Surgery Duration Prediction using Multitask Feature Selection

Efficient optimization of operation room (OR) activity poses a significant challenge for hospital managers due to the complex and risky nature of the environment. The traditional "one size fits all" approach to OR scheduling is no longer practical, and personalized medicine is required to meet the diverse needs of patients, care providers, medical procedures, and system constraints within limited resources. This paper aims to introduce a scientific and practical tool for predicting surgery durations and improving OR performance for maximum benefit to patients and the hospital. Previous works used machine-learning models for surgery duration prediction based on preoperative data. The models consider covariates known to the medical staff at the time of scheduling the surgery. However, model selection becomes crucial, where the number of covariates used for prediction depend on the available sample size. Our proposed approach utilizes multitask regression to select a common subset of predicting covariates for all tasks with the same sample size while allowing the model's coefficients to vary between them. A regression task can refer to a single surgeon or operation type or the interaction between them. By considering these diverse factors, our method provides an overall more accurate estimation of the surgery durations, and the selected covariates that enter the model may help to identify the resources required for a specific surgery. We found that when the regression tasks were surgeon-based or based on the pair of operation type and surgeon, our suggested approach outperformed the compared baseline suggested in a previous study. However, our approach failed to reach the baseline for an operation type-based task. By accurately estimating surgery durations, hospital managers can provide care to a greater number of patients, optimize resource allocation and utilization, and reduce waste. This research contributes to the advancement of personalized medicine and provides a valuable tool for improving operational efficiency in the dynamic world of medicine.

Supporting healthcare workers in vaccination efforts

Encouraging healthcare workers (HCWs) to be vaccinated is a global challenge and plays a fundamental role in combating COVID-19 pandemic. Beyond national policy, which could be different between countries, the decision to be vaccinated involves personal opinions, values, risk perception and attitudes. HCWs may have their own concerns and fears about vaccination beyond being part of the health system. They have a national role in encouraging public vaccination and therefore we recommend strengthening their involvement as policy agents. The health system should equip HCWs with information on the nature and scope of circulating concerns in their communities. At the same time, be attentive to their concerns, equip them with established knowledge and work to strengthen their confidence in the vaccine.

Patient-centeredness-a cultural targeted survey among junior medical managers

BACKGROUND

Patient-centeredness is a core element in healthcare. However, there is a gap between the understanding of this term by healthcare professionals, and patients' capability, self-efficacy, and willingness to take part in medical decisions. We aim to expose standpoints toward "patient centeredness" among junior medical managers (JMM), as they bridge between policy strategies and patients. We try to reveal cultural differences by comparing the views of the majority and the minority subpopulations of Israel (Arabic and Hebrew speakers).

METHODS

A cross-sectional survey among JMM studying for an advanced degree in health-system management at three academic training colleges in Israel was conducted in February-March 2022. The respondents completed a structured questionnaire comprising four sections: a) perceptions of trust, accountability, insurance coverage, and economic status; b) perceptions regarding decision-making mechanisms; c) preferences toward achieving equity, and d) demographic details.

RESULTS

A total of 192 respondents were included in the study-50% Hebrew speakers and 50% Arabic speakers. No differences were found between Arabic and Hebrew speakers regarding perception of trust, accountability, insurance coverage, and economic status. JMM from both subpopulations believed that patients' gender and age do not influence physicians' attitudes but Arabic-speaking respondents perceived that healthcare professionals prefer educated patients or those with supportive families. All respondents believed that patients would like to be more involved in medical decisions; yet Arabic-speakers perceived patients as tending to rely on physicians' recommendations while Hebrew speakers believed that patients wish to lead the medical decision by themselves.

CONCLUSIONS

Patient-centeredness strategy needs to be implemented bottom-up as well as top-down, in a transparent nationwide manner. JMM are key actors in carrying out this strategy because they realize policy guidelines in the context of social disparities, enabling them to achieve a friendly personalized dialogue with their patients. We believe that empowering these JMM may create a ripple effect, yielding a bottom-up perception of equity and initiating change.

Resilience of hospital staff facing COVID-19 pandemic: Lessons from Israel

Introduction

The COVID-19 pandemic has placed additional burden on already strained healthcare systems worldwide, intensifying the responsibility and burden of healthcare workers. Although most hospital staff continued working during this stressful and challenging unprecedented pandemic, differences in the characteristics and attributes were noted between sectors and hospital departments. Israeli healthcare workers are trained and experienced in coping with national emergencies, but the pandemic has exposed variations in staff reactions. Understanding the intrinsic differences between sectors and departments is a key factor in staff and hospital preparedness for unexpected events, better resource utilization for timely interventions to mitigate risk and improve staff wellbeing.

Objective

To identify and compare the level of resilience, secondary traumatization and burnout among hospital workers, between different sectors and hospital departments, during the COVID-19 pandemic.

Methods

Cross-sectional research to assess the resiliency, secondary traumatization and burnout of healthcare workers at a large general public hospital in central Israel. The sample consisted of 655 participants across various hospital units exposed to COVID-19 patients.

Results

Emergency department physicians had higher rates of resilience and lower rates of burnout and secondary traumatization than staff in other hospital departments. In contrast, staff from internal medicine departments demonstrated the highest levels of burnout (4.29). Overall, physicians demonstrated higher levels of resilience (7.26) and lower levels of burnout compared to other workers.

Conclusion

Identifying resilience characteristics across hospital staff, sectors and departments can guide hospital management in education, preparation and training of healthcare workers for future large-scale health emergencies such as pandemics, natural disasters, and war.

Group versus individual occupational therapy for toddlers with autism as a means to improve access to public health-care services. Randomised controlled pilot study

INTRODUCTION

In recent years, the increasing prevalence of autism-spectrum disorder has resulted in an increased demand for therapies including occupational therapy. In this pilot trial, we aimed to compare the efficacy of group versus individual occupational therapy among toddlers with autism as a means to improve accessibility to care.

METHODS

Toddlers (2-4 years) undergoing autism evaluation in our public child developmental centre were recruited and randomised to receive 12 weekly sessions of group or individual occupational therapy based on the same mode of intervention: Developmental, Individual-Differences and Relationship-based (DIR). Primary outcomes related to intervention implementation included waiting days, nonattendance, intervention period, number of sessions attended and therapist satisfaction. Secondary outcomes were the Adaptive Behaviour Assessment System questionnaire, the Paediatric Quality of Life Inventory and the Peabody Developmental Motor Scale (PDMS-2).

RESULTS

Twenty toddlers with autism were included, 10 in each occupational therapy mode of intervention. Children waited fewer days before beginning group occupational therapy compared to individual therapy (52.4 ± 28.1 vs. 108.8 ± 48.0 days p < 0.01). Mean numbers of nonattendance was similar for both interventions (3.2 ± 2.82 vs. 2 ± 1.76, p > 0.05). Worker satisfaction scores were similar at the beginning and end of the study (6.1 ± 0.4 vs. 6.07 ± 0.49, p > 0.05). There were no significant differences between the percentage changes in individual and group therapy outcomes for adaptive score (6.0 ± 16.0 vs. 4.5 ± 17.9, p > 0.05), quality of life (1.3 ± 20.9 vs. 18.8 ± 24.5, p > 0.05) and fine motor skills (13.7 ± 36.1 vs. 15.1 ± 41.5, p > 0.05).

CONCLUSIONS

In this pilot study, the group DIR-based occupational therapy for toddlers with autism improved access to services and allowed earlier interventions, with no clinical inferiority to individual therapy. Further research is required to examine group clinical therapy benefit.

Attitudes of Healthcare Workers in Israel towards the Fourth Dose of COVID-19 Vaccine

Attitudes of healthcare workers (HCWs) toward vaccines are extremely important for increasing vaccination coverage. We conducted a cross-sectional study at the beginning of the fourth COVID-19 vaccination dose campaign among 124 HCWs to evaluate attitudes towards the fourth dose and willingness to get vaccinated. At that time, Israel was the first country to approve the fourth vaccine dose. Most women were unwilling to get the fourth vaccine dose compared to men; 53.9% of physicians were unwilling to get vaccinated compared to 83.3% of nurses and 69% of other HCWs professions. The most frequent concerns regarding the vaccine were its efficacy, benefit, and necessity. The perceived risk and perceived severity of the health risk involved with getting vaccinated with the fourth dose were higher among HCWs who stated that they would not get vaccinated compared to those who were vaccinated or intended to get vaccinated. In contrast, HCWs who were vaccinated with the fourth dose, or those who were planning to get vaccinated, gave higher scores to the perceived benefit of the booster, its advantages, its perceived safety, its ability to protect from severe illness, and the perceived extent of scientific information about the risk associated with the booster. A logistic regression model revealed that perception of the fourth dose's benefits and risk significantly predict the willingness of HCWs to get vaccinated. Willingness to vaccinate their own children, acceptance of a hypothetical annual booster vaccine, and having less severe adverse effects after prior vaccination were also associated with willingness to get the fourth dose. These findings could help policy makers in developing strategies to expand the acceptance and coverage of the COVID-19 booster doses.

Attitudes of healthcare workers and members of the public toward the COVID-19 vaccine: A cross-sectional survey

The COVID-19 pandemic has led to the rapid development and implementation of vaccines. However, uncertainty about their safety and effectiveness among some people has led to vaccine hesitancy. We conducted a cross-sectional survey in March 2021 among individuals from the general Israeli population and health-care workers (HCWs) to examine risk perception toward the COVID-19 vaccine, trust in health-care providers and information sources used for making health-related decisions. The study population included 739 respondents: 42.6% HCWs and 57.4% members of the public. Participants' perceived risk toward the vaccine was relatively low in both populations. Higher perceived benefit of the vaccine, higher perceived extent of knowledge that doctors have about the risk associated with the vaccine, higher perceived freedom to choose whether to get vaccinated and higher trust in health-care providers predicted lower perceived risk toward the vaccine. Individuals who showed greater health responsibility, those who usually get vaccinated against influenza and those who had greater objective knowledge on the COVID-19 vaccine demonstrated lower perceived risk. No statistically significant difference in trust level was found between HCWs and members of the public. Both populations regarded information from medical sources as their greatest influence on health-related decisions. The study points to the factors influencing the perceived risk toward the COVID-19 vaccine and emphasizes the unique status of HCWs having their own views and concerns about the vaccine as individual members. Policymakers should consider these factors when planning national vaccination campaigns.

[THE FUTURE OF HOSPITALS IN ISRAEL - PLANNING CONSIDERATIONS AND THE STANDPOINTS OF MANAGERS]

INTRODUCTION

Planning the future national hospitalization system requires consideration of demographic trends, innovative treatments and policy approaches. The existing situation alone does not allow proper planning in extremely dynamic systems that operate within the framework of scarce resources.

OBJECTIVES

To identify managers' attitudes regarding hospital planning, deployment and managerial mechanisms in comparison with evidence in the literature.

METHODS

A survey among hospital managers following a focused conference.

RESULTS

Of the 50 respondents, half of the group thought that a general hospital should include 900-2000 beds. The majority prefer an autonomous management style, or a cluster of only a few hospitals. In a scenario of overload and shortage of beds, the majority prefer adding beds to the existing hospital, while about a quarter of the respondents suggest establishing another hospital in the area, or merging nearby hospitals. About half supported home care, or transferring patients to a nearby hospital, including in the private sector, or the transfer of appropriate patients to chronic care institutions. About a third of the respondents supported telemedicine. In terms of national deployment, the preference was that the hospital should be located in high population areas and able to provide sufficient geographical accessibility. Yet, 60% of participants emphasized the importance of social determinants to low socio-economic populations.

CONCLUSIONS

The survey revealed original standpoints and ideas towards willingness to promote targeted solutions. Healthcare leaders should consider and adapt local ideas to achieve effective planning following the insights of those working in the field.

DISCUSSION

Targeted conferences aimed at discussing health policy are an effective platform for presenting complex issues and for sharing ideas with colleagues for the benefit of meaningful long-term processes.

Shortening shift’s length—Should we ask the residents if this is what they want?

Introduction

Work overload in hospitals enforced reducing shifts length of physicians in many countries over the last decade. In Israel, the current shift standard is of 26 hours, however, there is a residents’ struggle alongside a governmental intent to short the shifts to 16 hour. We aim to evaluate residents and interns support and preferences regarding shortening shifts and their ramifications to quality of life and residency programs.

Methods

A structured questionnaire was distributed to all resident and interns in a single center. We evaluated their current quality of residency and life, their support in the shorter shifts model, offering alternative program components such as reduced pay, longer residency or replacement in order to allow rest. We compared those who support the new model to those who objected to identify common characteristics to draw a resident profile for acceptance of change.

Results

Overall, 151 physicians answer the questionnaire. 70.2% support the shorter shifts model. Residents above 35 years old and those reaching completion of residency, significantly less support the shortening shifts model. No other demographic nor professional parameters were different between the supporters and non-supporters. Option of reduced pay or longer residency dramatically reduced the support rate to less than 30% and 20%, respectively. Replacement by other physician (resident or senior physician) in order to allow rest was supported by only 40%.

Conclusion

Residents’ standpoints regarding a desirable change are crucial to plan a successful implementation. A national survey is required before a new model is introduced, to achieve an optimal transparent efficient process.

Patient preferences and choices as a reflection of trust-A cluster analysis comparing postsurgical perceptions in a private and a public hospital

Background

Active participation of patients in managing their medical treatment is a major component of the patient empowerment process and may contribute to better clinical outcomes. Patient perceptions and preferences affect the patient–physician encounter in a variety of dimensions, such as patient autonomy, freedom of choice and trust in the healthcare system. The Israeli healthcare system is mostly publicly funded, with additional private healthcare services for surgery and other medical treatments. The aim of this study was to compare the perceptions and preferences of patients in the public and private hospitals in Israel.

Methods

A cross‐sectional study among 545 individuals who had surgical procedures at two hospitals in Israel (one public and one private). A structured questionnaire comprising 23 items was used to collect perceptions via personal telephone interviews. The responses were categorized into five clusters and compared by type of health services provider (public vs. private) and sociodemographic characteristics (gender, age and education level).

Results

A hierarchical cluster analysis methodology identified five conceptual groups: trust, concern towards medical errors, dialogue between medical staff and the patient/patient's family, confidentiality and staff bias towards more informed patients, or those with supportive families. Four main themes that highlight patients' preferences were found: physical conditions, personal empowerment and perceived autonomy, patient experience and patient–provider encounter communication. Significant differences between the private and the public healthcare systems were found in four clusters: trust and patient care, patient's concerns, the extent of explanation and medical staff's commitment. Differences secondary to sociodemographic parameters were noticed: patients treated at the private hospital scored significantly higher items of trust, medical staff caring and the importance of choosing their treating surgeon, while patients treated at the public hospital scored higher staff commitment to the patient than those treated at the private hospital.

Conclusions

The study revealed the perceptions underlying the decisions of patients to undergo surgical procedures in public or private hospitals. Mutual learning could pave the way to better patient–physician encounters.

Patient or Public Contribution

Patients from the two hospitals were involved in this study by responding to the questionnaire. The data presented is based on the patient's responses.

[EDUCATING MEDICAL STUDENTS TO PROFESSIONALISM AND SAFETY IN HEALTHCARE AND THE IMPACT OF THE COVID-19 EPIDEMIC - AN ISRAELI PERSPECTIVE]

INTRODUCTION

Medical students' education traditionally focuses on professionalism (knowledge and skills) alongside compassion. Recently, the importance of quality of care, safety and error prevention has increased. Teaching students through adopting the terminology, tools and insights of quality and safety will not only promote safety, but may also increase treatment effectiveness, patient satisfaction and staff commitment. The Covid-19 epidemic, enforcing social distancing and strict protective actions, have all deepened the challenges in safety-targeted education, incurring implementation difficulties: 1) restricting bedside teaching; 2) reducing simulations and clerkship peer discussions;, 3) distorting the equilibrium of risk management/safety insight and clinical perception significance (anamnesis, physical examination).

AIMS

This study aimed to examine standpoints towards safety education in medical studies among students and teacher.

METHODS

A survey was conducted among students in pre-clinical courses, department directors/tutors and focus-group discussions among managers.

RESULTS

Medical students ranked safety-targeted education as highly important alongside academic knowledge, clinical skills and compassion. Department head managers and teaching physicians rated compassion and safety as highly important, more than research curiosity, values, resilience, family involvement and clinical proficiency, and much more than technical skills and the patient's preferences. In the first epidemic wave, safety-targeted education was graded higher by the focus-group leaders, when compared to teaching physicians, and scoring was similar for resilience, compassion, proficiency and knowledge. During the second wave, the department heads emphasized the importance of safety.

CONCLUSIONS

Transparency analysis of medical students' standpoints may reveal barriers to implement safety/quality measures in their curriculum.

Parents' attitudes toward children's vaccination as a marker of trust in health systems

Children's vaccination is a major goal in health-care systems worldwide; nevertheless, disparities in vaccination coverage expose socio-demographic accessibility gaps, unawareness, physicians' disapproval and parents' incomplete adherence reflecting insufficient public-provider trust. Our goal was to analyze parents' attitude toward children's vaccination in correlation with trust among stakeholders. A total of 1031 parents replied to a "snowball" questionnaire; 72% reported high trust in their physician, 42% trusted the authorities, 11% trusted internet groups. Among minorities, parents who fully vaccinate their children were younger, live in urban areas, eat all kinds of foods and trust the authorities, similar to the general population. Low adherence to children's vaccination was correlated with trusting internet groups. Females complied significantly more to child vaccination, although in our study mothers were more highly educated and trusted authorities more than males. The results enable to draw a profile of the "vaccination compliant parent" (with an academic degree, young, urban, eats all kinds of foods, uses conservative medicine). Trust is a major factor influencing vaccination, yet external forces such as community voices, social trends and opinions of religious leaders may play a role in vaccination adherence, beyond personal beliefs, individual habits and self-care. In Israel, education and "healthy behavior" perception alongside generous coverage encourage most parents to comply with the routine vaccination program. In the shade of pandemic outbreaks, we suggest a social-determinant transparent approach to encourage parents to vaccinate their children. Social and religious leaders can pose as agents of change, especially in the case of less educated parents.

Analyzing patient trust through the lens of hospitals managers-The other side of the coin

Trust is an essential element in patient-physician relationships, yet trust is perceived differently among providers and customers exist. During January-February 2020 we examined the standpoints of medical managers and administrative directors from the private and public health hospitals on patient-physician trust, using a structured questionnaire. Thirty-six managers in public and private hospitals (24 from the public sector and 12 from the private sector) responded to the survey. Managers in the private sector rated trust higher in comparison to managers in the public sector, including trust related to patient satisfaction, professionalism and accountability. Managers from public hospitals gave higher scores to the need for patient education and shared responsibility prior to medical procedures. Administrative directors gave higher scores to various dimensions of trust and autonomy while medical managers gave higher scores to economic considerations. Trust is a fundamental component of the healthcare system and may be used to improve the provision and quality of care by analyzing standpoints and comparable continuous monitoring. Differences in position, education and training influence the perception of trust among managers in the health system. This survey may allow policy makers and opinion leaders to continue building and maintaining trust between patients and care providers.

Developing a new flexible tool for handover

Background

Transferring medical information among professionals and between shifts is a crucial process, allowing continuity of care and safety, especially for complex patients in life-threatening situations. This process, handover, requires focusing on specific, essential medical information while filtering out redundant and unnecessary details.

Objectives

To create and implement a tool for handover that would be flexible enough to meet the unique needs of specific departments.

Methods

We used Plan–Do–Study–Act (PDSA) methodology to prospectively develop, implement, evaluate and reassess a new handover tool in a 900-bed teaching hospital in central Israel. Nurses from 35 departments participated in developing a tool that presents the staff’s viewpoint regarding the most critical information needed for handover.

Results

A total of 78 nurse managers and 15 doctors (63.7%) completed the questionnaire. Based on exploratory factor analysis, 15 items explained 58.9% of the variance. Four key areas for handover were identified, in addition to basic patient identification: (i) updated clinical status, (ii) medical information, (iii) special clinical treatment and (iv) treatments not yet initiated. Subsequently, a Flexible Handover Structured Tool (FAST) was designed that identifies patients’ needs and is flexible for the specific needs of departments. Revisions based on hands-on experience led to high nurse satisfaction with the new tool in most departments. The FAST format was adopted easily during the COVID-19 pandemic.

Conclusion

Implementing a new handover tool—FAST—was challenging, but rewarding. Using PDSA methodology enabled continuous monitoring, oversight and adaptive corrections for better implementation of this new handover reporting tool.

Robotic vs. open surgery in obese women with low-grade endometrial cancer: comparison of costs and quality of life measures

Background

This retrospective study compared perioperative measures, costs, quality of life and survival after open vs. robotic surgery, among obese women diagnosed with low-grade endometrial cancer.

Methods

Obese women (body mass index (BMI) ≥ 30) who underwent open or robotic surgery for endometrial cancer, in one of two tertiary medical centers in the center of Israel, 2013–2016, postoperative grade 1–2, were included. Costs per patient, including 30-days post-surgery were calculated. Quality of life was evaluated by Physical and Mental Components of the SF-36 and a recovery from surgery questionnaire. Overall survival outcomes were obtained from patients’ files. Surgical outcomes, including operating and anesthesia times, length of hospital stay, and intraoperative and postoperative complications according to the Clavien-Dindo classification scale were reviewed.

Results

In all, 138 women with BMI ≥30 underwent open (n = 61) or robotic surgery (n = 77) during the study period. The groups had similar BMI, comorbidities, demographics and tumor characteristics. Robotic surgery was associated with shorter hospital stays (mean 1.7 vs. 4.8 days; P < .0001) and fewer postoperative complications (Clavien-Dindo > 2, 5.2% vs. 19.7%; P = .0008), but longer operating theater time (3.8 vs. 2.8 h; P < .001). Costs are equivalent when at least 350 robotic surgeries are performed annually, not including the initial system costs. Quality of life measures were better after robotic surgery. SF-36 showed better measures for robotic surgery (Physical 56 vs. 39 and Mental 73 vs. 56; P < .01). After robotic surgery, patients tended to recover quicker when compared to open surgery, as they returned to normal activities earlier, with less need for family and governmental assistance (mean recovery time, 23 vs. 70 days; P < 0.006 and mean change in preoperative total functioning score, − 1.5 vs. -3.9: P < 0.05, respectively). Overall, 5-year survival was 89.8% for the open surgery group vs. 94% for the robotic surgery group (log rank, P = 0.330).

Conclusions

Obese women with low-grade endometrial cancer had better quality of life after robotic vs. open surgery. They also had shorter hospital stays and fewer postoperative complications. Centers with high volumes of robotic surgery can achieve similar costs when comparing both methods. These results were achieved without jeopardizing survival. Our results further emphasize the need for the Israeli healthcare system to include specific reimbursement for robotic procedures in the population we studied.

Gender medicine: Lessons from COVID-19 and other medical conditions for designing health policy

Gender-specific differences in the prevalence, incidence, comorbidities, prognosis, severity, risk factors, drug-related aspects and outcomes of various medical conditions are well documented. We present a literature review on the extent to which research in this field has developed over the years, and reveal gaps in gender-sensitive awareness between the clinical portrayal and the translation into gender-specific treatment regimens, guidelines and into gender-oriented preventive strategies and health policies. Subsequently, through the lens of gender, we describe these domains in detail for four selected medical conditions: Asthma, obesity and overweight, chronic kidney disease and coronavirus disease 2019. As some of the key gender differences become more apparent during adolescence, we focus on this developmental stage. Finally, we propose a model which is based on three influential issues: (1) Investigating gender-specific medical profiles of related health conditions, rather than a single disease; (2) The dynamics of gender disparities across developmental stages; and (3) An integrative approach which takes into account additional risk factors (ethnicity, socio-demographic variables, minorities, lifestyle habits etc.). Increasing the awareness of gender-specific medicine in daily practice and in tailored guidelines, already among adolescents, may reduce inequities, facilitate the prediction of future trends and properly address the characteristics and needs of certain subpopulations within each gender.

Retroperitoneal lymph node recurrence of epithelial ovarian cancer: Prognostic factors and treatment outcome

OBJECTIVE

To evaluate the treatment outcome and survival of patients with epithelial ovarian cancer recurrence isolated to the retroperitoneal lymph nodes compared to intraperitoneal spread.

METHODS

A retrospective cohort study including women with recurrence of epithelial ovarian, cancer, who were treated at a single medical center, between 2000 and 2015. Patients were classified into three groups according to the site of recurrence: intraperitoneal only, retroperitoneal lymph nodes only, and both. Response to treatment was assessed by the RECIST criteria.

RESULTS

Out of 135 patients in our cohort, 66 were diagnosed with intraperitoneal recurrence, 30 with retroperitoneal lymph node recurrence and 39 with combined site recurrence. The clinical, pathological and surgical characteristics were similar among all groups, besides CA-125 which was significantly lower in the retroperitoneal recurrence group at diagnosis, end of treatment and recurrence. The median follow-up period was 45.8 months. Overall survival (OS) and post relapse survival (PRS) were significantly higher in the retroperitoneal recurrence group vs. the intraperitoneal and combined site recurrence groups. (OS - 93.07, 47.9 and 41.7 months, respectively, p < .001, PRS - 68.57, 29.67 and 19.7 months, respectively, p < .001). On cox's regression analysis, retroperitoneal recurrence was found to be an independent prognostic factor for survival.

CONCLUSIONS

The site of recurrence has significant prognostic value regarding PRS and OS. Patients with recurrence limited to the retroperitoneal lymph nodes have a favourable prognosis with median survival longer than 5 years.

Hospital staff perspectives towards health technology assessment: data from a multidisciplinary survey

BACKGROUND

Technology adoption in hospitals is usually based on cost-effectiveness analysis, feasibility and potential success. Different countries have embraced a range of principles to accomplish an effective comprehensive process of health technology assessment (HTA). The aim of the study was to analyse the viewpoints and relative weight of technology-oriented hospital staff members toward the clinical, social, technological and economic aspects of HTA.

METHODS

Using a structured questionnaire, a survey was conducted among different professionals in an 850-bed hospital.

RESULTS

We revealed a range of viewpoints among hospital staff members according to their personal characteristics and professional standpoints. The clinical aspects of HTA were considered 'highly important' (HI) by most participants, especially the 'lifesaving' parameter. Similarly, the 'lack of effective alternative technology' was ranked HI by a high percentage of participants, independent of their profession. Economic aspects were ranked HI only by half of the participants, while social and technological aspects were ranked HI only by a relatively low percentage. Nurses added 'improving quality of life', 'increasing teamwork efficiency' and 'improving medical standards'. Allied health professionals focused on 'lack of effective alternative technologies' as a main argument for adoption of HTA, alongside increasing efficiency, budget savings and contribution to hospital reputation. Engineers emphasised the requirement of significant investment in infrastructure and increasing efficiency. Administrators ranked patient experience as HI. Interestingly, the high ranking of social aspects correlated with older responders, while junior staff ranked safety significantly higher.

CONCLUSIONS

A multi-perspective multidisciplinary approach would be beneficial for policy-makers at hospitals and even on a national scale in Israel.

Truth-telling and doctor-assisted death as perceived by Israeli physicians

Background

Medicine has undergone substantial changes in the way medical dilemmas are being dealt with. Here we explore the attitude of Israeli physicians to two debatable dilemmas: disclosing the full truth to patients about a poor medical prognosis, and assisting terminally ill patients in ending their lives.

Methods

Attitudes towards medico-ethical dilemmas were examined through a nationwide online survey conducted among members of the Israeli Medical Association, yielding 2926 responses.

Results

Close to 60% of the respondents supported doctor-assisted death, while one third rejected it. Half of the respondents opposed disclosure of the full truth about a poor medical prognosis, and the others supported it. Support for truth-telling was higher among younger physicians, and support for doctor-assisted death was higher among females and among physicians practicing in hospitals. One quarter of respondents supported both truth-telling and assisted death, thereby exhibiting respect for patients’ autonomy. This approach characterizes younger doctors and is less frequent among general practitioners. Another quarter of the respondents rejected truth-telling, yet supported assisted death, thereby manifesting compassionate pragmatism. This was associated with medical education, being more frequent among doctors educated in Israel, than those educated abroad. All this suggests that both personal attributes and professional experience affect attitudes of physicians to ethical questions.

Conclusions

Examination of attitudes to two debatable medical dilemmas allowed portrayal of the multi-faceted medico-ethical scene in Israel. Moreover, this study, demonstrates that one can probe the ethical atmosphere of a given medical community, at various time points by using a few carefully selected questions.

Electronic supplementary material

The online version of this article (10.1186/s12910-019-0350-5) contains supplementary material, which is available to authorized users.

Chairing the internal medicine department- analysis of current state and future trends in Israel

Background

Professional skills and academic records of the highest degree are essential requirements for the chairmanship of internal medicine departments. Whether the new generation and future successors of Israeli chairmen is endowed with these attributes is not known.

Purpose

To determine whether there is a lack of future suitable successors for the current heads of internal medicine departments in Israel and to compare the demographic, academic and professional characteristics of the older and newer generations of department heads.

Methods

An online anonymous questionnaire was nationally distributed during 2016 to all active heads of internal medicine departments in Israel (n = 101). First round was followed by two runs of personal phone calls to promote participation.

Results

Sixty-seven (67%) of chairmen responded. The vast majority of current chairs of internal medicine departments are males (N = 59, 88%) over 50 years of age (N = 58, 86%) with established academic background with lecturer degree or higher (N = 57, 85%).

Only 19 (28%) of current heads assigned a future successor. Comparison of chairmen who did and did not assigned successors demonstrated that assignment of successors was associated with higher academic status (P < 0.02) and longer chairmanship (p < 0.01) but not with mean age of current chairmen (p < 0.08). Nevertheless, most assignments (55%) were done by chairmen in the 61 to 67 years age group. As compared to current chairmen, the designated successors have lesser academic status (p < 0.01) and are characterized by a higher female prevalence (P < 0.03).

Conclusions

Significant demographic, professional and academic differences exist between the current chairs of internal medicine departments in Israeli hospitals and their future successors. This underscores the need for reassessment of the availability and requirements of this crucial position.

Adverse Drug Event Rate in Israeli Hospitals: Validation of an International Trigger Tool and an International Comparison Study

BACKGROUND

Adverse drug events (ADEs) are a major cause of morbidity and mortality worldwide. Hence, identifying and monitoring ADEs is of utmost importance. The Trigger Tool introduced by the Institute of Healthcare Improvement in the United States has been used in various countries worldwide, but has yet to be validated in Israel.

OBJECTIVES

To validate the international Trigger Tool in Israel and to compare the results with those generated in various countries.

METHODS

A retrospective descriptive correlative analysis surveying four general hospitals in Israel from different geographical regions was conducted. Patient medical charts (n=960) were screened for 17 established triggers and confirmed for the presence of an ADE. Trigger incidence was compared to the actual ADE rate. Further comparison among countries was conducted using published literature describing Trigger Tool validation in various countries.

RESULTS

A total of 421 triggers in 279 hospitalizations were identified, of which 75 ADEs in 72 hospitalizations (7.5%) were confirmed. In addition, two ADEs were identified by chart review only. Mean positive predictive value was 17.81% and overall sensitivity was 97%. We found 1.54 ADEs for every 100 hospitalization days, 7.8 ADEs per 100 admissions, and 1.81 ADEs for every 1000 doses of medication. Of the 77 ADEs identified, 22.7% were defined as preventable.

CONCLUSIONS

Our results support the Trigger Tool validity in Israel as a standardized method. Further studies should evaluate between hospital and region differences in ADE rate, in particular for the preventable events.

[HOSPITAL ACCREDITATION - TIME FOR RETHINKING?]

Accreditation provides an incentive to promote processes improving quality and enhancing patient safety, both in hospital and community settings. For the past three decades, many western, as well as developing countries, have adopted this methodology. Israel too has taken this pathway to adopt accreditation in general, geriatric and psychiatric hospitals as part of a national mission. Beyond the benefits to the patient, accreditation has numerous advantages: raising the professional accountability of healthcare providers, defining targets for improvement based on the strategies of the Ministry of Health and specifying standardization of care and regulations. Accreditation guides care-givers to develop insights on the quality and perception of innovation and facilitates trust, workers' coherence and teamwork. Alongside these benefits, thoughts about the future of the process arise: A variety of accreditation programs exists around the world, while several governments implement other incentives for healthcare system improvement- such as quality indices. Moreover, professionals resist this methodology, which may be considered to be over-complex to maintain. Since we have already assimilated concepts, perspectives, knowledge and experience in this challenging process, the outlook for preserving a nationwide hospital-based accreditation in the current format should be re-examined, in order to establish a long-lasting quality mechanism.

The bone marrow is patrolled by NK cells that are primed and expand in response to systemic viral activation

The bone marrow hosts NK cells whose distribution, motility and response to systemic immune challenge are poorly understood. At steady state, two-photon microscopy of the bone marrow in Ncr1^gfp/+ mice captured motile NK cells interacting with dendritic cells. NK cells expressed markers and effector molecules of mature cells. Following poly (I:C) injection, RNA-Seq of NK cells revealed three phases of transcription featuring immune response genes followed by posttranscriptional processes and proliferation. Functionally, poly (I:C) promoted upregulation of granzyme B, enhanced cytotoxicity in vitro and in vivo, and, in the same individual cells, triggered proliferation. Two-photon imaging revealed that the proportion of sinusoidal NK cells decreased, while at the same time parenchymal NK cells accelerated, swelled and divided within the bone marrow. MVA viremia induced similar responses. Our findings demonstrate that the bone marrow is patrolled by mature NK cells that rapidly proliferate in response to systemic viral challenge while maintaining their effector functions.

[A PUBLIC HOSPITAL IN THE ERA OF 'INNOVATION-DRIVEN MEDICINE' - HUMAN EXCELLENCE AND EVOLVING TECHNOLOGY]

Assaf Harofeh Medical Center is the fourth largest governmental hospital in Israel, with 900 beds, approximately 165,000 annual ER visits, and 23,000 operations. The Medical Center encourages human excellence and medical innovation, together with "patient centered" perspectives, providing optimal holistic service, alongside caring for the staff. The management concept of "participatory leadership" leads to multi-sectorial integration, conducting combined physician-nurse quality projects in all departments. As part of leading the field of quality and accreditation and the desire to share knowledge and experience, the School for Quality and Accreditation was established to train medical teams from the hospital and other medical centers. This issue presents articles that illuminate some of the work on our flourishing campus. The hospital serves a diverse population both demographically, and socio-economically. We feel responsibility for this population beyond the provision of medical care. The many centers of excellence in prominent clinical fields and the platform for providing continuous education for the medical staff to carry out basic and clinical research, are at the forefront for the future. Following demographic expansion of the population around the hospital, the task of providing optimal and equitable medical services is challenging. Over the next decade, the hospital is expected to be united with psychiatric and geriatric hospitals to create an integrated medical center.

[A MODEL TO SOLVE BARRIERS IN TREATING COMPLEX MEDICAL PATIENTS - 'DIABETIC FOOT' AS A CASE STUDY]

AIMS

To identify barriers for diabetic foot detection within the medical team, to plan and conduct interventions to solve these barriers and to follow-up their outcomes, resulting in creating a model to cope with barriers in the treatment of complicated patients.

BACKGROUND

Diabetes mellitus is a rising epidemic worldwide, with a significant medical and economic impact (about 20% of the annual health expenditure). A major complication of diabetes is 'diabetic foot', including neuropathy and peripheral vascular disease, resulting in leg ulcers and amputation. Morbidity and mortality in amputated patients are significantly higher, while in 85% of the patients, a preventable leg ulcer could be detected prior to amputation. Screening and patient education may reduce leg ulcers and amputation by 45%.

METHODS

Identify barriers and solutions, ranking their relative weight and correlation matrix, by a focus group.

RESULTS

Identifying the relative weight of the barriers, revealed that professional barriers were dominant, followed by policy, administrative and educational barriers.

CONCLUSIONS

Identifying barriers and their solutions in the measuring process of quality medical indices, may improve the scope and quality of the measurement, as well as affect health outcomes. A model for detecting barriers increased the involvement of staff to improve processes and promote interdisciplinary communication. It is recommended to intensify the engagement in resolving barriers as part of the quality improvement processes.

DISCUSSION

Identifying barriers is a crucial step for their removal. Adjusting optimized solutions, setting a clear policy, guidance and the cooperation of a multidisciplinary team, defining "diabetic foot assessment tool" as a required "quality index", and conducting periodic controls of the implementation of this standard, enhance the translation of policy to feasible activity measures.

['FLEXIBLE WALLS' IN HOSPITALS - ASSESSING THE 'VALUE' OF SOCIAL IMPACT ON ARCHITECTURE]

BACKGROUND

: The development of hospital architecture is influenced by social trends, with mutual influence. Architecture enables 'organic-design' that leads to development, growth and adaptation of the structure to changing functions. A literature review reveals different perceptions of the flexibility of adapting hospital structure to changing needs, focusing on external forces pressures (expensive technologies, budgetary constraints limiting innovation implementation and regulatory barriers), as well as patients' demands. The degree of contribution of structural changes to the measured or perceived benefit to the patient and staff, has not yet been fully assessed. Expressions of this benefit are infection-control and increasing operational efficiency by energy saving and sustainability.

OBJECTIVES

To examine workers' perceptions towards value-based-architecture in relation to the patient or staff in a hospital setting.

METHODS

A survey was conducted among health care workers who underwent management training, using a structured questionnaire.

RESULTS

Sixty responders ranked hospital leadership and relevant professionals (engineers and architects) as key players in the decision to change architecture in a hospital; economists, doctors and nurses were ranked as less important, while patients and families were ranked the lowest. Among the factors that contribute to the 'value' of the decision were the agility to adapt to emergency, and to changing morbidity trends in an efficient way. Factors ranked as being of medium importance were the contribution to hospital profitability and, to a lesser extent, the contribution to branding and improved service.

CONCLUSIONS

'Flexible walls' (shifting rooms between departments according to clinical need) can provide a response to morbidity changes.

DISCUSSION

Hospital workers can play a role in the process of value-based architecture, thereby improving decisions concerning hospital construction and increasing their commitment to additional quality processes.

[THE IMPACT OF ACCREDITATION - ACHIEVEMENTS, BENEFITS AND BARRIERS: COMPARING THE VIEWPOINTS OF THE PROCESS LEADERS AND THE HOSPITAL STAFF]

AIMS

Evaluating the impact of the accreditation process on the basis of achievements, benefits and barriers from the viewpoint of leaders of the hospital accreditation in comparison to the hospital staff members.

BACKGROUND

The implementation of standards for accreditation aim to improve the safety and quality of treatment. Partaking in this process has raised dilemmas regarding the actual benefits of accreditation in relation to the efforts invested in its achievement. Examining the standpoints of leaders of the process can reflect on the influence of this mechanism both on hospital activity and on hospital staff.

METHODS

A survey was conducted among two groups: The first group, the JCI accreditation leaders group, included 35 participants (the steering committee, 15 chapter heads and the hospital management); and 71 participants from the extended headquarters (senior physicians, nurses and administration staff). The second group included 564 hospital personnel from the medical, nursing, alternative medicine, administrators and housekeeping staff. The questionnaire included 46 statements in five fields: the effectiveness and benefit from the process, weaknesses, barriers, leadership and administration of the accreditation.

RESULTS

All the respondents to the survey perceived the process as a leverage for implementing significant changes in all levels of the organization. There were high levels of agreement on the benefit of the process regarding the effective and affective contribution - high morale, feelings of accomplishment and team pride, improvement in communication, cooperation and social cohesion. The weaknesses of the process, including financial costs, bureaucracy, paper overflow and work overload, were awarded relatively low scores. The advantages of the process were ranked high in both groups; the accreditation leaders group attributed the process benefits to the organization as a whole, ranking it significantly higher, as well as for the individual. The hospital staff rated as significantly higher: the contribution of the process on the department level and the opportunity to promote accomplishments that were not reached in the past.

CONCLUSIONS

The survey raised organizational discussion which minimized the objections to the process of change. Focusing on chosen aspects bridged between managers and on-site staff to find effective solutions.

DISCUSSION

In order to promote successful inter-organizational processes the hospital requires both leadership and a well-formulated strategic program. The secondary gains from the broad process encompassing the whole organization, such as in the case of accreditation, are expressed in the form of social cohesion, cooperation, group pride and high staff morale.

The proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation

Objective

To evaluate the rate of medication related errors in the pediatric ward and pediatric emergency department (PED), before and after implementing intervention strategies according to the Joint Commission International (JCI) accreditation program.

Design

A retrospective cross-sectional study that included chart review.

Setting

A university affiliated pediatric ward and PED.

Participants

Children 0-18 years old admitted on February 2013 (before the JCI program) and February 2014 (during implementation of the JCI program).

Intervention(s)

A training program designed to meet the JCI official standards on medication prescribing.

Main outcome measure(s)

The number of prescribing and medication administration errors in the 2 years.

Results

We collected 937 valid prescription orders and 924 administration orders (1861 medical orders) from February 2013, and 961 valid prescription orders and 958 administration orders (1919 medical orders) from February 2014. There was a significant reduction in prescribing errors from 6.5 to 4.2% between years 2013 and 2014 (P = 0.03). There was no significant difference in administration error rates between the two periods (104 (11.3%) in the first period and 114 (11.9%) in the second; P = 0.61).

Conclusions

The errors rate we found was within the range described in the literature. Quality assurance interventions can significantly reduce medication prescribing errors.

Active dissemination of cellular antigens by DCs facilitates CD8+ T-cell priming in lymph nodes

Antigen (Ag) specific activation of naïve T cells by migrating dendritic cells (DCs) is a highly efficient process, although the chances for their colocalization in lymph nodes (LNs) appear low. Ag presentation may be delegated from Ag-donor DCs to the abundant resident DCs, but the routes of Ag transfer and how it facilitates T-cell activation remain unclear. We visualized CD8⁺ T cell-DC interactions to study the sites, routes, and cells mediating Ag transfer in mice. In vitro, Ag transfer from isolated ovalbumin (OVA)⁺ bone marrow (BM) DCs triggered widespread arrest, Ca²⁺ flux, and CD69 upregulation in OT-I T cells contacting recipient DCs. Intravital two-photon imaging revealed that survival of Ag-donor DCs in LNs was required for Ag dissemination among resident CD11c⁺ DCs. Upon interaction with recipient DCs, CD8⁺ T cells clustered, upregulated CD69, proliferated and differentiated into effectors. Few DCs sufficed for activation, and for efficient Ag dissemination lymphocyte function associated antigen 1 (LFA-1) expression on recipient DCs was essential. Similar findings characterized DCs infected with a replication-deficient OVA-expressing Vaccinia virus known to downregulate MHC-I. Overall, active Ag dissemination from live incoming DCs helped activate CD8⁺ T cells by increasing the number of effective presenting cells and salvaged T-cell priming when Ag-donor DCs could not present Ag.

From Population Databases to Research and Informed Health Decisions and Policy

Background

In the era of big data, the medical community is inspired to maximize the utilization and processing of the rapidly expanding medical datasets for clinical-related and policy-driven research. This requires a medical database that can be aggregated, interpreted, and integrated at both the individual and population levels. Policymakers seek data as a lever for wise, evidence-based decision-making and information-driven policy. Yet, bridging the gap between data collection, research, and policymaking, is a major challenge.

The model

To bridge this gap, we propose a four-step model: (A) creating a conjoined task force of all relevant parties to declare a national program to promote collaborations; (B) promoting a national digital records project, or at least a network of synchronized and integrated databases, in an accessible transparent manner; (C) creating an interoperative national research environment to enable the analysis of the organized and integrated data and to generate evidence; and (D) utilizing the evidence to improve decision-making, to support a wisely chosen national policy. For the latter purpose, we also developed a novel multidimensional set of criteria to illuminate insights and estimate the risk for future morbidity based on current medical conditions.

Conclusion

Used by policymakers, providers of health plans, caregivers, and health organizations, we presume this model will assist transforming evidence generation to support the design of health policy and programs, as well as improved decision-making about health and health care, at all levels: individual, communal, organizational, and national.

Cardiac anomalies and associated comorbidities in a large adolescent population

OBJECTIVE

To determine the prevalence, secular trends and associations of heart disease in a large unscreened, otherwise basically healthy, adolescent population.

SUBJECTS AND METHODS

Cross-sectional study of the cardiac status of 113,694 adolescents from the northern district of Israel, who completed the profiling process between the ages of 16 and 19, including all essential measures over a 22-year period. Results of imaging were categorized as either isolated valvar or structural abnormalities, and their clinically significant subgroups defined prospectively. The findings were correlated with the socio-demographic and anthropometric data and non-cardiac health conditions.

RESULTS

Of those sent for echocardiography, 1257 (0.93% of the total population) had isolated valvar disease and 216 (0.19%) had structural abnormalities, with 20% of both groups considered significant. Females had lower prevalence of heart disease. There was peak prevalence in the second 5-year period. Tall subjects or a past history of rheumatic fever had more valvar abnormalities. Thin subjects or those with skeletal anomalies had more structural abnormalities. Significant valvar and structural anomalies were more common in subjects with learning disorders, endocrine disorders and diabetes mellitus. Fewer valvar abnormalities were diagnosed in obese subjects. Heart disease was more common in those with non-solid tumors.

CONCLUSION

Appreciable numbers of potentially healthy adolescents were found to have heart disease. There appeared to be an association with body size, skeletal abnormalities and relatively common medical disorders, the cause of which remains to be determined in prospective studies that could change the way common adolescent disease should be followed.

Determining the Optimal Inhibitory Frequency for Cancerous Cells Using Tumor Treating Fields (TTFields)

Tumor Treating Fields (TTFields) are an effective treatment modality delivered via the continuous, noninvasive application of low-intensity (1-3 V/cm), alternating electric fields in the frequency range of several hundred kHz. The study of TTFields in tissue culture is carried out using the TTFields in vitro application system, which allows for the application of electric fields of varying frequencies and intensities to ceramic Petri dishes with a high dielectric constant (Ɛ > 5,000). Cancerous cell lines plated on coverslips at the bottom of the ceramic Petri dishes are subjected to TTFields delivered in two orthogonal directions at various frequencies to facilitate treatment outcome tests, such as cell counts and clonogenic assays. The results presented in this report demonstrate that the optimal frequency of the TTFields with respect to both cell counts and clonogenic assays is 200 kHz for both ovarian and glioma cells.

Supplementary Health Insurance from the consumer point of view: Are Israelis consumers doing an informed rational choice when purchasing Supplementary Health Insurance?

BACKGROUND

The National Health Insurance Law in Israel ensures basic health basket eligibility for all its citizens. A supplemental health insurance plan (SHIP) is offered for an additional fee. Over the years, the percentage of supplemental insurance's holders has risen considerably, ranking among the highest in OECD countries. The assumption that consumers implement an informed rational choice based on relevant information is doubtful. Are consumers sufficiently well informed to make market processes work well?

OBJECTIVES

To examine perspectives, preferences and knowledge of Israelis in relation to SHIP.

METHODOLOGY

A telephone survey was conducted with a representative sample of the Israeli adult population. 703 interviews were completed. The response rate was 50.3%.

FINDINGS

85% of the sample reported possessing SHIP. This survey found that most of the Israeli public parched additional insurance coverage however did not show a significant knowledge about the benefits provided by the supplementary insurance, at least in the three measurements used in this study.

CONCLUSIONS, POLICY IMPLICATIONS AND RECOMMENDATIONS

The scope of SHIP acquisition is very broad and cannot be explained in economic terms alone. Acquiring SHIP became a default option rather than an active decision. It is time to review the goals, achievements and side effects of SHIP and to create new policy for the future.

[THE SECOND VICTIM: TREATING THE HEALTH CARE PROVIDERS]

During their professional careers, physicians and other health care providers are repeatedly exposed to emotional stress. This is usually secondary to coping with the results of a medical error or complicated medical event. Generally, in the above cases, the patient and his/her family are in the center of the medical system, being "the first victim" of such an event, while the involved caregiver, who provided the medical service, is categorized as the "second victim". "Second victims" may feel anxiety, fear, guilt or anger and experience social withdrawal, which may lead to troubling memories, depression and insomnia. Over the years, this situation may lead to deterioration in his/her work and personal life and, in rare circumstances, may lead to pharmaceutical and even alcohol consumption. In the literature there are even some rare case reports of "second victims" who have committed suicide. To meet these challenges, several leading institutions in western countries have developed formal support programmes that allow health care providers to cope with their emotional distress by obtaining timely support in an emphatic, confidential, non-judgmental environment. The above scheme of support is not meant to disrupt any correct medical investigation or to stand between the "second victim" and his superiors, but rather to allow them to cope with these events. We believe that the time has come to develop national support programs appropriate to our culture and behavioural circumstances. Local health care organizations should build a supporting scheme for the "second victims", helping them to cope with these events, thereby assisting them to return to their daily work and former routine.

Using the social structure of markets as a framework for analyzing vaccination debates: The case of emergency polio vaccination

The framework of the social structure of markets was used to analyze an online debate revolving around an emergency poliovirus vaccination campaign in Israel. Examination of a representative sample of 200 discussions revealed the activity of three parties: authoritative agents promoting vaccinations, alternative agents promoting anti-vaccination, both representing sellers, and the impartial agents, representing the customers-the general public deliberating whether to comply with vaccination or not. Both sellers interacted with consumers using mechanisms of luring and convincing. The authoritative agents conveyed their message by exhibiting professionalism, building trust and offering to share information. The alternative agents spread doubts and evoked negative emotions of distrust and fear. Among themselves, the alternative agents strived to discredit the authoritative agents, while the latter preferred to ignore the former. Content analysis of discussions conducted by the general public reveal reiteration of the messages conveyed by the sellers, implying that the transaction of pro and anti-vaccination ideas indeed took place. We suggest that the framework of the market as a social structure can be applied to the analysis of other vaccination debates, and thereby provide additional insights into vaccination polemics.

Conductance saturation in a series of highly transmitting molecular junctions

Revealing the mechanisms of electronic transport through metal-molecule interfaces is of central importance for a variety of molecule-based devices. A key method for understanding these mechanisms is based on the study of conductance versus molecule length in molecular junctions. However, previous works focused on transport governed either by coherent tunnelling or hopping, both at low conductance. Here, we study the upper limit of conductance across metal-molecule-metal interfaces. Using highly conducting single-molecule junctions based on oligoacenes with increasing length, we find that the conductance saturates at an upper limit where it is independent of molecule length. With the aid of two prototype systems, in which the molecules are contacted by either Ag or Pt electrodes, we find two different possible origins for conductance saturation. The results are explained by an intuitive model, backed by ab initio calculations. Our findings shed light on the mechanisms that constrain the conductance of metal-molecule interfaces at the high-transmission limit.

Adolescent BMI at Northern Israel: From Trends, to Associated Variables and Comorbidities, and to Medical Signatures

The increasing prevalence of abnormal body mass index (BMI), mainly obesity, is becoming a significant public health problem. This cross-sectional study aimed to provide a comprehensive view of secular trends of BMI, and the associated socio-demographic variables and comorbidities among adolescents with abnormal BMI. Individuals of the study population were born mainly between 1970 and 1993, and were examined at 16 to 19 years of age during the years 1987 to 2010, at 1 conscription center in the northern district of Israel.The study population included 113,694 adolescents. Univariate and multivariable logistic regression models were used to investigate the associations between BMI categories, socio-demographic variables, and medical conditions.A downward trend in the prevalence of normal BMI among both male and female adolescents was obtained, while trends of overweight and obesity (in both genders) and underweight (only among females) rose. Socio-demographic variables such as religion, education, family-related parameters, residential environment, country of birth, and origin were all associated with different risks for abnormal BMI. Obesity was associated with higher risk for hyperlipidemia, endocrine disorders (only in males), knee disorders, and hypertension type I + II (in both genders). Overweight was associated with knee disorders (only in females). Underweight, exclusively in males, was associated with increased risk for endocrine disorders, proteinuria, and cardiac disorders. Hierarchical clustering analysis revealed the intricate relations between gender, BMI, and medical signatures. It brought to light novel clusters of diseases that were abundant among populations having above-normal BMI or underweight males. Furthermore, above-normal BMI was associated with a lower rate of cardiac anomalies and scoliosis/kyphosis, whereas being underweight was associated with a lower risk for hypertension and flat foot.This study provides a reliable and in-depth view of secular trends in height, weight, and BMI of male and female adolescents. It supports previous associations between abnormal BMI and demographic variables and comorbidities, while uncovering novel associations, mainly regarding medical signatures of each gender-BMI group. This might lead to better monitoring, early detection, prevention, and treatment of various conditions associated to abnormal BMI categories and gender groups.

Heparanase of murine effector lymphocytes and neutrophils is not required for their diapedesis into sites of inflammation

Heparanase, the exclusive mammalian heparan sulfate-degrading enzyme, has been suggested to be utilized by leukocytes to penetrate through the dense basement membranes surrounding blood venules. Despite its established role in tumor cell invasion, heparanase function in leukocyte extravasation has never been demonstrated. We found that TH1/TC1-type effector T cells are highly enriched for this enzyme, with a 3.6-fold higher heparanase mRNA expression compared with naive lymphocytes. Using adoptive transfer of wild-type and heparanase-deficient effector T cells into inflamed mice, we show that T-cell heparanase was not required for extravasation inside inflamed lymph nodes or skin. Leukocyte extravasation through acute inflamed skin vessels was also heparanase independent. Furthermore, neutrophils emigrated to the inflamed peritoneal cavity independently of heparanase expression on either the leukocytes or on the endothelial and mesothelial barriers, and overexpression of the enzyme on neutrophils did not facilitate their emigration. However, heparanase absence significantly reduced monocyte emigration into the inflamed peritoneal cavity. These results collectively suggest that neither leukocyte nor endothelial heparanase is required for T-cell and neutrophil extravasation through inflamed vascular barriers, whereas this enzyme is required for optimal monocyte recruitment to inflamed peritoneum.

Electron-vibration interaction in the presence of a switchable Kondo resonance realized in a molecular junction

The interaction of individual electrons with vibrations has been extensively studied. However, the nature of electron-vibration interaction in the presence of many-body electron correlations such as a Kondo state has not been fully investigated. Here, we present transport measurements on a Copper-phthalocyanine molecule, suspended between two silver electrodes in a break-junction setup. Our measurements reveal both zero bias and satellite conductance peaks, which are identified as Kondo resonances with a similar Kondo temperature. The relation of the satellite peaks to electron-vibration interaction is corroborated using several independent spectroscopic indications, as well as ab initio calculations. Further analysis reveals that the contribution of vibration-induced inelastic current is significant in the presence of a Kondo resonance.

[Consensus conferences in Israel--a collaborative model for national policy making]

The determination of an integrated national policy on controversial issues is a challenge for health systems worldwide. A common method to reach agreements for national policies in different countries throughout the world is group discussion that involves all stakeholders. A structured model of discussion on medical technologies started in the 1970s, mostly in North America, spreading to Europe and in the last decade also crossed borders to India, South America and Israel. Public discussion in the format of a consensus conference is a complex process that includes a thorough literature review for technology assessment, combining academic information using a technique of close consultation with experts, extensive panel discussion and dialogue with representatives of the public. At the end of the process a broad consensus is determined facilitating national-level policy implementation. The multiple factors involved, the issues addressed, the nature of the health system where the intended results will be applied, as well as political and social characteristics, produce variations among different countries. Therefore, this process requires flexibility in adjusting the classic model according to the awakening needs. The advantages of this method include encouraging the appropriate utilization of existing technologies, contemporary assessment by leading experts, aligning between all involved parties, public sharing and more. The initial model of the consensus conference was implemented in an orderly, systematic, structured process which allowed broad discussion, and many factors for thorough preparation. The disadvantages are its complexity, length and cost. In order to cope with the dynamics of the health system in israel, forcing policymakers to make decisions in real time, parts of the model were adjusted to address the issues arising in the system. Hence, a new process was developed--a derivative of the original Israeli model, with an emphasis on professional reviews, group discussion, and involvement of leading factors in the system. The participation of patients and the public in the process requires a thorough examination.