Selective Intra-Arterial Doxorubicin Eluting Microsphere Embolization for Desmoid Fibromatosis: A Combined Prospective and Retrospective Study

Simple Summary

Desmoid fibromatoses (DFs) are locally aggressive tumors composed of monoclonal fibroblasts within an abundant extracellular matrix. Systemic treatment with doxorubicin is effective, but associated with significant toxicity. We investigated arterial doxorubicin eluting embolization (DEE), an approach that delivers high doxorubicin concentrations to the tumor with limited systemic drug exposure, in 24 patients (median age, 24 years; interquartile range, 16–34). Most patients (71%) had one or more than one prior DFs treatment (surgery, systemic therapy, or both). Patients underwent a median of two (range, 1–4) DEE treatments, with a median of 49 mg (range, 8–75) doxorubicin per treatment. Efficacy outcomes were available for 23 patients. With a median follow-up of 8 months (interquartile range, 3–13), median tumor volumes decreased by 59% (interquartile range, 40–71%). Of 23 patients, 9 (39%), 12 (52%), and 2 (9%) had a partial response, stable disease, and progressive disease, respectively. The procedure was safe and well tolerated.

Abstract

Desmoid fibromatoses (DFs) are locally aggressive tumors composed of monoclonal fibroblasts within an abundant extracellular matrix. Systemic doxorubicin treatment is effective, but toxic. We investigated arterial doxorubicin eluting embolization (DEE), an approach characterized by high drug concentrations in the tumor alongside limited systemic drug exposure. The primary and secondary endpoints were radiological response using MRI and RECIST 1.1, respectively. The study included 24 patients (median age, 24; interquartile range, 16–34 years). Data were collected prospectively for 9 patients and retrospectively for 15 patients. The most frequent tumor locations were chest/abdomen wall and neck/shoulder/axilla (29% each). Of 24 patients, 7 (24%) were treatment naïve, and 17 (71%) had received one or two prior treatments. Patients underwent a median of two treatments (range, 1–4), with a median of 49 mg (range, 8–75) doxorubicin/treatment. Efficacy outcomes were available for 23 patients. With a median follow-up of 8 months (interquartile range, 3–13), median tumor volumes decreased by 59% (interquartile range, 40–71%) and T2 signal intensity decreased by 36% (interquartile range, 19–55%). Of 23 patients, 9 (39%), 12 (52%), and 2 (9%) had a partial response, stable disease, and progressive disease, respectively. DEE was safe and well tolerated, with one reported grade 3–4 adverse event (cord injury). In conclusion, DEE was safe and achieved rapid clinical/volumetric responses in DFs.

Using Machine Learning to Identify Intravenous Contrast Phases on Computed Tomography

PURPOSE

The purpose of the present work is to demonstrate the application of machine learning (ML) techniques to automatically identify the presence and physiologic phase of intravenous (IV) contrast in Computed Tomography (CT) scans of the Chest, Abdomen and Pelvis.

MATERIALS AND METHODS

Training, testing and validation data were acquired from a dataset of 82,690 chest and abdomen CT examinations performed at 17 different institutions. Free text in DICOM metadata was utilized as weak labels for semi-supervised classification training. Contrast phase identification was approached as a classification task, using a 12-layer CNN and ResNet18 with four contrast-phase output. The model was reformulated to fit a regression task aimed to predict actual seconds from time of IV contrast administration to series image acquisition. Finally, transfer learning was used to optimize the model to predict contrast presence on CT Chest.

RESULTS

By training based on labels inferred from noisy, free text DICOM information, contrast phase was predicted with 93.3% test accuracy (95% CI: 89.3%, 96.6%) . Regression analysis resulted in delineation of early vs late arterial phases and a nephrogenic phase in between the portal venous and delayed excretory phase. Transfer learning applied to Chest CT achieved an AUROC of 0.776 (95% CI: 0.721, 0.832) directly using the model trained for abdomen CT and 0.999 (95% CI: 0.998, 1.000) by fine-tuning.

CONCLUSIONS

The presence and phase of contrast on CT examinations of the Abdomen-pelvis accurately and automatically be ascertained by a machine learning algorithm. Transfer learning applied to CT Chest achieves high precision with as little as 100 labeled samples.

Using machine learning algorithms to review computed tomography scans and assess risk for cardiovascular disease: Retrospective analysis from the National Lung Screening Trial (NLST)

BACKGROUND

The National Lung Screening Trial (NLST) demonstrated that annual screening with low dose CT in high-risk population was associated with reduction in lung cancer mortality. Nonetheless, the leading cause of mortality in the study was from cardiovascular diseases.

PURPOSE

To determine whether the used machine learning automatic algorithms assessing coronary calcium score (CCS), level of liver steatosis and emphysema percentage in the lungs are good predictors of cardiovascular disease (CVD) mortality and incidence when applied on low dose CT scans.

MATERIALS AND METHODS

Three fully automated machine learning algorithms were used to assess CCS, level of liver steatosis and emphysema percentage in the lung. The algorithms were used on low-dose computed tomography scans acquired from 12,332 participants in NLST.

RESULTS

In a multivariate analysis, association between the three algorithm scores and CVD mortality have shown an OR of 1.72 (p = 0.003), 2.62 (p < 0.0001) for CCS scores of 101-400 and above 400 respectively, and an OR of 1.12 (p = 0.044) for level of liver steatosis. Similar results were shown for the incidence of CVD, OR of 1.96 (p < 0.0001), 4.94 (p < 0.0001) for CCS scores of 101-400 and above 400 respectively. Also, emphysema percentage demonstrated an OR of 0.89 (p < 0.0001). Similar results are shown for univariate analyses of the algorithms.

CONCLUSION

The three automated machine learning algorithms could help physicians to assess the incidence and risk of CVD mortality in this specific population. Application of these algorithms to existing LDCT scans can provide valuable health care information and assist in future research.

PEGylated Liposomal Methyl Prednisolone Succinate does not Induce Infusion Reactions in Patients: A Correlation Between in Vitro Immunological and in Vivo Clinical Studies

PEGylated nanomedicines are known to induce infusion reactions (IRs) that in some cases can be life-threatening. Herein, we report a case study in which a patient with rare mediastinal and intracardiac IgG4-related sclerosing disease received 8 treatments of intravenously administered PEGylated liposomal methylprednisolone-succinate (NSSL-MPS). Due to the ethical requirements to reduce IRs, the patient received a cocktail of premedication including low dose of steroids, acetaminophen and H2 blockers before each infusion. The treatment was well-tolerated in that IRs, complement activation, anti-PEG antibodies and accelerated blood clearance of the PEGylated drug were not detected. Prior to the clinical study, an in vitro panel of assays utilizing blood of healthy donors was used to determine the potential of a PEGylated drug to activate complement system, elicit pro-inflammatory cytokines, damage erythrocytes and affect various components of the blood coagulation system. The overall findings of the in vitro panel were negative and correlated with the results observed in the clinical phase.

Automated opportunistic osteoporotic fracture risk assessment using computed tomography scans to aid in FRAX underutilization

Methods for identifying patients at high risk for osteoporotic fractures, including dual-energy X-ray absorptiometry (DXA)^1,2 and risk predictors like the Fracture Risk Assessment Tool (FRAX)^3-6, are underutilized. We assessed the feasibility of automatic, opportunistic fracture risk evaluation based on routine abdomen or chest computed tomography (CT) scans. A CT-based predictor was created using three automatically generated bone imaging biomarkers (vertebral compression fractures (VCFs), simulated DXA T-scores and lumbar trabecular density) and CT metadata of age and sex. A cohort of 48,227 individuals (51.8% women) aged 50-90 with available CTs before 2012 (index date) were assessed for 5-year fracture risk using FRAX with no bone mineral density (BMD) input (FRAXnb) and the CT-based predictor. Predictions were compared to outcomes of major osteoporotic fractures and hip fractures during 2012-2017 (follow-up period). Compared with FRAXnb, the major osteoporotic fracture CT-based predictor presented better receiver operating characteristic area under curve (AUC), sensitivity and positive predictive value (PPV) (+1.9%, +2.4% and +0.7%, respectively). The AUC, sensitivity and PPV measures of the hip fracture CT-based predictor were noninferior to FRAXnb at a noninferiority margin of 1%. When FRAXnb inputs are not available, the initial evaluation of fracture risk can be done completely automatically based on a single abdomen or chest CT, which is often available for screening candidates^7,8.

A66 Tracing the evolutionary history of an emerging Salmonella 4,[5],12:i:- clone in the United States

Salmonellosis is one of the leading causes of foodborne disease worldwide, with an estimated one million cases a year in the United States. Salmonella 4,[5],12: i:-, a monophasic variant of Salmonella typhimurium, is an emerging serovar that has been associated with multiple foodborne outbreaks throughout the world, mostly attributed to pig and pig products. Recently, we have demonstrated that two distinct groups of Salmonella 4,[5],12:i:- circulate in the USA and Europe, with the majority of isolates recovered during recent years belonging to an emerging multidrug-resistant clade (Elnekave et al. 2018). We applied Bayesian phylodynamic reconstruction to uncover the evolutionary history of this clade. We used a dataset of whole-genome sequences of 1446 4,[5],12:i:- isolates from different sources (livestock, human, food products, and others) from the USA (n = 752) and Europe (n = 694), collected between 2008 and 2017 and belonging to the Multilocus Subtype 34, which was predominant in the emerging clade (Elnekave et al. 2018). A subset (n = 110) of Salmonella 4,[5],12:i: isolates was then randomly selected after stratifying by location and year of isolation in order to achieve balanced sampling. Evidence of temporal signal was confirmed by looking at root-to-tip divergences using TempEst. Evolutionary hypotheses using strict and relaxed-clock models were tested using BEAST for a variety of demographic models and assuming a general time reversible substitution model. Model selection was performed by estimating Bayes Factors using path sampling and stepping-stone sampling. The selected model was then used for applying discrete trait models comparing different scenarios of transmission between locations (i.e. bidirectional symmetric/asymmetric or unidirectional). Our preliminary phylodynamic inference results indicate that the origin of this subtype was in Europe and dates back to 1990 (HPD 95%: 1984–2001). We report an exponential growth rate of 0.362 per year, which corresponds to a doubling time of 1.43 years. Our results suggest that this subtype was introduced to the US in the year 2000 (HPD 95%: 1994–2006). Phylodynamic analysis suggests that the recent increase in isolation of Salmonella 4,[5],12:i:- from different sources in the USA may be due to the exponential expansion of an emerging clone which originated in Europe and then expanded to the USA. The emergence and expansion of this serovar is of great public health importance due to the high prevalence of multidrug resistance traits found in USA isolates from this group and especially due to the presence of plasmid-mediated resistance genes for quinolones and extended spectrum cephalosporins, key antimicrobials used for the treatment of invasive Salmonella infections.

Simulating Dual-Energy X-Ray Absorptiometry in CT Using Deep-Learning Segmentation Cascade

PURPOSE

Osteoporosis is an underdiagnosed condition despite effective screening modalities. Dual-energy x-ray absorptiometry (DEXA) screening, although recommended in clinical guidelines, remains markedly underutilized. In contrast to DEXA, CT utilization is high and presents a valuable data source for opportunistic osteoporosis screening. The purpose of this study was to describe a method to simulate lumbar DEXA scores from routinely acquired CT studies using a machine-learning algorithm.

METHODS

Between January 2010 and September 2014, 610 CT studies of the abdomen and pelvis were used to develop spinal column and L1 to L4 multiclass segmentation. DEXA simulation training and validation used 1,843 pairs of CT studies accompanied by DEXA results obtained within a 6-month interval from the same individual. Machine learning-based regression was used to determine correlation between calculated grade (on the basis of vertebrae L1-L4) and DEXA t score.

RESULTS

Analysis of the t score equivalent, generated by the algorithm, revealed true positives in 1,144 patients, false positives in 92 patients, true negatives in 245 patients, and false negatives in 212 patients, resulting in an accuracy of 82%. Sensitivity for the detection of osteoporosis or osteopenia was 84.4% (95% confidence interval, 82.3%-86.2%), and specificity was 72.7% (95% confidence interval, 67.7%-77.2%).

CONCLUSIONS

The presented algorithm can identify osteoporosis and osteopenia with a high degree of accuracy (82%) and a small proportion of false positives. Efforts to cull greater information using machine-learning algorithms from pre-existing data have the potential to have a marked impact on population health efforts such as bone mineral density screening for osteoporosis, in which gaps in screening currently exist.

Doxorubicin-Eluting Intra-Arterial Therapy for Pediatric Extra-Abdominal Desmoid Fibromatoses: A Promising Approach for a Perplexing Disease

Systemic doxorubicin is effective for desmoid fibromatosis (DF), but its use is limited by dose-dependent cardiotoxicity. A protocol of selective intra-arterial doxorubicin drug-eluting embolization (DEE) was designed to maximize target tissue efficacy of doxorubicin, while minimizing systemic exposure. Four children with recurrent or refractory DF were treated between 2014 and 2017. Tumor volumes were reduced by 54%-97% over a follow-up interval of 6-32 months. A single patient experienced transient lower extremity paresthesia (Common Terminology Criteria for Adverse Events grade I). Further investigation is needed to better establish these promising results for doxorubicin DEE in DF treatment.

Malignancy Detection on Mammography Using Dual Deep Convolutional Neural Networks and Genetically Discovered False Color Input Enhancement

Breast cancer is the most prevalent malignancy in the US and the third highest cause of cancer-related mortality worldwide. Regular mammography screening has been attributed with doubling the rate of early cancer detection over the past three decades, yet estimates of mammographic accuracy in the hands of experienced radiologists remain suboptimal with sensitivity ranging from 62 to 87% and specificity from 75 to 91%. Advances in machine learning (ML) in recent years have demonstrated capabilities of image analysis which often surpass those of human observers. Here we present two novel techniques to address inherent challenges in the application of ML to the domain of mammography. We describe the use of genetic search of image enhancement methods, leading us to the use of a novel form of false color enhancement through contrast limited adaptive histogram equalization (CLAHE), as a method to optimize mammographic feature representation. We also utilize dual deep convolutional neural networks at different scales, for classification of full mammogram images and derivative patches combined with a random forest gating network as a novel architectural solution capable of discerning malignancy with a specificity of 0.91 and a specificity of 0.80. To our knowledge, this represents the first automatic stand-alone mammography malignancy detection algorithm with sensitivity and specificity performance similar to that of expert radiologists.

Pasireotide for malignant insulinoma

Malignant insulinoma usually has a poor prognosis, as no efficient medical treatment is available. The somatostatin analogs octreotide and lanreotide have limited ability to control the hypoglycemic events. Pasireotide is a multi-receptor targeted somatostatin-analog with improved affinity for SSTR5. There is to date no reported treatment experience with this drug in such tumors.

CASE DESCRIPTION

A 72-year-old patient with a G2 stage IV insulinoma, who underwent excision of the primary pancreatic tumor and multiple hepatic metastases, required further treatment for recurrent hypoglycemic events. The glycemic control achieved with pasireotide LAR was better compared with lanreotide and everolimus. However, none of these treatments showed tumor anti-proliferative effects.

CONCLUSIONS

Pasireotide monthly injections achieved improved glycemic control in a patient with malignant insulinoma and recurrent hypoglycemic events compared with other medical treatments.

Long-term outcomes comparing surgery to embolization-ablation for treatment of solitary HCC<7 cm

BACKGROUND

Resection has been the standard of care for patients with solitary hepatocellular carcinoma (HCC). Transarterial embolization and percutaneous ablation are alternative therapies often reserved for suboptimal surgical candidates. Here we compare long-term outcomes of patients with solitary HCC treated with resection versus combined embo-ablation.

METHODS

We previously reported a retrospective comparison of resection and embo-ablation in 73 patients with solitary HCC<7 cm after a median follow-up of 23 months. This study represents long-term updated follow-up over a median of 134 months.

RESULTS

There was no difference in survival among Okuda I patients who underwent resection versus embo-ablation (66 vs 58 months, p=.39). There was no difference between the groups in the rate of distant intrahepatic (p=.35) or metastatic progression (p=.48). Surgical patients experienced more complications (p=.004), longer hospitalizations (p<.001), and were more likely to require hospital readmission within 30 days of discharge (p=.03).

CONCLUSION

Over a median follow up of more than 10 years, we found no significant difference in overall survival of Okuda 1 patients with solitary HCC<7 cm who underwent surgical resection versus embo-ablation. Our data suggest that there may be a greater role for primary embo-ablation in the treatment of potentially resectable solitary HCC.

The field effectiveness of routine and emergency vaccination with an inactivated vaccine against foot and mouth disease

High potency, inactivated foot and mouth disease (FMD) vaccines may be used in non endemic countries for emergency vaccination during outbreaks in order to prevent virus spread. In endemic countries either standard or high potency vaccines are used for routine vaccination. Despite their wide use there is a shortage of data on the field effectiveness of inactivated FMD vaccines. Epidemics of FMD caused by viruses of serotype O occur frequently in Israel, where a high potency (≥6PD(50)) vaccine is used for both routine and emergency vaccination. We investigated an outbreak of FMD caused by a virus of serotype O, which took place during 2011 in a feedlot and an adjacent dairy herd. Post outbreak testing of antibodies against non-structural protein demonstrated that infection occurred in 96% of the calves that received two doses of vaccine at least three months prior to the outbreak and more than 50% showed clinical signs consistent with FMD. Replacement heifers that had been vaccinated 3-5 times with the last vaccination administered 7 months prior to the outbreak were all infected and 18% showed clinical signs. Testing of cattle sera of the same vaccination status as the affected cattle demonstrated low neutralizing antibody (NA) titers against the field virus strain and an r(1) value of 0.37 compared to the vaccine strain. In contrast, cattle vaccinated only once but up to two weeks before the outbreak, were almost all protected from clinical disease and to a lesser extent, protected from FMD virus infection, despite low NA titers. We conclude that emergency vaccination was highly effective due to a mechanism not associated with NA, whereas routine vaccination with the same vaccine formulation provided only limited protection due to poor longevity of the elicited immunity and low matching with the field strain (despite an r(1) higher than 0.3).

The interventional radiologist's perspective on lung biopsy

Percutaneous image-guided lung biopsies are commonly performed by radiologists. Here, we review common indications and contraindications for the procedure, image guidance and tissue retrieval options, and other special considerations.

Immune responses to Pneumocystis murina are robust in healthy mice but largely absent in CD40 ligand-deficient mice

Pneumocystis is a pathogen of immunocompromised hosts but can also infect healthy hosts, in whom infection is rapidly controlled and cleared. Microarray methods were used to examine differential gene expression in the lungs of C57BL/6 and CD40 ligand knockout (CD40L-KO) mice over time following exposure to Pneumocystis murina. Immunocompetent C57BL/6 mice, which control and clear infection efficiently, showed a robust response to infection characterized by the up-regulation of 349 primarily immune response-associated genes. Temporal changes in the expression of these genes identified an early (Week 2), primarily innate response, which waned before the infection was controlled; this was followed by primarily adaptive immune responses that peaked at Week 5, which coincided with clearance of the infection. In conjunction with the latter, there was an increased expression of B cell-associated (Ig) genes at Week 6 that persisted through 11 weeks. In contrast, CD40L-KO mice, which are highly susceptible to developing severe Pneumocystis pneumonia, showed essentially no up-regulation of immune response-associated genes at Days 35-75. Immunohistochemical staining supported these observations by demonstrating an increase in CD4+, CD68+, and CD19+ cells in C57BL/6 but not CD40L-KO mice. Thus, the healthy host demonstrates a robust, biphasic response to infection by Pneumocystis; CD40L is an essential upstream regulator of the adaptive immune responses that efficiently control infection and prevent development of progressive pneumonia.

IL-13Ralpha2 and IL-10 coordinately suppress airway inflammation, airway-hyperreactivity, and fibrosis in mice

Development of persistent Th2 responses in asthma and chronic helminth infections are a major health concern. IL-10 has been identified as a critical regulator of Th2 immunity, but mechanisms for controlling Th2 effector function remain unclear. IL-10 also has paradoxical effects on Th2-associated pathology, with IL-10 deficiency resulting in increased Th2-driven inflammation but also reduced airway hyperreactivity (AHR), mucus hypersecretion, and fibrosis. We demonstrate that increased IL-13 receptor alpha 2 (IL-13Ralpha2) expression is responsible for the reduced AHR, mucus production, and fibrosis in BALB/c IL-10(-/-) mice. Using models of allergic asthma and chronic helminth infection, we demonstrate that IL-10 and IL-13Ralpha2 coordinately suppress Th2-mediated inflammation and pathology, respectively. Although IL-10 was identified as the dominant antiinflammatory mediator, studies with double IL-10/IL-13Ralpha2-deficient mice illustrate an indispensable role for IL-13Ralpha2 in the suppression of AHR, mucus production, and fibrosis. Thus, IL-10 and IL-13Ralpha2 are both required to control chronic Th2-driven pathological responses.

The Impact of Gown-Use Requirement on Hand Hygiene Compliance

BACKGROUND

Hand hygiene compliance remains low, despite its effectiveness in preventing infections. Gowns are routinely used to reduce dissemination of organisms within hospitals. Use of gowns is time consuming and costly, and their effectiveness, compared with that of hand hygiene alone, is debated. Among the arguments supporting a gown-use requirement is the potential to boost awareness of infection control, leading to improved hand hygiene compliance.

METHODS

Hand hygiene compliance was recorded in a 14-month crossover trial comparing compliance at 2 intensive care units during periods with and without a gown-use requirement.

RESULTS

During 170 h of observation, 1619 hand hygiene opportunities were recorded. Compliance was 10% before care was given and 36% after care was given. Compliance with glove and gown use was 62% and 63%, respectively. After-care hand hygiene compliance for nurses, physicians, and therapists was 40%, 38%, and 22%, respectively. Compliance after patient contact, body fluid contact, and other in-room activity was 42%, 48%, and 22%, respectively. For periods with and without a gown-use requirement, overall after-care compliance (37% vs. 34%) and rates by personnel and activity type were similar. In the subgroup of patients on contact precautions, hand hygiene compliance during the period with a gown-use requirement versus the period without a gown-use requirement was 11% versus 10% (P=.85) before care was given and 45% versus 39% (P=.09) after care was given. In this subgroup, after adjustment for type of in-room activity, medical personnel, intensive care unit, and observer, the predicted after-care hand hygiene compliance during periods with and without a gown-use requirement was 48% versus 41% (P=.02).

CONCLUSIONS

The hypothesis that a gown-use requirement might improve hand hygiene compliance in the intensive care unit could not be confirmed. In the subgroup of patients on contact precautions, improvement in hand hygiene compliance associated with the gown-use requirement was small and did not affect precare rates.

High-Throughput GoMiner, an 'industrial-strength' integrative gene ontology tool for interpretation of multiple-microarray experiments, with application to studies of Common Variable Immune Deficiency (CVID)

BACKGROUND

We previously developed GoMiner, an application that organizes lists of 'interesting' genes (for example, under-and overexpressed genes from a microarray experiment) for biological interpretation in the context of the Gene Ontology. The original version of GoMiner was oriented toward visualization and interpretation of the results from a single microarray (or other high-throughput experimental platform), using a graphical user interface. Although that version can be used to examine the results from a number of microarrays one at a time, that is a rather tedious task, and original GoMiner includes no apparatus for obtaining a global picture of results from an experiment that consists of multiple microarrays. We wanted to provide a computational resource that automates the analysis of multiple microarrays and then integrates the results across all of them in useful exportable output files and visualizations.

RESULTS

We now introduce a new tool, High-Throughput GoMiner, that has those capabilities and a number of others: It (i) efficiently performs the computationally-intensive task of automated batch processing of an arbitrary number of microarrays, (ii) produces a human-or computer-readable report that rank-orders the multiple microarray results according to the number of significant GO categories, (iii) integrates the multiple microarray results by providing organized, global clustered image map visualizations of the relationships of significant GO categories, (iv) provides a fast form of 'false discovery rate' multiple comparisons calculation, and (v) provides annotations and visualizations for relating transcription factor binding sites to genes and GO categories.

CONCLUSION

High-Throughput GoMiner achieves the desired goal of providing a computational resource that automates the analysis of multiple microarrays and integrates results across all of the microarrays. For illustration, we show an application of this new tool to the interpretation of altered gene expression patterns in Common Variable Immune Deficiency (CVID). High-Throughput GoMiner will be useful in a wide range of applications, including the study of time-courses, evaluation of multiple drug treatments, comparison of multiple gene knock-outs or knock-downs, and screening of large numbers of chemical derivatives generated from a promising lead compound.

The healthcare experiences of Arab Israeli women in a reformed healthcare system

Arab Israeli women are subject to unique social stresses deriving from their status as part of an ethno-political minority and from their position as women in a patriarchal community. Collectively, their health profiles rate poorly in comparison to Jewish Israeli women or to women in the vast majority of developed countries.

OBJECTIVES

To examine the experiences of Arab Israeli women in the contemporary Israeli healthcare system, following implementation of the National Health Insurance Law (NHIL).

METHODS

The study combined quantitative and qualitative research methodologies. A telephone survey utilizing a structured questionnaire was conducted during August-September 1998 among a random national sample of 849 women, with a response rate of 83%. Between the months of January and July of 2000, qualitative data was attained via participant-observation, long and short semi-structured interviews, and focus groups in one large Muslim Arab Israeli village.

FINDINGS

Arab Israeli women in the national survey reported poorer self-assessed health, lower rates of care by a woman primary care physician, lower satisfaction ratings for primary care physicians and more frequently foregoing medical care than did native or immigrant Jewish Israeli women. Three major factors contributing to Arab Israeli women's healthcare experiences were elucidated by the qualitative study: (1) the threat of physical and social exposure (2) difficulties in communicating with male physicians and (3) the stifling effect of family politics and surveillance on healthcare.

DISCUSSION

We discuss our findings in relation to structural changes associated with the recent reform of the Israeli health care system. We conclude by suggesting policy measures for better adapting primary care services to the needs of Arab Israeli women, and note the relevance to other systems that aim to provide service to cultural and ethno-political minorities, in which healthcare delivery is shaped by unique local circumstances.