Improving the value of clinical research through the use of Common Data Elements.

The use of Common Data Elements can facilitate cross-study comparisons, data aggregation, and meta-analyses; simplify training and operations; improve overall efficiency; promote interoperability between different systems; and improve the quality of data collection. A Common Data Element is a combination of a precisely defined question (variable) paired with a specified set of responses to the question that is common to multiple datasets or used across different studies. Common Data Elements, especially when they conform to accepted standards, are identified by research communities from variable sets currently in use or are newly developed to address a designated data need. There are no formal international specifications governing the construction or use of Common Data Elements. Consequently, Common Data Elements tend to be made available by research communities on an empiric basis. Some limitations of Common Data Elements are that there may still be differences across studies in the interpretation and implementation of the Common Data Elements, variable validity in different populations, and inhibition by some existing research practices and the use of legacy data systems. Current National Institutes of Health efforts to support Common Data Element use are linked to the strengthening of National Institutes of Health Data Sharing policies and the investments in data repositories. Initiatives include cross-domain and domain-specific resources, construction of a Common Data Element Portal, and establishment of trans-National Institutes of Health working groups to address technical and implementation topics. The National Institutes of Health is seeking to lower the barriers to Common Data Element use through greater awareness and encourage the culture change necessary for their uptake and use. As National Institutes of Health, other agencies, professional societies, patient registries, and advocacy groups continue efforts to develop and promote the responsible use of Common Data Elements, particularly if linked to accepted data standards and terminologies, continued engagement with and feedback from the research community will remain important.

Diameter-by-age reference curves for the uterine cervix by computerized tomography.

OBJECTIVE: To create diameter-by-age reference curves for the uterine cervix using computerized tomographic studies. METHODS: Measurements of the anterior-posterior (AP) and lateral diameters of nonpathological cervices were made at the level of the vaginal fornices in 499 computerized tomographic studies. Patients were grouped by 10-year age intervals. For each age group, median AP and lateral cervical diameters were calculated, as were 10th and 90th percentile values. Values for the 3 curves were smoothed across age categories using second-order polynomial regression procedures. RESULTS: The median AP diameter was 26 mm (range, 15-45 mm), and the median lateral diameter was 32 mm (range, 20-70 mm). For both measurements, the range of values between the 10th and 90th percentiles decreased with increasing age, creating funnel-shaped plots. CONCLUSIONS: Radiological measurements of cervical diameters and comparison to standard curves may contribute information in the evaluation of uterine cervical pathology or may heighten awareness of pathologies not previously identified.

[Development of an evidence-based managerial decision aid to assist in the provision of secondary medical services in the Israel Defense Forces (IDF)].

BACKGROUND: Increasing global expenditures on health, together with increased patient demand for quality and service, have created a need for health care management tools based on economic and quaLity-based criteria. Despite the recognition of this need, decision-support tools are Lacking. In the Israel Defense Forces (IDF), policy change and budgetary and quality constraints necessitated the development of an evidence-based managerial decision aid, to assist in providing medical services at acceptable quality and availability leveLs, while addressing economic concerns. OBJECTIVE: To develop a decision-support model for the IDF Medical Corps, that balances the conflicting considerations of service avaiLabiLity and cost. METHODS: The authors developed a manageriaL model to characterize regional secondary medical care, and to compare it to country-wide patterns and to historic regional patterns. Secondary care systems were then analyzed by specialty. Finally, the relative costs of medical encounters for each speciaLty were anaLyzed. RESULTS: Core specialties examined included dermatology, orthopedics and otolaryngology. Two-thirds of all referrals to core specialists were made to intra-organizational resources. Furthermore, several intra-organizationaL clinics were found to have short waiting times and low output indices. In response to the application of the model, IDF Medical Corps policy was updated and suppliers were reprioritized, yielding substantial savings of up to NIS 5.5 million in 2006 alone. This cost saving enabled budgetary reallocation and alternative investment in the emergency and primary health care systems. CONCLUSION: Applying efficient managerial tools can lead to cost savings and to increased quality and availability of services. These tools must effectively follow changes in the dynamics of the health care system. These changes are to be impLemented rapidly, in order to provide practical guidance for medical administrators and to enable them to infLuence the real-time utiLization of medical services.

Hypertension and socioeconomic status.

PURPOSE OF REVIEW: The impact of socioeconomic status on hypertension is complicated and unclear. In this article, we review the findings of recently published studies pertaining to the association between socioeconomic status and hypertension. Specifically, we focus on several potentially modifiable modes of pathogenesis involved in this association, including education, occupation, and social environment. We also review several mechanisms through which the effects of socioeconomic status on hypertension may be mediated. RECENT FINDINGS: Several modifiable socioeconomic determinants, such as education and occupation, are associated with hypertension. Additional socioeconomic status markers such as urban or rural dwelling and individual, local or national economic conditions are also associated with hypertension, although these associations are complicated and at times somewhat contradictory. Possible explanations for this impact include awareness of hypertension prevention and control and better accessibility and adherence to medical treatment among higher socioeconomic status groups, as well as low birth weight and higher job strain among lower socioeconomic status groups. SUMMARY: Low socioeconomic status is associated with higher blood pressure. There is a need to develop and test culturally appropriate interventions to reduce the prevalence of hypertension among these populations to minimize the resultant cardiovascular morbidity and mortality.

Relative impact of socioeconomic status on blood pressure lessons from a large-scale survey of young adults.

BACKGROUND: Although several studies reported on the association between socioeconomic status (SES) and hypertension, the results are conflicting, the quantification is problematic, only a few focused on young adults, and the effects of various key determinants of SES, such as education and job type, need further clarification. We aimed to assess the influence of SES on blood pressure in a large population of young adults. METHODS: We studied 11,053 male Israel Defense Force officers who underwent periodic medical evaluation during the years 1991 to 1999. Subjects completed a detailed medical questionnaire and underwent physical examination. We calculated mean systolic and diastolic blood pressure (SBP and DBP, respectively) by level of education, rank, and job type (as measures of SES), adjusting for demographic variables and body mass index (BMI). RESULTS: Adjusted means of SBP and DBP were highest among low-ranking officers (SBP, 119 mm Hg, compared with 117 and 115 mm Hg among intermediate and high-ranking officers, respectively, P < .001; DBP, 77 mm Hg, compared with 76 mm Hg among intermediate and high-ranking officers, P = .001). No differences were observed for level of education, but the mean SBP was higher among office workers (117 mm Hg v 116 mm Hg among physical workers, P = .038). The partial eta(2) for rank, age, and BMI was found to be 0.003, 0.008, and 0.066, respectively, for SBP, and 0.002, 0.026 and 0.054, respectively, for DBP. CONCLUSIONS: Low SES, as reflected by low rank, is associated with elevated blood pressure. However, as a whole, SES is a weak determinant of blood pressure compared with age and BMI.

Influenza vaccine refusal in Israeli young adults.

OBJECTIVE: The purpose of this study was to identify correlates of noncompliance with influenza immunization among young adults and to determine the reasons leading to immunization refusal. METHODS: Self-administered questionnaires were distributed in 10 military bases during two consecutive annual Israel Defense Force influenza vaccination campaigns. Multivariate logistic regression was performed to identify independent correlates. RESULTS: Of 2,000 questionnaires distributed over two seasons, 942 were completed and returned. Of those, 401 respondents were not vaccinated either because of medical contraindication or for administrative reasons. The remaining 541 respondents who reported either receiving the vaccine or refusing to receive it were analyzed. Risk groups for vaccine refusal included older age (17.9% vs. 3.5% refusal rate) and officer rank (25.9% vs. 13.8% refusal rate). The main reasons for vaccine refusal differed significantly between officers and nonofficers (chi2 = 7.587, p = 0.023). Officers refused mainly (60%) because of fear of possible vaccine adverse effects, whereas nonofficers refused mainly (44.2%) because of disbelief in the vaccine's efficacy in preventing illness. CONCLUSION: Officers serve as a negative role model in this case, and efforts directed toward dissemination of evidence-based information regarding vaccine-related adverse effects should be introduced to increase vaccination rates in this group.

Validity of self-assessment of skin reaction after smallpox vaccination.

OBJECTIVE: Smallpox vaccinees should be evaluated for the presence of a major skin reaction ("take") one week after vaccination, but this could prove to be logistically infeasible in the context of an emergency mass-vaccination campaign. We validated a tool for self-evaluation of the vaccination site for presence of take. METHODS: We conducted a prospective, double-blinded, paired-measurement validation study of 174 non-naive adult vaccinees and their physician evaluators. Subjects provided paired, blinded, independent assessments of take 7-9 days after vaccination. RESULTS: Overall, vaccinees and evaluators agreed on 157 of 174 (90.2%) take assessments. Sensitivity of the tool was 99.1%, and specificity was 75%. The positive predictive value of self-assessment was 87.2% and the negative predictive value was 98%. Specificity of the tool and measures of agreement were significantly modified by age, education, and occupation. When adjusted for the expected take rate among a population including naive vaccinees, positive predictive value and overall agreement increased significantly. CONCLUSIONS: Self-assessment may be a feasible option for evaluation of take in the event of mass smallpox vaccination. The predictive values and overall agreement of the tool are satisfactory, and can be expected to increase when used in a largely naive population.

Parental smoking and education as determinants of overweight in Israeli children.

INTRODUCTION: Obesity is a well-recognized risk factor for many chronic diseases. Pediatric overweight is an especially severe problem because its childhood onset increases the overall length of exposure to the detrimental effects of overweight, accelerates the onset of chronic disease, and affects children's physical, psychological, and social development. Several parental traits have been shown to be associated with an increased risk for childhood overweight. In our study, we quantified the mutual effects of parental education and smoking on the risk of filial overweight in a large population-based sample of Israeli schoolchildren, adjusting for the effects of age, sex, and immigration status. METHODS: Data were collected in 1997 and 2000 from 8623 Israeli schoolchildren aged 8 to 13 years in two cross-sectional samples. Overweight was defined as body mass index (BMI) of greater than the 85th percentile for age and sex, and severe overweight was defined as BMI greater than the 95th percentile for age and sex. RESULTS: Mean BMI was positively associated with number of parental smokers for a child. Parental smoking was an independent risk factor for both overweight and severe overweight, with a dose-response relationship between the number of parental smokers and the risk of filial overweight. Children whose parents did not attend college were at increased risk for overweight (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.03-1.42) and severe overweight (OR, 1.49; 95% CI, 1.09-2.05) compared with children whose parents both attended college. Children with one college-educated parent were at increased risk for severe overweight (OR, 1.31; 95% CI, 1.004-1.71) compared with children whose parents both attended college. CONCLUSION: Parental education and smoking are independent risk factors for filial overweight. Children of less-educated, smoking parents should be targeted for overweight prevention and intervention efforts. These findings should also be included as key messages in adult smoking prevention and cessation campaigns. Parents who smoke should be warned that not only is their own health at stake, but their children are also at increased risk for overweight and its associated diseases.

Evaluation of arterial compliance in polycythemia vera patients: short and long-term influence of phlebotomy.

BACKGROUND: Thrombosis is a major cause of morbidity and mortality in polycythemia vera. Hypercoagulability is principally due to hyperviscosity of the whole blood, an exponential function of the hematocrit. PV is also associated with endothelial dysfunction that can predispose to arterial disease. Reduction of the red cell mass to a safe level by phlebotomy is the first principle of therapy in PV. This therapy may have some effect on the arterial compliance in PV patients. OBJECTIVES: To estimate the influence of phlebotomies on large artery (Cl) and small artery compliance (C2) in PV patients by using non-invasive methods. METHODS: Short-term hemodynamic effects of phlebotomy were studied by pulse wave analysis using the HDI-Pulse Wave CR2000 (Minneapolis, MN, USA) before and immediately after venesection (350-500 ml of blood). We repeated the evaluation after 1 month to measure the long-term effects. RESULTS: Seventeen PV patients were included in the study and 47 measurements of arterial compliance were performed: 37 for short-term effects and 10 for long-term effects. The mean large artery compliance (C1) before phlebotomy was 12.0 ml/mmHg x 10 (range 4.5-28.6), and 12.6 ml/mmHg x 10 (range 5.2-20.1) immediately after phlebotomy (NS). The mean small artery compliance (C2) before and immediately after phlebotomy were 4.4 mg/mmHg x 10 (range 1.2-14.3) and 5.5 mg/mmHg x 10 (range 1.2-15.6) respectively (delta C2-1.1, P < 0.001). No difference in these parameters could be demonstrated in the long-term arm. CONCLUSIONS: Phlebotomy immediately improves arterial compliance in small vessels of PV patients, but this effect is short lived.

Successful steroid withdrawal in lung transplant recipients: result of a pilot study.

OBJECTIVE: Corticosteroids play a key role in immunosuppression after transplantation. However, because chronic steroid treatment may cause significant morbidity and mortality, steroid-free immunosuppression remains a desirable goal. To the best of our knowledge, there are no reports on successful steroid withdrawal (SW) in lung transplant recipients. METHODS: The study group included 35 patients who underwent heart-lung, double-lung or single-lung transplantation. Criteria for initiation of SW were stable pulmonary function tests and absence of clinical or bronchoscopic evidence of acute or chronic rejection in the last 6 months. Pulmonary function, blood pressure and metabolic parameters were compared between the patients who underwent SW and those who did not. RESULTS: Eight patients (23%) underwent SW. Median follow-up was 19 months (range 11-23 months). Compared to the non-withdrawal group, the withdrawal group was older (60+/-6 vs. 52+/-13 years, P=0.01, r=0.49), had higher rates of emphysema (88% vs. 18%, P=0.01) and use of a cyclosporine-based regimen (62% vs. 26%, P=0.0001), and had longer time from transplantation to the withdrawal attempt (70+/-13 vs. 29+/-26 months, P=0.0002). The SW group showed no adverse effects in graft function and no deterioration on pulmonary function tests. SW had a beneficial metabolic effect, with a decrease in mean cholesterol level from 229+/-45 to 194+/-25 mg/dl (P=0.02) and no significant change in weight, systolic blood pressure or glucose level. In the non-withdrawal group, mean cholesterol levels increased from 175+/-34 to 209+/-57 mg/dl (P=0.0005), weight increased from 72+/-15 to 80+/-14 kg (P=0.0001), and systolic blood pressure increased from 125+/-15 to 139+/-16 mmHg (P=0.001); glucose levels did not change. There was a significant correlation between total cholesterol level and weight in both groups (P=0.0006, r=-0.56 and P=0.01, r=-0.46, respectively). CONCLUSIONS: Late SW is safe in stable patients after lung transplantation. There was no evidence of rejection or a deterioration in pulmonary function. Lipid profile improvement and blood pressure stabilization accompanied the termination of steroid therapy.

Secular trends in age at menarche, smoking, and oral contraceptive use among Israeli girls.

INTRODUCTION: The improved nutrition and socioeconomic status of the population in industrialized countries has resulted in a decrease in the mean age at menarche. This trend raises the question of whether cigarette smoking and the use of oral contraceptives, health behaviors often adopted during adolescence, may also be starting at a younger age. Cigarette smoking and use of oral contraceptives are a public health concern because they pose an increased risk for development of chronic diseases, particularly in combination. This study was designed to identify secular trends in age at menarche, at first cigarette, and at first use of oral contraceptives among a large population-based sample of young Israeli women and to assess whether these trends are associated with sociodemographic factors. METHODS: A systematic, population-based survey used data obtained from female recruits to the Israel Defense Force from 1986 to 2000. During the study period, 11,392 questionnaires were collected from Jewish women aged 18 to 19 years. Participants were interviewed concerning geographic origin and level of education, father's geographic origin and level of education, current smoking status, use of oral contraceptives, and recalled age at first menstruation, first cigarette, and first use of oral contraceptives. RESULTS: Reported mean age (-/+ D) at menarche showed a monotonic trend of decreasing over time, from 13.41 (-/+ .30) years for women born before 1970 to 13.03 (-/+ 1.28) years for those born after 1978 (P < .001). Women born after 1978 were twice as likely to experience menarche by the age of 11 as those born prior to 1970 (odds ratio 2.0; 95% confidence interval, 1.41-2.82). Significant trends toward younger age at first use were observed for cigarettes and oral contraceptives. CONCLUSION: The trends of earlier age at menarche, first cigarette, and first use of oral contraceptives suggest health behaviors among young women that may herald increased chronic disease morbidity in the future. These trends indicate the need for further investigation and preventive measures aimed at this population.

Infectious diarrheal outbreaks in the Israeli military, 1988-2002.

We analyzed 865 diarrheal outbreaks with an identified bacterial pathogen or unknown cause that occurred in the Israeli military between 1988 and 2002. The number of outbreaks per year declined over the study period, as did the proportion of outbreaks with an identified pathogen. Shigella, Salmonella, and Staphylococcus species were the bacteria most commonly isolated. Seventy percent of the outbreaks involved < 35 cases and only 5% involved > 100 cases. More than one-half of the outbreaks occurred in field units, but these outbreaks were smaller than those in other units. The most commonly identified cause of the outbreaks was a lapse in maintaining standards of food preparation. Improvements in infrastructure and enhanced attention to surveillance, education, and infection control have resulted in a marked decline in the number of outbreaks in recent years.

[Education level and origin as predictors of hospitalization among Jewish adults in Israel: a population-based study].

BACKGROUND: Age, sex, origin and level of education are recognized as predictors of healthcare utilization. However, the joint effects of these variables on the risk of hospitalization have yet to be described for specific diagnostic categories, such as diseases of the circulatory, respiratory, genitourinary, digestive and nervous systems, infectious and parasitic diseases, malignant neoplasms, injury and poisoning. OBJECTIVES: To evaluate the association between origin, education, sex, age and the risk of hospitalization due to major diagnostic categories. METHODS: Cross-sectional study linking population-based databases, including Israeli census and hospitalization records. RESULTS: The study encompassed 35,413 hospitalized subjects and 386,317 non-hospitalized subjects. Origin other than Israel was a risk factor for hospitalization, with an odds ratio of 1.31 (95% CI 1.25-1.36) for Asia, 1.43 (1.37-1.50) for Africa, and 1.24 (1.20-1.29) for Europe-America (P for all origins <0.0001). Compared to subjects with post-high school educations, those with high school educations were 1.18 times more likely to be hospitalized (1.14-1.21), while those with elementary school educations experienced a risk of 1.32 (1.28-1.37) (P < 0.0001). Origin was a marked risk factor for hospitalization due to malignancy, with an odds ratio of 2.19 (1.71-2.79) for European-American origin relative to Israeli origin (P < 0.0001). The inverse association between education level and risk of hospitalization was constant across all diagnostic categories other than malignancy. CONCLUSIONS: Lower education was found to be a significant risk factor for hospitalization in most diagnostic categories. Origin was associated with increased risk for hospitalization due to malignant neoplasms and diseases of the respiratory, nervous, genitourinary and circulatory systems.

[Smallpox vaccination techniques: considerations and unresolved issues].

The smallpox vaccine is the oldest--and was, for 90 years, the only--vaccine known to man. Many vaccination techniques have been used over time, with no fewer than ten employed during the 20th century alone. In Israel, two main techniques were used prior to smallpox eradication in 1978--multiple punctures using a standard needle, and jet injection--while most other countries adopted the bifurcated needle as the method of choice. Despite the vaccination experience gained over time, doubt remains today as to the preferred vaccination technique. During 2002, when Israel became the first country to conduct large-scale smallpox vaccination in the 21st century, multiple standard needle puncture was adopted as the method of choice, while at the same time the bifurcated needle was readopted in the United States. The article reviews the various smallpox vaccination techniques, the supporting scientific data, and the current lacunae in knowledge related to the subject. Together, these factors will most likely influence the adoption of a preferred vaccination technique during a smallpox emergency.

[Antiviral prophylaxis following possible sexual exposure to HIV].

In Israel, as in certain European countries, national health guidelines exist for preventive treatment after possible post-coital exposure to the HIV virus. Scientifically, this treatment is still regarded as experimental, though over the past years there is a mounting level of evidence of its efficacy. The administration of prophylaxis for HIV after unprotected coitus may be justified by the similar risk of HIV transmission for certain sexual and occupational exposures. Other considerations include: biological plausibility, the effectiveness of post-exposure prophylaxis in animal studies and occupational exposures in humans, efficacy in the prevention of vertical HIV transmission, and cost effectiveness studies. The preventive post-exposure treatment bears many side effects and possible complications, and therefore, each case should be cautiously analyzed before starting such treatment. This article reviews the scientific evidence on this topic, the considerations taken by the physician in initiating post coital HIV exposure treatment, and the guidelines available in Israel and throughout the world.

Sizing the Problem of Improving Discovery and Access to NIH-Funded Data: A Preliminary Study.

OBJECTIVE: This study informs efforts to improve the discoverability of and access to biomedical datasets by providing a preliminary estimate of the number and type of datasets generated annually by research funded by the U.S. National Institutes of Health (NIH). It focuses on those datasets that are "invisible" or not deposited in a known repository. METHODS: We analyzed NIH-funded journal articles that were published in 2011, cited in PubMed and deposited in PubMed Central (PMC) to identify those that indicate data were submitted to a known repository. After excluding those articles, we analyzed a random sample of the remaining articles to estimate how many and what types of invisible datasets were used in each article. RESULTS: About 12% of the articles explicitly mention deposition of datasets in recognized repositories, leaving 88% that are invisible datasets. Among articles with invisible datasets, we found an average of 2.9 to 3.4 datasets, suggesting there were approximately 200,000 to 235,000 invisible datasets generated from NIH-funded research published in 2011. Approximately 87% of the invisible datasets consist of data newly collected for the research reported; 13% reflect reuse of existing data. More than 50% of the datasets were derived from live human or non-human animal subjects. CONCLUSION: In addition to providing a rough estimate of the total number of datasets produced per year by NIH-funded researchers, this study identifies additional issues that must be addressed to improve the discoverability of and access to biomedical research data: the definition of a "dataset," determination of which (if any) data are valuable for archiving and preservation, and better methods for estimating the number of datasets of interest. Lack of consensus amongst annotators about the number of datasets in a given article reinforces the need for a principled way of thinking about how to identify and characterize biomedical datasets.

Significance of a plasma D-dimer test in patients with primary pulmonary hypertension.

BACKGROUND: D-dimer, a degradation product of fibrin, has been increasingly used as a marker or prognostic factor in various thrombotic diseases. OBJECTIVE: To assess the significance of a d-dimer test in patients with primary pulmonary hypertension (PPH). PATIENTS AND METHODS: Fourteen patients with PPH (12 women and 2 men) aged 25 to 68 years (mean +/- SD age, 50 +/- 14 years) entered the study. Plasma d-dimer was determined by Miniquant assay (Biopool International; Venture, CA) 3 +/- 5 months after the disease onset, and patients were followed up for 1 year. We compared the d-dimer levels to the demographic, clinical, and hemodynamic data of the patients. RESULTS: D-dimer levels were positively correlated with New York Heart Association classification (r = 0.59, p = 0.01) and pulmonary artery pressure (r = 0.43, p = 0.03) and were negatively correlated with oxygen saturation (r = - 0.45, p = 0.03) and 6-min walk distance (r = - 0.49, p = 0.04). One-year survival was also negatively correlated with d-dimer (point-biserial r = - 0.71, p = 0.004), with a higher d-dimer value associated with poorer survival. No significant correlations were found between d-dimer values and sex, age, diffusing capacity of the lung for carbon monoxide, or cardiac index. CONCLUSION: D-dimer levels may have a role in the evaluation of patients with PPH. This simple, noninvasive test may be helpful for identifying patients who are at a higher risk for severe disease.

Susceptibility of the influence of weight on blood pressure in men versus women: lessons from a large-scale study of young adults.

BACKGROUND: Weight and blood pressure (BP) are closely related. The aim of this study was to quantify this relationship and compare it to other factors in a population of relatively young adults, with particular focus on the possible role of gender. METHODS: We conducted a cross-sectional analysis of the Young Adult Periodic Examinations in Israel (YAPEIS) database of healthy people aged 25 to 45 years undergoing routine periodic examinations. Between 1991 and 1999, 38,558 subjects (88.1% men, mean age 36 +/- 8 years) were examined. The correlation between BP and weight was evaluated with adjustments for age, sex, physical activity, cigarette smoking, and fasting blood glucose levels. RESULTS: Blood pressure correlated positively with body mass index (BMI), spanning the spectrum of BMI values. Weight accounted for 8% to 10% of BP variance. The odds ratio for hypertension increased by 16% for each additional unit of BMI, compared to 6% for each year increase in age. The relative propensity of men toward hypertension, typical of this age group, was less pronounced at higher BMI values (male:female ratio = 2.2 at BMI <25 kg/m(2), and 1.28 at BMI > or =35 kg/m(2)). CONCLUSIONS: The association between BP and body weight is at least as strong as that between BP and age and is especially prominent in women.

The epidemiologic pyramid of bioterrorism.

Recent events have drawn world attention to "mythological diseases"--such as anthrax, plague and smallpox--which have been out of the spotlight for some decades. Much of our current knowledge of epidemic intervention and disease prevention was acquired over history through our experience with these diseases, such that the sudden panic over the reemergence of these historically well-known entities is perplexing. Over time, changes in the balance of the epidemiologic triangle have driven each of these disease systems towards a new equilibrium with which we are not familiar. While the pathogens may be similar, these are not the diseases of the past. These new disease systems are insufficiently described by the classic epidemiologic triangle, which lacks a dimension necessary for providing a valid model of the real-world effects of bioterror-related disease. Interactions within the classic epidemiologic triangle are now refracted through the prism of the global environment, where they are mediated, altered, and often amplified. Bioterror-associated diseases must be analyzed through the epidemiologic pyramid. The added dimension represents the global environment, which plays an integral part in the effects of the overall disease system. The classic triangle still exists, and continues to function at the base of the new model to describe actual agent transmission, but the overall disease picture should be viewed from the height of the fourth apex of the pyramid. The epidemiologic pyramid also serves as a practical model for guiding effective interventional measures.

SWOT analysis: strengths, weaknesses, opportunities and threats of the Israeli Smallpox Revaccination Program.

During September 2002, Israel began its current revaccination program against smallpox, targeting previously vaccinated "first responders" among medical and emergency workers. In order to identify the potential strengths and weaknesses of this program and the conditions under which critical decisions were reached, we conducted a SWOT analysis of the current Israeli revaccination program, designed to identify its intrinsic strengths and weaknesses, as well as opportunities for its success and threats against it. SWOT analysis--a practical tool for the study of public health policy decisions and the social and political contexts in which they are reached--revealed clear and substantial strengths and weaknesses of the current smallpox revaccination program, intrinsic to the vaccine itself. A number of threats were identified that may jeopardize the success of the current program, chief among them the appearance of severe complications of vaccination. Our finding of a lack of a generation of knowledge on smallpox vaccination highlights the need for improved physician education and dissipation of misconceptions that are prevalent in the public today.