Effect of lactation on the recurrence rate of gestational diabetes mellitus: a retrospective cohort study.

PURPOSE: To examine the impact of lactation on the recurrence rate of gestational diabetes mellitus (GDM). METHODS: Retrospective cohort study performed in a single teaching hospital on data between 2009 and 2016. The study group consisted of women who had a diagnosis of GDM and breastfed exclusively for ≥ 1 month. The control group consisted of women who had a diagnosis of GDM and did not breastfeed or added formula < 1 month postpartum. Data regarding breastfeeding duration, timing and amount of formula supplementation were obtained by a telephone questionnaire. We hypothesized that the recurrence of GDM would be lower in women who breastfed exclusively for ≥ 1 month. Therefore, to detect a decrease from 50 to 30% in the recurrence rate of GDM with alpha (one-sided) of 0.05 and 80% power, a sample size of 168 (84 per group) was needed. RESULTS: Overall, 229 women were found eligible; 139 and 90 in the study and control groups, respectively. Except for parity, baseline demographic and obstetric variables were not different between the two groups. After adjusting for parity, the incidence of GDM in subsequent pregnancy was significantly lower among the study compared to the control group [48 (34.5%) and 41 (45.6%), respectively; one-tailed p = 0.043; RR 0.56; 95% CI 0.35-0.90)]. The cesarean delivery (CD) rate was significantly lower as well [28 (20.1%) and 31 (34.4%), respectively; two-tailed p = 0.02; RR 0.48, 95% CI 0.26-0.89)]. CONCLUSION: Exclusive lactation for ≥ 1 month reduced the recurrence rate of GDM and possibly the risk of CD in the subsequent pregnancy.

A critical evaluation of comparative regulatory strategies for monitoring pharmaceuticals in recycled wastewater.

Pharmaceuticals are a subset of micropollutants, present in the environment in trace concentrations. Because of their persistent nature, these chemicals are of particular concern. Little is known about how mixtures of pharmaceutical residues, found in WWTP effluents, affect the environment or public health. Yet, numerous studies show negative outcomes for both aquatic and terrestrial organisms, suggesting that they are given both to bioaccumulation and uptake in plants. Israel leads the world in effluent reuse (86%), almost exclusively utilized for purposes of agricultural irrigation. Pharmaceuticals, however, are not included in Israel's water regulatory oversight or management, essentially creating an epidemiological experiment among its citizens and environment. Globally, these compounds also are not commonly subject to monitoring or regulation. This study reviews and analyzes water policies and regulation worldwide that address the presence of pharmaceuticals in water resources, with a particular focus on Australia, Singapore, Switzerland, and the USA. Furthermore, the study investigates the reasons why these chemicals are not yet regulated in Israel. Based on a comprehensive evaluation of the data and analysis of the regulatory rationale in other countries, a list of recommended pharmaceutical standards that should be measured and monitored in Israel's wastewater treatment system is proposed. The suggested prioritization criteria should be at the heart of a new regulatory agenda for controlling pharmaceutical contamination in wastewater.

Effect of inter-twin delivery interval on umbilical artery pH and Apgar score in the second twin.

BACKGROUND: To examine the effect of inter-twin delivery interval on umbilical artery pH and Apgar score of the second twin after vaginal delivery of the first twin. METHODS: Retrospective study conducted at a single teaching hospital. All pregnant women with twin gestation who delivered the first twin vaginally at more than 24 weeks between 1995 and 2015 were included. Major malformations and intrauterine deaths of one or both twins were excluded. Women were divided into those who had an inter-twin delivery interval of less than 30 minutes (group 1) or 30 minutes or more (group 2). Primary outcome was umbilical artery pH less than 7.1 and/or Apgar score less than 7 at 5 minutes of the second twin. Generalized linear regression with log was performed to evaluate the association with delivery interval. RESULTS: Of 88 145 deliveries during this period, 1955 (2.2%) were twins. Overall, 713 twin pregnancies, 596 (83.6%) in group 1 and 117 (16.4%) in group 2, were eligible and included. Mean inter-delivery interval was 11.0 ± 6.5 and 52.5 ± 31.5 minutes in groups 1 and 2, respectively. After adjusting for variables found significantly different between the groups in univariate analysis, inter-delivery interval of less than 30 minutes or 30 minutes or more was not a significant risk factor for pH less than 7.1 and/or Apgar less than 7 (P = .91). The cesarean rate for delivery of the second twin after vaginal delivery of the first twin was 4.3% overall, with a higher rate among group 2 compared with group 1 (18.2% and 3.2%, respectively; P = .001). CONCLUSIONS: The second twin's Apgar score and cord artery pH are probably not affected when the inter-twin delivery interval exceeds 30 minutes.

Endocrine disrupting compounds in streams in Israel and the Palestinian West Bank: Implications for transboundary basin management.

Endocrine disrupting compounds (EDCs) frequently enter surface waters via discharges from wastewater treatment plants (WWTPs), as well as from industrial and agricultural activities, creating environmental and health concerns. In this study, selected EDCs were measured in water and sediments along two transboundary streams flowing from the Palestinian Authority (PA) into Israel (the Zomar-Alexander and Hebron-Beer Sheva Streams). We assessed how the complicated conflict situation between Israel and the PA and the absence of a coordinated strategy and joint stream management commission influence effective EDC control. Both streams receive raw Palestinian wastewater in their headwaters, which flows through rural areas and is treated via sediment settling facilities after crossing the 1949 Armistice Agreement Line. Four sampling campaigns were conducted over two years, with concentrations of selected EDCs measured in both the water and the sediments. Results show asymmetrical pollution profiles due to socio-economic differences and contrasting treatment capacities. No in-stream attenuation was observed along the stream and in the sediments within the Palestinian region. After sediment settling in treatment facilities at the Israeli border, however, significant reductions in the EDC concentrations were measured both in the sediments and in the water. Differences in sedimentation technologies had a substantial effect on EDC removal at the treatment location, positively affecting the streams' ability to further remove EDCs downstream. The prevailing approach to addressing the Israeli-Palestinian transboundary wastewater contamination reveals a narrow perspective among water managers who on occasion only take local interests into consideration, with interventions focused solely on improving stream water quality in isolated segments. Application of the "proximity principle" through the establishment of WWTPs at contamination sources constitutes a preferable strategy for reducing contamination by EDCs and other pollutants to ensure minimization of public health risks due to the pollution of streams and underlying potable groundwater.

Should we blame the rich for clogging our landfills?

Conventional wisdom often holds that relatively high consumption levels among the affluent contributes to the generation of high volumes of municipal solid waste (MSW). Comparing data from different cities in Israel suggests otherwise. Regression analysis reveals that aggregate per capita waste outputs of cities are only vaguely correlated with their socio-economic indicators. In fact, the apparent 'hedonic' waste of the richest cities, compared with the average ones, accounts for only about 2% of the total waste production. Israel's main economic area, the Tel Aviv district, produces a quarter more MSW per capita than other districts, suggesting a need for special attention by policy makers. A surprisingly strong predicator of MSW per capita is water consumption by municipalities, dedicated for public gardening. The trimmings of the municipal landscape constituting an unobserved fraction of total MSW data, are estimated to be responsible for 15% of Israel's MSW, making it an additional target area for consideration and intervention.

Pharmacological treatment of ectopic pregnancy: Accuracy, safety and cost-effectiveness of day 1-7 ß-hCG measurements.

OBJECTIVE: The aim of the present study was to compare accuracy, safety and cost-effectiveness of three ß-hCG measurements protocols, applied in managing ectopic pregnancies (EP) with methotrexate (MTX): (1) day 1 to 7 ß-hCG levels, (2) day 1 to 4 ß-hCG levels and (3) day 4 to 7 ß-hCG levels. METHODS: Cost-minimization analysis (CMA) based on a retrospective study of patients treated with single-dose MTX for EP, was evaluated at a single institution between January 2001 to May 2021. Successful MTX treatment was defined as no surgical intervention. We evaluated safety by analyzing cases of day 4 interventions and cases of inconsistency between the different protocols. Predicting accuracy was assessed by the area under the receiver operating characteristic (AUC) curve. RESULTS: A total of 229 patients with single dose MTX treatment were included. Overall, 184 (80.3%) patients were treated successfully with a single dose of MTX. For days 1 and 7 the optimal cutoff point was 7% reduction in ß-hCG levels with sensitivity, specificity and PPV of 76.6% (69.9-82.5, 95% CI), 75.5% (60.5-87.1, 95% CI) and 92.8% (88.4-95.6, 95% CI), respectively. There was no significant difference between the protocols' AUC. None of the patients had any change of management during their day 4 visit in our 20 years of records. The cost for each visit day (day 4 and 7) was calculated with a total cost of 251 USD per patient. CONCLUSION: Patients treated with MTX for EP, measurement of day 1 and day 7 ß-hCG serum levels has a cost minimization advantage and is not inferior to the traditional protocol for predictive accuracy and safety.

Treatment with vitamin K in hip fracture patients receiving warfarin.

BACKGROUND: Hip fractures are common in the elderly population, but surgical treatment of these fractures within the first 48 hours decreases morbidity and mortality. The management of patients with hip fracture requiring surgery who are taking warfarin anticoagulation is unclear. OBJECTIVES: To determine the effect of vitamin K on hip fracture patients treated with warfarin. METHODS: We retrospectively examined the management of 21 patients with hip fractures who were being treated with warfarin at the time of admission. Vitamin K was given to 11 of the 21 patients. A third group, which served as a control, consisting of 35 hip fracture patients who were not being treated with anticoagulants was also evaluated. RESULTS: Patients who received vitamin K took fewer days to reach target international normalized ratio (INR) (1.73 +/- 0.90 vs. 4.30 +/- 1.89, P < 0.001) and had less preoperative time (2.64 +/- 1.12 vs. 5.10 +/- 2.42 days, P < 0.008) when compared with patients who did not receive vitamin K. In addition, these patients had statistically significantly shorter hospitalization stays (9.4 +/- 1.9 and 13.2 +/- 4.9 days, one-sided P < 0.06). There was no difference in the amount of blood found in the wound drains (111.8 +/- 68.5 vs. 103.0 +/- 69.4 ml) or the number of blood units administered (1.45 +/- 1.29 vs. 2.00 +/- 2.75 units). CONCLUSIONS: Treatment with vitamin K for hip fracture patients who receive warfarin shortens preoperative time, reduces the length of hospitalization and probably reduces morbidity and mortality.

The relative advantages of criminal versus administrative environmental enforcement actions in Israel.

Most environmental enforcement programs have separate criminal and administrative procedures for addressing violations. Pitting "criminal"versus"administrative" enforcement as mutually exclusive alternatives constitutes a "false dilemma". Clearly, the government response should be influenced by the severity of pollution and the specific circumstances of the polluter. Yet, policy makers seeking to improve environmental compliance need to have a clearer picture about the merits of each approach and their relative effectiveness. This research empirically assesses the effectiveness of criminal versus administrative enforcement activities in Israel. After considering the philosophical implications associated with each regulatory approach, the results of a year-long study are presented. A series of performance indicators are utilized, with particular weight on compliance status in the field, to assess the condition of environmental violations several years subsequent to completion of enforcement activities. The state of 100 violations of air, water and hazardous materials laws that had been addressed through the criminal process were matched with results of comparable violations, against which administrative actions were taken. Results suggest that while criminal enforcement is a longer process, compliance following these actions was significantly greater than in administrative enforcement cases. The findings also underline the significance of a systematic follow-up system for tracking violations after enforcement actions are complete. Finally, the study confirms the benefits of targeted assistance to improve compliance among violators of environmental standards.

Positive psychology as a strategy for promoting sustainable population policies.

Demographic stability constitutes a paramount global environmental objective. Yet, decades of efforts, highlighting the perils of overpopulation, have failed to slow the rapid global population growth. In considering an alternative strategy, insights from the field of positive psychology are explored for their potential to inform future demographic policies. After briefly reviewing sustainable advocacy efforts, different theories behind individual fertility decisions are presented. Following, key components of prominent successful family planning interventions are analysed using a 'positive psychology' perspective. Three 'positive psychology' strategies are explored for their potential to inform sustainable population: a "direct" approach that emphasizes individual benefits rather than indirect gains through mitigation of damages; an emphasis on the convergence between the collective and individual benefits of two--child families; and application of behavioral change theories in demographic policies to better facilitate sustainable individual fertility decisions. The paper posits that a positive psychology conceptualization offers a promising way to re-think the design of demographic policies and frame sustainable population interventions.

Ultrahigh-gain monolithic multipass Nd:glass amplifier.

A novel scheme for a flashlamp-pumped ultrahigh-gain laser amplifier is presented. It is based on a monolithic slab design achieving a gain of 10(5). The measured ratio between pulse and prepulse output power was 5x10(7).

The implications of climate change driven depletion of Lake Kinneret water levels: the compelling case for climate change-triggered precipitation impact on Lake Kinneret's low water levels.

The dramatic drop in water levels in the Kinneret Lake (Sea of Galilee) during the past years is evaluated. Recently published measurements of temperature, precipitation and other hydrological data support the position that climate change is driving the contraction of this iconic water resource. The article presents a range of evidence confirming long-term shifts in the hydrological dynamics of the watershed and details the associated ecological implications. In response to these trends, Israel's government has decided to build a desalination plant along the Northern Mediterranean shoreline that will provide water to replenish the depleted water levels in lake. Given the likelihood of continued global warming expediting increased evaporation and reduced precipitation, such climate adaptation policies constitute prudent public policy.

Trend in cesarean delivery rate among twin pregnancies over a 20 years epoch and the accompanied maternal and perinatal outcomes.

OBJECTIVE: To examine the trend of cesarean delivery (CD) rate among twin pregnancies and the trend in maternal and neonatal morbidities within two decades. STUDY DESIGN: Population-based cohort study, conducted at a single teaching hospital in Israel on data between January 1995 and December 2015. All pregnant women with twin gestation who delivered at a gestational age of 24 weeks or more were included. Data on mode of deliveries, Apgar score <7 at 5 min, cord artery pH < 7.1, early postpartum hemorrhage, blood transfusion, and intrapartum fever for each year were extracted and plotted, and trends were analyzed. CDs performed for one or both twins were divided to laboring, i.e., after a trial of labor, and non-laboring CDs. Data was obtained from the hospital discharge register with ICD-9 codes and crosschecked with the labor medical records. The Cochran-Armitage Trend Test was used to identify trends and correlations. RESULTS: Of all 88,145 deliveries that took place during this period, 1955 (2.2%) were twins. Of these 53 were ineligible and were excluded. There was a statistically significant trend (increase) in twins birth over time (p = 0.004). CD rate increased significantly from 43.4% in 1995 to 66.0% in 2015 (p = 0.001). This increase was observed only among non-laboring cesareans (p = 0.001). Multivariate logistic regression analysis revealed that maternal and early neonatal morbidities examined did not differ significantly during the study period. CONCLUSION: Non-laboring CD rate increased significantly over the past two decades among twin pregnancies. Despite this increase, maternal and early neonatal morbidities did not change.

Impact of epidural on labor duration and vacuum deliveries in twin gestations.

INTRODUCTION: Epidural analgesia may lead to a prolonged second stage, and increased instrumental vaginal deliveries rate in singleton gestations. We aimed to examine the association between epidural and vacuum deliveries rate and second stage duration among twin deliveries. METHODS: Retrospective study conducted at a single teaching hospital on data between January 1995 and December 2015. All twin pregnancies, >24 weeks that had a trial of labor were included. Twins with major malformations, intrauterine death, or had a caesarean delivery without a trial of labor, were excluded. Women were divided to those who had an epidural analgesia (group 1) and those who did not (group 2). Primary outcome was vacuum delivery rate. RESULTS: Of all 1955 twin pregnancies delivered during the study period, 827 (42.3%) were eligible and included; 332 (40.1%) in group 1 and 495 (59.9%) in group 2. Vacuum delivery rate of any twin was 7.5% and 6.3% in groups 1 and 2, respectively (p = 0.48; Relative Risk 1.20; 95% Confidence Interval: 0.72-2.0). Vacuum delivery rate of first twin only or second twin only did not differ significantly as well. After adjusting for variables that differed significantly between the groups in univariate analysis, second stage duration of first and second twins in group 1 was significantly longer than in group 2 (p = 0.001; ratio=1.66; 95% Confidence Interval: 1.42-1.94 and p = 0.001; ratio=1.40; 95% Confidence Interval: 1.24-1.58, respectively). CONCLUSIONS: Epidural use in twin deliveries did not affect vacuum deliveries rate. Epidural was associated with a prolonged second stage of both twins.

Will demography defeat river rehabilitation efforts? The case of the River Jordan.

In the age-old debate between technological optimists and pessimists, desalination has been hailed as a "game changer" that can fundamentally alter the dynamics of water management under conditions of scarcity. While water from desalination facilities can reduce uncertainties in municipal supply, they are unlikely to replace the missing flow required to rehabilitate rivers and streams. The Jordan River is an iconic, but highly degraded water body whose restoration has been the subject of extensive research as well as numerous proposals and strategies. A review of the present state of the River and prospects for successful rehabilitation efforts reveals that neither the increase in the riparian population nor the reduced water supply due to climate change in the Jordan basin has been considered sufficiently in restoration strategies. Demographic pressures produce acute water shortages which make the provision of future environmental flows highly unlikely. While much can and should be done to improve its environmental condition, the Jordan River offers a cautionary tale for water scarce regions about the challenge of stream restoration initiatives in the face of accelerated population growth, notwithstanding the potential benefits of desalination as a source of drinking water.

A simple model for estimating the concentrations of natural estrogens in raw wastewater.

This study provides a tool for predicting the concentrations of the natural estrogens (NEs) estrone, 17ß-estradiol and estriol in raw wastewater (WW). Data characterizing the biochemical oxygen demand (BOD), NE concentrations, and discharges of raw sewage to wastewater treatment plants (WWTPs) were collected from various publications and used in the model formulation. A strong correlation was found between the log transformed BOD and the log transformed estrone load (r2=0.84, n=61), the log transformed 17ß-estradiol load (r2=0.89, n=52) and the log transformed estriol load (r2=0.80, n=40). The models are reasonably accurate when compared to the measured concentrations and slightly better than previous modeling efforts. The relative amounts of data falling within ±50% error were 67% for estrone, 63% for 17ß-estradiol, and 55% for estriol. Because the model was developed from a wide array of WWTPs from five continents, it is universal and can be used for projecting concentrations of NEs from a wide range of mixed domestic and industrial sources, but may be less precise when sources contain high levels of NEs or BOD (e.g., WW from dairy farms and food processing plants). The model is expected to improve our ability to predict the fate of NEs in WWTPs and in the receiving environment, which currently relies on estimating the concentrations of NEs in raw wastewater. Its application is especially valuable since direct measurement of NEs in raw WW is expensive and practically impossible in many developing countries due to the lack of expertise and funds.

Rethinking the sustainability of Israel's irrigation practices in the Drylands.

Broad utilization of drip irrigation technologies in Israel has contributed to the 1600 percent increase in the value of produce grown by local farmers over the past sixty-five years. The recycling of 86% of Israeli sewage now provides 50% of the country's irrigation water and is the second, idiosyncratic component in Israel's strategy to overcome water scarcity and maintain agriculture in a dryland region. The sustainability of these two practices is evaluated in light of decades of experience and ongoing research by the local scientific community. The review confirms the dramatic advantages of drip irrigation over time, relative to flood, furrow and sprinkler irrigation and its significance as a central component in agricultural production, especially under arid conditions. In contrast, empirical findings increasingly report damage to soil and to crops from salinization caused by irrigation with effluents. To be environmentally and agriculturally sustainable over time, wastewater reuse programs must ensure extremely high quality treated effluents and ultimately seek the desalinization of recycled sewage.

Occurrence and fate of endocrine disrupting compounds in wastewater treatment plants in Israel and the Palestinian West Bank.

Israel and its Palestinian neighbors constitute a unique venue for evaluating the treatment efficiency and potential environmental risks of endocrine disrupting compounds (EDCs) in wastewater treatment plants (WWTPs), because of their physical proximity yet contrasting societal dynamics. Israel primarily relies on advanced tertiary sewage treatment and recycles over 85% of its treated wastewater, while in the Palestinian Authority (PA), there is only secondary treatment levels at WWTPs and reuse is minimal (<1%). To evaluate the extent of EDC occurrence and treatment efficiency, we conducted four sampling campaigns over two consecutive years, and measured the concentrations of selected EDCs in raw wastewater (WW), treated WW and sludge in six WWTPs in Israel, as well as in two Palestinian plants. Low concentrations of bisphenol A, octylphenol and triclosan measured in the raw WW in the Palestinian WWTPs reflected the relatively modest industrial activity and consumption habits as compared to the westernized consumer patterns in Israel. On the other hand, hormone concentrations in raw WW were higher in the Palestinian WWTPs than those in the Israeli WWTPs, presumably because of a dilution effect associated with a higher water per capita consumption among Israelis. Despite these differences in raw WW concentrations, the removal efficiency in all advanced WWTPs was relatively high when compared to averages reported internationally.

Why endocrine disrupting chemicals (EDCs) challenge traditional risk assessment and how to respond.

Endocrine disrupting compounds (EDCs) are a diverse group of "chemicals of emerging concern" which have attracted much interest from the research community since the 1990s. Today there is still no definitive risk assessment tool for EDCs. While some decision making organizations have attempted to design methodology guidelines to evaluate the potential risk from this broadly defined group of constituents, risk assessors still face many uncertainties and unknowns. Until a risk assessment paradigm is designed specifically for EDCs and is vetted by the field, traditional risk assessment tools may be used with caution to evaluate EDCs. In doing so, each issue of contention should be addressed with transparency in order to leverage available information and technology without sacrificing integrity or accuracy. The challenges that EDCs pose to traditional risk assessment are described in this article to assist in this process.