Morbidity and mortality from road injuries: results from the Global Burden of Disease Study 2017.

BACKGROUND: The global burden of road injuries is known to follow complex geographical, temporal and demographic patterns. While health loss from road injuries is a major topic of global importance, there has been no recent comprehensive assessment that includes estimates for every age group, sex and country over recent years. METHODS: We used results from the Global Burden of Disease (GBD) 2017 study to report incidence, prevalence, years lived with disability, deaths, years of life lost and disability-adjusted life years for all locations in the GBD 2017 hierarchy from 1990 to 2017 for road injuries. Second, we measured mortality-to-incidence ratios by location. Third, we assessed the distribution of the natures of injury (eg, traumatic brain injury) that result from each road injury. RESULTS: Globally, 1 243 068 (95% uncertainty interval 1 191 889 to 1 276 940) people died from road injuries in 2017 out of 54 192 330 (47 381 583 to 61 645 891) new cases of road injuries. Age-standardised incidence rates of road injuries increased between 1990 and 2017, while mortality rates decreased. Regionally, age-standardised mortality rates decreased in all but two regions, South Asia and Southern Latin America, where rates did not change significantly. Nine of 21 GBD regions experienced significant increases in age-standardised incidence rates, while 10 experienced significant decreases and two experienced no significant change. CONCLUSIONS: While road injury mortality has improved in recent decades, there are worsening rates of incidence and significant geographical heterogeneity. These findings indicate that more research is needed to better understand how road injuries can be prevented.

European Electronic Personal Health Records initiatives and vulnerable migrants: A need for greater ethical, legal and social safeguards.

The effective collection and management of personal data of rapidly migrating populations is important for ensuring adequate healthcare and monitoring of a displaced peoples' health status. With developments in ICT data sharing capabilities, electronic personal health records (ePHRs) are increasingly replacing less transportable paper records. ePHRs offer further advantages of improving accuracy and completeness of information and seem tailored for rapidly displaced and mobile populations. Various emerging initiatives in Europe are seeking to develop migrant-centric ePHR responses. This paper highlights their importance and benefits, but also identifies a number of significant ethical, legal and social issues (ELSI) and challenges to their design and implementation, regarding (1) the kind of information that should be stored, (2) who should have access to information, and (3) potential misuse of information. These challenges need to be urgently addressed to make possible the beneficial use of ePHRs for vulnerable migrants in Europe.

Lower Cancer Rates Among Druze Compared to Arab and Jewish Populations in Israel, 1999-2009.

The Druze are a small ethnic minority in Israel amounting to about 130,000 residents (or 1.7 % of the total population of the country). Unlike other population groups, the Druze strive to keep their own traditions and marry mainly inside their own community. During the last decade, cancer morbidity among both Jews and Arabs in Israel has been increasing, while data on the Druze are little known and have not been analyzed and compared to other population groups to date. To compare cancer morbidity rates among Druze, Arabs and Jews in Israel during 1999-2009, gender-specific and age-standardized incidence rates of all site cancers and specific cancers of three population groups (Jews, Arabs and Druze) were received from the Israel National Cancer Registry for the period 1999-2009. Based on these rates, periodical incidence rates were calculated and mutually compared across the groups stratified by gender. As the analysis shows, the Druze had significantly lower cancer rates compared to both Arabs and Jews. Thus, for all site cancers, there were significantly higher cancer rates in Jewish males versus Druze males (RR = 1.39, 95 % CI = 1.16-1.65) and in Jewish females versus Druze females (RR = 1.53, 95 % CI = 1.27-1.85), but not statistically significant for Arab males versus Druze males (RR = 1.12 95 % CI = 0.93-1.35). Lung cancer rates in Arab males were also higher compared to Druze males (RR = 1.84, 95 % CI = 1.13-3.00). Jewish males had statistically significant higher rates of prostate cancer compared to Druze males (RR = 2.47, 95 % CI = 1.55-3.91). For thyroid and colon cancers, risks were not significantly different at the 95 % CI level; however, the risks were significantly different at the 90 % CI level (RR = 3.62, 90 % CI 1.20-11.02 and RR = 1.69, 90 % CI = 1.03-2.77, respectively). Jewish females had significantly higher rates of invasive breast cancer (RR = 2.25, 95 % CI = 1.55-3.25), in situ cervical cancer (RR = 4.01, 95 % CI = 1.27-12.66) and lung cancer (RR = 3.22, 95 % CI = 1.12-9.24) compared to Druze females. We thus observed lower cancer rates among Druze versus Arab and Jewish populations in Israel. A reason for these differences may be due to different nutritional habits. Druze still keep a less processed nutritional lifestyle, than is common in industrial society. There may also be other reasons that have not been identified yet.

Application of the double kernel density approach to the analysis of cancer incidence in a major metropolitan area.

RATIONALE: Although cancer is a main cause of human morbidity worldwide, relatively small numbers of new cancer cases are recorded annually in single urban areas. This makes the association between cancer morbidity and environmental risk factors, such as ambient air pollution, difficult to detect using traditional methods of analysis based on age standardized rates and zonal estimates. STUDY GOAL: The present study investigates the association between air pollution and cancer morbidity in the Greater Haifa Metropolitan Area in Israel by comparing two analytical techniques: the traditional zonal approach and more recently developed Double Kernel Density (DKD) tools. While the first approach uses age adjusted Standardized Incidence Ratios (SIRs) for small census areas, the second approach estimates the areal density of cancer cases, normalized by the areal density of background population in which cancer events occurred. Both analyses control for several potential confounders, including air pollution, proximities to main industrial facilities and socio-demographic attributes. RESULTS: Air pollution variables and distances to industrial facilities emerged as statistically significant predictors of lung and NHL cancer morbidity in the DKD-based models (p<0.05) but not in the models based on SIRs estimates (p>0.2). CONCLUSION: DKD models appear to be a more sensitive tool for assessing potential environmental risks than traditional SIR-based models, because DKD estimates do not depend on a priory geographic delineations of statistical zones and produce a smooth and continuous disease 'risk surface' covering the entire study area. We suggest using the DKD method in similar studies of the effect of ambient air pollution on chronic morbidity, especially in cases in which the number of statistical areas available for aggregation and comparison is small and recorded morbidity events are relatively rare.

A web-based program to increase knowledge and reduce cigarette and nargila smoking among Arab university students in Israel: mixed-methods study to test acceptability.

BACKGROUND: Among Arab citizens in Israel, cigarette and nargila (hookah, waterpipe) smoking is a serious public health problem, particularly among the young adult population. With the dramatic increase of Internet and computer use among Arab college and university students, a Web-based program may provide an easy, accessible tool to reduce smoking rates without heavy resource demands required by traditional methods. OBJECTIVE: The purpose of this research was to examine the acceptability and feasibility of a pilot Web-based program that provides tailored feedback to increase smoking knowledge and reduce cigarette and nargila smoking behaviors among Arab college/university students in Israel. METHODS: A pilot Web-based program was developed, consisting of a self-administered questionnaire and feedback system on cigarette and nargila smoking. Arab university students were recruited to participate in a mixed-methods study, using both quantitative (pre-/posttest study design) and qualitative tools. A posttest was implemented at 1 month following participation in the intervention to assess any changes in smoking knowledge and behaviors. Focus group sessions were implemented to assess acceptability and preferences related to the Web-based program. RESULTS: A total of 225 participants-response rate of 63.2% (225/356)-completed the intervention at baseline and at 1-month poststudy, and were used for the comparative analysis. Statistically significant reductions in nargila smoking among participants (P=.001) were found. The intervention did not result in reductions in cigarette smoking. However, the tailored Web intervention resulted in statistically significant increases in the intention to quit smoking (P=.021). No statistically significant increases in knowledge were seen at 1-month poststudy. Participants expressed high satisfaction with the intervention and 93.8% (211/225) of those who completed the intervention at both time intervals reported that they would recommend the program to their friends, indicating excellent acceptability and feasibility of the intervention. This was further emphasized in the focus group sessions. CONCLUSIONS: A tailored Web-based program may be a promising tool to reduce nargila smoking among Arab university students in Israel. The tailored Web intervention was not successful at significantly reducing cigarette smoking or increasing knowledge. However, the intervention did increase participants' intention to quit smoking. Participants considered the Web-based tool to be an interesting, feasible, and highly acceptable strategy. TRIAL REGISTRATION: ISRCTN registry ISRCTN59207794; http://www.isrctn.com/ISRCTN59207794 (Archived by WebCite at http://www.webcitation.org/6VkYOBNOJ).

Green spaces and adverse pregnancy outcomes.

OBJECTIVE: The objective of this study was to evaluate the associations between proximity to green spaces and surrounding greenness and pregnancy outcomes, such as birth weight, low birth weight (LBW), very LBW (VLBW), gestational age, preterm deliveries (PTD) and very PTD (VPTD). METHODS: This study was based on 39,132 singleton live births from a registry birth cohort in Tel Aviv, Israel, during 2000-2006. Surrounding greenness was defined as the average of satellite-based Normalised Difference Vegetation Index (NDVI) in 250 m buffers and proximity to major green spaces was defined as residence within a buffer of 300 m from boundaries of a major green space (5000 m(2)), based on data constructed from OpenStreetMap. Linear regression (for birth weight and gestational age) and logistic regressions models (for LBW, VLBW, PTD and VPTD) were used with adjustment for relevant covariates. RESULTS: An increase in 1 interquartile range greenness was associated with a statistically significant increase in birth weight (19.2 g 95% CI 13.3 to 25.1) and decreased risk of LBW (OR 0.84, 95% CI 0.78 to 0.90). Results for VLBW were in the same direction but were not statistically significant. In general, no associations were found for gestational age, PTD and VPTD. The findings were consistent with different buffer and green space sizes and stronger associations were observed among those of lower socioeconomic status. CONCLUSIONS: This study confirms the results of a few previous studies demonstrating an association between maternal proximity to green spaces and birth weight. Further investigation is needed into the associations with VLBW and VPTD, which has never been studied before.

Bridging cross-cultural gaps: monitoring herbal use during chemotherapy in patients referred to integrative medicine consultation in Israel.

INTRODUCTION: The high prevalence of the use of traditional herbs among patients with cancer is a cause for concern with regard to potentially adverse interactions with conventional oncology treatments. In this study, we explore herbal use among patients with cancer in northern Israel who are referred by their health care providers to complementary and traditional medicine (CTM) consultations provided to them within the conventional oncology department. The study's objectives were to identify which herbs patients use and to examine the scope of current research on the efficacy and safety regarding the identified herbs. PATIENTS AND METHODS: Herbal use by patients receiving oncology care was assessed prospectively from July 2009 to July 2012 by integrative physicians (IPs) trained in herbal medicine. Historical, ethnobotanical, basic research, and clinical data regarding the identified herbs were explored by using a keyword search in PubMed and Middle Eastern ethnohistorical literature. RESULTS: Disclosure of herbal use was reported by 154 of the 305 patients (50.5 %) interviewed by IPs. The use of 85 single herbs and 30 different herbal formulas was documented during the initial or follow-up IP assessments. Patients reported 14 quality of life-associated indications for herbal use. The ten most prevalent herbs displaying in vitro/in vivo anticancer activity and nine other herbs were preliminarily assessed concerning potential risks, safety, and interaction with chemotherapy. CONCLUSIONS: Herbal use by patients with cancer in northern Israel is widespread and calls for further study in order to address issues of safety and effectiveness. We recommend constructing a multinational and multidisciplinary team of researchers with ethnopharmacological and clinical expertise that will explore the use of herbs among patients with cancer in a cross-cultural perspective attuned with patients' affinity to traditional herbal medicine.

World War II-related post-traumatic stress disorder and breast cancer risk among Israeli women: a case-control study.

BACKGROUND: Several studies have suggested that post-traumatic stress disorder (PTSD) is related to adverse health outcomes. There are limited data on PTSD and cancer, which has a long latency period. We investigated the association between World War II (WWII)-related PTSD and subsequent breast cancer (BC) risk among Jewish WWII survivors and examined whether this association was modified by exposure to hunger during WWII. METHODS: We compared 65 BC patients diagnosed in 2005 through 2010 to 200 population-based controls who were members of various organizations for Jewish WWII survivors in Israel. All participants were born in Europe, lived at least six months under Nazi rule during WWII, and immigrated to Israel after the war. We estimated PTSD using the PTSD Inventory and applied logistic regression models to estimate the association between WWII-related PTSD and BC, adjusting for potential confounders. RESULTS: We observed a linear association between WWII-related PTSD and BC risk. This association remained significant following adjustment for potential confounders, including obesity, alcohol consumption, smoking, age during WWII, hunger exposure during WWII, and total number of traumatic life events (OR = 2.89, 95% CI = 1.14-7.31). However, the level of hunger exposure during WWII modified this effect significantly. CONCLUSIONS: These findings suggest an independent association between WWII-related PTSD and subsequent BC risk in Jewish WWII survivors that is modified by hunger, a novel finding. Future research is needed to further explore these findings.

Cancer incidence among physicians in Israel.

BACKGROUND: Physicians' occupational environment includes exposures to potential carcinogenic factors on a regular basis. The prevalence of specific tumor types and subsequent mortality are reported to be elevated in physicians. OBJECTIVES: To assess the incidence of various cancer types among Israeli physicians of various specialties, as compared with the general population, and to determine the role, if any, of gender and ethnicity. METHODS: This historical retrospective cohort analysis incorporated data on Israeli officially licensed physicians and information retrieved from the Israel National Cancer Registry database (INCR). Physicians were divided into five groups: non-specialists, internists, pediatricians, surgeons, and potentially at-risk specialties. Data were collected retrospectively for the years 1980-2007. RESULTS: The study cohort comprised 37,789 physicians, of whom 33,393 (88.37%) were Jews and 4396 (11.63%) were Arabs. Comparing Jewish physicians to the general population revealed higher rates of: a) breast cancer among female specialized physicians, and b) melanoma among specialized male and female physicians. All cancer types were more prevalent in the Arab physicians than in the general Arab population. CONCLUSIONS: This study revealed incidences of specific cancer types among different medical specialties as compared to the general population. Hopefully, these findings will prompt changes in the occupational environment of physicians of particular specialties in order to reduce their high risk for cancer occurrence.

Prognostic factors predicting ischemic wound healing following hyperbaric oxygenation therapy.

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.

Cancer incidence and survival among adolescents in Israel during the years 1998 to 2009.

PURPOSE: Our goal was to describe adolescent cancer incidence and survival in Israel, and to identify demographic and epidemiologic variations among adolescents with cancer. PATIENTS AND METHODS: We used data from the Israel National Cancer Registry in order to examine the incidence and survival of adolescent cancer in Israeli adolescents aged 15-19 years, diagnosed during the years 1998-2009. Cases were analyzed according to sex, ethnicity and geographical region, as well as comparison to other countries in the region and other western countries. RESULTS: Among the 1,532 new cases of adolescent cancer, there was a total incidence rate of 226 cases per million. The incidence rate for males was higher than for females (230 and 222, respectively) and higher for Jewish adolescents than for Arab adolescents (235 and 194, respectively). The largest groups were Lymphomas (69 per million), Malignant Epithelial Neoplasms (49 per million), and Leukemias (21 per million). We estimated the survival probability updated to December 2009, and calculated the 5-year survival for new cases until the end of 2004. The overall survival at 5 years was 78%, with 62% for the Arabic population and 81% for the Jewish population, dependent on the diagnosis. CONCLUSIONS: The results of this study show little difference in the predominance of some adolescent cancers in comparison with other developed countries. This study may add more information for further investigation of the genetic and environmental factors that cause adolescent cancer in Israel. As well as delineate the genetic basis for ethnic origin disparities in survival.

Air pollution and congenital heart defects.

Environmental factors such as ambient air pollution have been associated with congenital heart defects. The aim of this study was to investigate the association between gestational exposure to air pollution and the risk of congenital heart defects. We conducted a registry-based cohort study with a total of 135,527 live- and still-births in the Tel-Aviv region during 2000-2006. We used a Geographic Information System-based spatiotemporal approach with weekly inverse distance weighting modeling to evaluate associations between gestational exposure to ambient air pollution during weeks 3-8 of pregnancy and the risk for congenital heart defects. The following pollutants were studied: carbon monoxide, nitrogen-dioxide, ozone, sulfur-dioxide and particulate matter with aerodynamic diameter smaller than 10 µm and 2.5 µm (PM10, PM2.5 respectively). Logistic models, adjusted for socio-demographic covariates were used to evaluate the associations. We found that maternal exposure to increased concentrations of PM10 was associated with multiple congenital heart defects (adjusted OR 1.05, 95% CI: 1.01 to 1.10 for 10 µg/m(3) increment). An inverse association was observed between concentrations of PM2.5 and isolated patent ductus arteriosus (adjusted OR 0.78, 95% CI: 0.68 to 0.91 for 5 µg/m(3) increment). Sensitivity analyses showed that results were consistent. Generally there were no evidence for an association between gaseous air pollutants and congenital heart defects.Our results for PM10 and congenital heart defects confirm results from previous studies. The results for PM2.5 need further investigations.

Cancer incidence and survival among infants in Israel, 1998-2007.

Cancer during the first year of life is relatively rare and often has clinical and biological properties different from those of the same histologic type of cancer occurring in older children. The aim of this study was to find differences in epidemiology and survival between infants and older children and to compare the percentage of distribution of infant cancer types in Israel with that reported in the United States. We collected infant <1 year of age cases diagnosed between 1998 and 2007 as having cancer from the database of the Israel National Cancer Registry, a total of 309 cases with an incidence rate of 228.5 cases per million. The largest group was diagnosed with neuroblastoma (35%) with an incident rate of 80 per million, followed by leukemia (15.9%), with acute lymphoid leukemia and acute myeloid leukemia accounting for most of this group and central nervous system malignancies comprised 10.7% of infant cancer. One hundred and fifty four new cases of infant girls was diagnosed compared to 155 infant boys with an incidence rates of 234 cases per million for girls and 224.7 for boys, not statistically significant (F:M rate ratio of 1.04). The 5-year survival rates seen in the different groups were leukemia: 55.3%, lymphoma: 71%, CNS tumors: 53.3%, neuroblastoma: 93.4%, retinoblastoma: 94.7% renal tumors: 90.9%, hepatic tumors: 63.3%, soft tissue sarcoma: 76.2%, germ cell neoplasms: 83.3%, and other epithelial neoplasms: 100%. Our study did not find survival differences with statistical significance upon comparing survival rates between different genders and ethnic groups.

Occupational exposures and symptoms among firefighters and police during the carmel forest fire: the Carmel cohort study.

BACKGROUND: From 2 to 5 December 2010, Israel experienced the most severe forest fire In its history, resulting in the deaths of rescue workers. Little research exists on the health risks to emergency responders during forest fires, and there is no published research to date on occupational health among firefighters in Israel. OBJECTIVES: To describe the exposures experienced by emer gency responders to smoke, fire retardants and stress; the utilization of protective equipment; and the frequency of corresponding symptoms during and following the Carmel Forest fire. METHODS: A cohort of 204 firfighers and 68 police who took part in rescue and fire-abating activites during the Carmel Forest fire were recruited from a representative sample of participating stations throughout the country and interviewed regarding their activities during the fire and their coinciding symptoms. Unpaired two-sample t-test compared mean exposures and symptom frequency for firefighters and police. Chi-square estimates of OR and 95%CI are provided for odds of reporting symptoms, incurring injury or being hospitalied for various risk factors RESULTS: Of the study participants, 87% reported having at least one symptom during rescue work at the Carmel Forest fire,with eye irritation (77%) and fatigue (71%) being the most comon. Occupational stress was extremely high during the fire; the average length of time working without rest was 18.4 hours among firefighters. CONCLUSION: Firefighter and police were exposed to smoke and ocupational stress prolonged periods during the fire. Further research is needed on the residual health effects from exposure to forest fires among emergency responders, and to identify areas for improvement in health preparedness.

Periodicity and time trends in the prevalence of total births and conceptions with congenital malformations among Jews and Muslims in Israel, 1999-2006: a time series study of 823,966 births.

BACKGROUND Congenital malformations (CMs) are a leading cause of infant disability. Geophysical patterns such as 2-year, yearly, half-year, 3-month, and lunar cycles regulate much of the temporal biology of all life on Earth and may affect birth and birth outcomes in humans. Therefore, the aim of this study was to evaluate and compare trends and periodicity in total births and CM conceptions in two Israeli populations. METHODS Poisson nonlinear models (polynomial) were applied to study and compare trends and geophysical periodicity cycles of weekly births and weekly prevalence rate of CM (CMPR), in a time-series design of conception date within and between Jews and Muslims. The population included all live births and stillbirths (n = 823,966) and CM (three anatomic systems, eight CM groups [n = 2193]) in Israel during 2000 to 2006. Data were obtained from the Ministry of Health. RESULTS We describe the trend and periodicity cycles for total birth conceptions. Of eight groups of CM, periodicity cycles were statistically significant in four CM groups for either Jews or Muslims. Lunar month and biennial periodicity cycles not previously investigated in the literature were found to be statistically significant. Biennial cycle was significant in total births (Jews and Muslims) and syndactyly (Muslims), whereas lunar month cycle was significant in total births (Muslims) and atresia of small intestine (Jews). CONCLUSION We encourage others to use the method we describe as an important tool to investigate the effects of different geophysical cycles on human health and pregnancy outcomes, especially CM, and to compare between populations.

Cancer incidence and survival among children and adolescents in Israel during the years 1998 to 2007.

Our goal was to describe childhood cancer incidence and survival in Israel and to identify demographic and epidemiologic variations among children and adolescents with cancer. We used data from the Israel National Cancer Registry to examine the incidence and survival of pediatric cancer in Israeli children aged 0 to 19 years, diagnosed during the years 1998 to 2007. Cases were analyzed according to sex, age, ethnicity, and geographic region. Among the 4255 cases of childhood cancer, there was a total age-adjusted incidence rate of 172.4 per million for children aged 0 to 19 years and 153.4 per million for children aged 0 to 14 years. The incidence rate for boys was higher than for girls (192.5 and 153.3, respectively) and higher for Jewish children than for Arab children (177.6 and 156.8, respectively). The largest groups were leukemias (22%), lymphomas (20.2%), and central nervous system tumors (17.4%). The number of new cases increased each year, but the incidence rate remained steady. The survival probability updated to December 2008 was estimated and the 5-year survival was calculated for the new cases until the end of 2003. The overall survival at 5 years was 80.8%, with 72.8% for the Arabic population and 83.2% for the Jewish population, and depended on the diagnosis. Incidence and survival in childhood cancer in Israel is at the same medium level compared with other parts of the world. This study may set the basis for investigating the genetic and environmental factors that cause pediatric cancer in Israel, delineating the genetic basis for ethnic origin disparities in survival.

Treatment of T cell lymphoblastic lymphoma in children and adolescents: Israel Society of Pediatric Hematology Oncology retrospective study.

BACKGROUND: Survival in T cell lymphoblastic lymphoma has improved over the past 30 years, largely due to treatment protocols derived from regimens designed for children with acute lymphoblastic leukemia. OBJECTIVES: To assess the outcome of the NHL-BFM-95 protocol in children and adolescents hospitalized during the period 1999-2006. METHODS: We conducted a retrospective multi-institutional, non-randomized study of children and adolescents up to age 21 with T cell lymphoma admitted to pediatric departments in six hospitals in Israel, with regard to prevalence, clinical characteristics, pathological characteristics, prognostic factors, overall survival (OS) and event-free survival (EFS). All patients had a minimal follow-up of one year after diagnosis. The study was based on the NHL-BFM-95 protocol. RESULTS: At a median follow-up of 4 years (range 1-9 years), OS and EFS for all patients was 86.5% and 83.8%, respectively. OS was 86.7% and 83.3% for patients with stage III and stage IV, respectively, and EFS was 83.3% and 83.3%, respectively. EFS was 62.5% for Arab patients and 89.7% for Jewish patients (P = 0.014). Patients who did not express CD45 antigen showed superior survival (P = 0.028). Five patients (13.5%) relapsed, four of whom died of their disease. Death as a consequence of therapy toxicity was documented in one patient while on the re-induction protocol (protocol IIA). CONCLUSIONS: Our study shows that OS and EFS for all patients was 86.5% and 83.8%, respectively.

Association between primary care physicians' evidence-based medicine knowledge and quality of care.

OBJECTIVE: Ample research has examined physicians' evidence-based medicine (EBM) knowledge and skills; however, previous research has not linked EBM knowledge to objective measures of process of care. DESIGN: A cross-sectional study of quality of care measures extracted from electronic medical records and EBM knowledge assessed via a validated questionnaire. SETTING: One region of the largest Health Maintenance Organization in Israel. PARTICIPANTS: Seventy-four physicians and their 8334 diabetic patients, 7092 coronary heart disease patients and 17 132 hypertensive patients. MAIN OUTCOME MEASURES: Outcome measures were four diabetes quality of care indicators (LDL tests, microalbumin tests, hemoglobin A1C tests, eye examination referrals), and two drug prescription indicators (statin prescription for coronary heart disease patients, and thiazide prescription for hypertensive patients). Independent variables were total EBM knowledge and its components: critical appraisal and information retrieval. RESULTS: Total EBM knowledge was independently and significantly associated with LDL testing (b = 0.13; P = 0.036), microalbumin testing (b = 0.33; P = 0.001), hemoglobin A1C testing (b = 0.17; P = 0.036), eye examination referrals (b = 0.16; P = 0.021) and statin prescriptions (b = 0.18; P = 0.025). Critical appraisal was independently associated with microalbumin tests (b = 0.46; P = 0.002) and eye examination referrals (b = 0.20; P = 0.048). Information retrieval was only independently associated with hemoglobin A1C testing (b = 0.43; P = 0.004). Thiazide prescription was not associated with EBM knowledge scores. CONCLUSIONS: Physicians' higher total EBM knowledge primarily correlates with better quality of care; however, correlations were modest and explained only a small portion in the variance of clinical performance. Results indicate that there might be a need to focus on teaching all the components of EBM rather than EBM microskills.

Parents, spouses, and children of hospitalized patients: evaluation of nursing care.

AIM: This paper is a report of a study of the effect of kinship type and gender on family members' evaluation of nursing care for patients and their families in hospital units. BACKGROUND: With increasing competition in the healthcare system, hospitals attribute great importance to client satisfaction, which is strongly related to the quality of nursing care. However, to date there has been little research into family members' evaluation of nursing care. METHODS: Questionnaires were administered to spouses, parents and children (n = 441) of hospitalized patients in three Israeli hospitals during 2007-2008. RESULTS: Kinship type interacted with gender in affecting family members' evaluation of the quality of nursing care. Among men, husbands were the most satisfied with nursing behaviour, treatment of the patients, and the information they receive. Fathers were the least satisfied. Overall family evaluation of the service was predicted by their evaluation of caring, treatment, and the patient's environment; departmental reputation was predicted by evaluation of treatment. CONCLUSION: Nurses should be trained to develop sensitivity to the diverse expectations and needs of relatives, as well as awareness of how their own preconceptions affect their behaviour toward patients' families. Nurses should develop self-awareness of possible stereotypes and prejudices that may bias their behaviour towards family members. Reactions of family members should also be included in surveys of client satisfaction with nursing care.

Fetal thickened nuchal soft tissues may first appear in the second trimester in Down syndrome.

PURPOSE: To describe a series of cases of late-onset fetal nuchal translucency in Down syndrome. METHOD: In our practice area, most pregnant women usually undergo 3 different sonographic examinations: a fetal nuchal translucency examination in the 1st trimester and 2 detailed surveys of all fetal organs in the early 2nd trimester and in midpregnancy. RESULT: During the study period (2003-2008), we detected 11 fetuses with new appearance of severe thickened nuchal soft tissues (>or=6 mm) at 14-16 weeks' gestation after a normal nuchal screening in the 1st trimester. All of these fetuses had trisomy 21. Associated structural anomalies were observed in 10/11 of the cases. In addition, there were 12 fetuses with new appearance of thickened nuchal soft tissues (<4 mm); all these fetuses had a normal karyotype and were normal at delivery. CONCLUSION: Obstetricians should be aware that a nuchal abnormality may first appear only at 14-16 weeks' gestation. Fetal karyotyping is advocated in these cases because of the high probability of Down syndrome.