncologic control of significant PCa can be achieved following FLA, with virtually no complications or adverse impact on quality of life. Longer follow-up is required to show that oncologic control is durable. PATIENT SUMMARY: Early results for focal laser ablation of prostate cancer are very encouraging. Until long-term oncologic control is demonstrated, focal laser ablation must be considered an investigational treatment option.

Needs, expectations and public knowledge concerning services outside the medical basket: a lesson from Israel.

Quality of and access to medical care are strongly related to the medical basket, the set of services covered under the national health insurance system. Various health systems offer institutional solutions to cover services that are not included in the basket in rare cases. In Israel, patients whose medical needs are not covered under the medical basket may apply to committees for exceptional cases which are run by all health funds. The article presents the findings of a cross-sectional telephone survey which was conducted to explore the public's familiarity with the committees for exceptional cases and their workings, eligibility, and reporting of treatment required outside the basket. Almost 25% of respondents reported that during the past ten years they or their close relatives needed medical care, physical examination, or drugs that were not included in the medical basket. The survey demonstrates the public's unfamiliarity with the committees and uncertainty as to entitlement of services which are out of the basket, as well as a tendency to prefer self payment and private insurance. Familiarity with committees is strongly related to education, race (nationality) and socio-economic status. The treating physician is the major source of information on the committee. In case of a need, preference is given to private purchase of drugs/services.

Breaking through the silence: illegality of performing resuscitation procedures on the "newly-dead".

Israeli author Daniel Sperling brings to a light a disturbing practice that is taking place in some teaching hospitals throughout the world--the practice of resuscitation procedures on newly dead patients without the consent of the next-of-kin. Mr. Sperling examines some of the policies and procedures in place to prevent such practice and also looks at the ethical principles that should guide such procedures. The paper also reviews the general issue of consent in the context of medical decision-making and discusses potential legal claims that might be available to persons who have not been consulted or informed before such procedures are performed. The evolving jurisprudence surrounding the treatment of the newly dead is analyzed and Mr. Sperling concludes by suggesting ways to improve upon the procedures currently in place at some teaching facilities.