Special forces medicine in Israel: history and future direction.

The Special Forces (SF) of the Israel Defense Force (IDF) have a long and pioneering history in tactical and medical aspects. Moreover, the importance of medical assistance is highly regarded in the Israeli SF community. Consequently, as current military challenges of Israel increase, the need for SF activity and for its medical support increases as well. Therefore, the authors anticipate that further development of SF medicine (SFM), as a specific branch of military medicine in Israel, will continue.

[Redesign of community-based health services: the solution for decreasing the quality gap].

The quality gap is defined as the gap between the observed and the expected, evidence-based, quality indicators. Experts agree that significant reduction of the quality gap requires transformation of the current system of health care provision. Maccabi Healthcare Services has formulated a "change package" in order to redesign its community-based healthcare services. This is based on a proactive approach in primary care, which manages all aspects of health for a defined community of members. This is built on multidisciplinary team-work, led by a physician and a nurse; planned visits for the management of patients with chronic diseases; one-stop-shopping for efficient health promotion; and encouraging patient-centeredness, which ensures that patient values will guide all clinical decisions and patients will be provided with support to enable self-management. The following conditions and infrastructure were required to allow for the redesign: 1) Redesign became a focus of the organizational strategy; 2) Building a comparative performance measurement for presentation at all managerial levels; 3) Agreement on the incentives to primary care clinics, which voluntarily joined the process of change; training of "quality leaders" who will use common terms and methodology to improve the quality of care. Starting in 2005 as a "pilot project", the change process has gradually evolved to include about 50 primary care clinics towards the end of the year 2007.

Deaths following influenza vaccination--background mortality or causal connection?

In October 2006, four deaths occurred in Israel shortly after influenza immunization, resulting in a temporary halt to the vaccination campaign. After an epidemiologic investigation, the Ministry of Health concluded that these deaths were not related to the vaccine itself and the campaign resumed; however, vaccine uptake was markedly reduced. Estimates of true background mortality in this high-risk population would aid in public education and quell unnecessary concerns regarding vaccine safety. We used data from a large HMO to estimate mortality in influenza vaccine recipients aged 55 and over during four consecutive winters (2003, 2004, 2005 and 2006). Date of immunization was ascertained from patient treatment files, vital status through Israeli National Insurance Institute data. We calculated crude death rates within 7, 14 and 30 days of influenza immunization, and used a Cox Proportional Hazards Model to estimate the risk of death within 14 days of vaccination, adjusting for age and comorbid conditions (age over 75, history of diabetes or cardiovascular disease, status as homebound patient) in 2006. The death rate among influenza vaccine recipients ranged from 0.01 to 0.02% within 7 days and 0.09-0.10% at 30 days. Influenza immunization was associated with a decreased risk of death within 14 days after adjustment for comorbidities (Hazard ratio, 0.33, 95% CI, 0.18-0.61). Our findings support the assumption that influenza vaccination is not associated with increased risk of death in the short term.