The Israeli Study of Surgical Infections (ISSI): II. Initial comparisons among hospitals with special focus on hernia operations.

In a study of 5,571 patients from the general surgery departments of 11 Israeli hospitals, the crude overall wound infection rates showed interhospital heterogeneity. The rates ranged from 6.3% to 12.4% (P(chi 2) = 0.039). Controlling for the different distributions of procedures performed in the various institutions did not reduce this variability. None of the hospitals had either consistently high or consistently low infection rates. A hospital could have low rates for one procedure and high rates for another. Therefore, the decision was made to proceed with procedure-specific analyses. This article details results of the analysis of 1,487 hernia operations. Four variables (old age, infection at another site, incarceration, and introduction of drains) accounted for almost all the differences in infection rates among the institutions. Of the four, presence of drains had the strongest association with infection (P derived from the logistic model less than 0.001). The risk was consistent in all hospitals and was unconfounded by other measurable factors. In contrast, the pattern of using drains seemed arbitrary and inconsistent, ranging from 9% of patients in one hospital to 41% in another. These findings were used as a basis for discussion with the surgical teams and for the initiation of a randomized clinical trial on the use of drains in hernia operations.

The Israeli Study of Surgical Infections (ISSI): I. Methods for developing a standardized surveillance system for a multicenter study of surgical infections.

The postoperative wound infection experience in 11 Israeli hospitals was investigated with two objectives: (1) to utilize the variability among hospitals for a better understanding of the determinants of these infections, and (2) to present surgeons and infection control teams with information upon which they can take action. This article summarizes the methods that were applied to maximize the uniformity of information obtained from hospitals. (1) The same kind of patients were sampled in every hospital. (2) The data collection system was standardized, and analyzed for errors. The overall error rate was small (2%) but there were potential problem areas, such as missing information on underlying diagnoses (12%). Few errors (1%) were found in the nurses' observations of the wounds. (3) All wound infections were diagnosed in a uniform manner by convening a panel of four specialists at the central Israeli Study of Surgical Infections (ISSI) office. (4) The definition of infection that was finally chosen for this multicenter study had to be broadened to include, in addition to pus, "discharge other than pus," because of the higher reliability among panel members. This definition was also clinically valid in terms of morbidity. (5) The rate of postdischarge infections was estimated and was not found to be related to the discharge policies in the various hospitals.

Follicular fluid contents as predictors of success of in-vitro fertilization-embryo transfer.

In order to establish criteria for selection of the best ova in in-vitro fertilization-embryo transfer (IVF-ET) programes we have examined the follicular fluid (FF) levels of plasminogen activator (PA), collagenolytic activity, progesterone (P) and alpha 2 macroglobulin (alpha 2M) and related them to the success of pregnancy. PA activity was similar in FF of pregnant and nonpregnant cycles, 13.8 +/- 3.9 mU/ml versus 14.6 +/- 2.9 (mean +/- SEM) respectively. By contrast, FF from pregnant cycles exhibited lower collagenolytic activity (49.6 +/- 3.9% versus 67.9 +/- 3.0; P less than 0.001). Likewise, in a semi-quantitative assay of alpha 2M, only 18.4% of the aspirates from pregnant cycles showed a precipitation line, whereas 76.8% of those from non-pregnant cycles were positive. Levels of P in aspirates from pregnant cycles were in the intermediate range, as compared with those from non-pregnant cycles (0.06-5.5 micrograms/ml versus 0.02-12.0 micrograms/ml). All these assays can be completed before ET and performed in IVF-ET programmes. In conclusion, it seems that a combination of follicular alpha 2M levels and collagenolytic activity, and to a lesser extent addition of P assay, may serve as good criteria for selecting the best embryos for establishment of pregnancy.

Insulin deficiency and insulin resistance in type 2 (non-insulin-dependent) diabetes: quantitative contributions of pancreatic and peripheral responses to glucose homeostasis.

A non-steady state dose-response study was designed to quantitate peripheral sensitivity to insulin and pancreatic responsiveness to glucose, and to assess their relative contribution to glucose intolerance in Type 2 diabetes (Type 2 DM, non-insulin-dependent). Eleven lean and eleven obese patients with mild diabetes (fasting plasma glucose, FPG, 10.3 +/- 1.0 and 9.4 +/- 0.6 mmol l-1, respectively) were examined; twenty-six lean and twelve weight-matched obese subjects served as controls. Pancreatic response was measured by sequential injection of 0.1, 0.3 and 0.9 g kg-1 glucose; peripheral sensitivity to insulin was determined from the rate of clearance (Kgluc) of 0.3 g glucose injected sequentially together with 25, 50 and 100 mU insulin kg-1 or with 0, 12.5 and 50 mU kg-1, under somatostatin infusion. The mean dose-response curve describing glucose-induced insulin release showed increased maximal capacity to secrete insulin in obese controls, while the responses of lean as well as obese Type 2 DM were reduced by more than 80%. The mean dose-response curves relating plasma exogenous insulin levels to Kgluc were similar in lean diabetics and lean controls. The curves of both obese controls and obese diabetics were shifted to the right, demonstrating similar insulin resistance. In four lean controls, sensitivity to insulin was tested also during a hyperglycemic clamp set at 10.3 +/- 0.6 mmol l-1. Hyperglycemia reduced the Kgluc at all insulin levels. Individual dose-response curves were transformed to single weighted numerical pancreatic responsiveness scores [PRS], and peripheral sensitivity scores [PSS].(ABSTRACT TRUNCATED AT 250 WORDS)

Advice from the obstetrician and other sources: do they affect women's breast feeding practices? A study among different Jewish groups in Jerusalem.

Breast feeding practices and the sources of advice that influenced them were studied in a sample of 276 women from North East Jerusalem. They were followed-up for 4 1/2 months and interviewed on 4 occasions during that period. It was found that 89.7% started breast feeding after parturition, 62.4% were breast feeding by 6 weeks, 40.3% were breast feeding after 3 months and 27.3% were still breast feeding by 4 1/2 months postpartum. Obstetrician's advice given at the 6 weeks postpartum examination was significantly associated with duration of breast feeding (P = 0.001). Other sources of guidance were not significantly related to duration of breast feeding when controlling for social class. Analysis of variance indicated that women of higher social classes breast fed more and for a longer period of time. There was no difference in the pattern of attendance at the obstetrician's examination by social class, although a very small proportion of women belonging to the lower social classes reported getting advice on breast feeding during that visit. There was a strong relation between advice of the obstetrician and percentage of women breast feeding 4 1/2 months postpartum. Country of origin of the women also affected breast feeding practices. Women of Western origin breast fed more and longer than women of Asian or North African origin. This might be explained by social movements that attempt a return to more natural life styles which are prominent in Western societies. The differential relationship between advice of obstetrician and women belonging to different social classes is discussed and key elements in the relation between obstetrician's advice and women's breast feeding practices are considered.

The effect of rises in food costs on food intake of three year olds in Jerusalem.

The food intake of two samples of children born five years apart were determined in 1975 and 1980 at three years of age in a low and middle class neighbourhood of Jerusalem. The 24-hour recall method was used. No deficiency in caloric intake was noted. The protein intake was twice the recommended dietary allowance (RDA), 3.7 gr/kg in the study group interviewed in 1975 and 3.3 gr/kg in those interviewed in 1980. The mean daily iron intake was only 40% of the RDA. The main sources for protein were milk and milk products, poultry and eggs. Significantly higher mean caloric and protein intakes were noted for the upper as compared to middle and low social class in 1980. Children from Asian origin had the lowest caloric and protein intake in 1975 and 1980 whereas those of European-American origin had the highest. Severe inflation and the resulting tenfold increase in food prices in Israel were not reflected in marked changes in dietary intake. The percentage expenditure on food was 25% of total income during both periods. The possible factors influencing the stability in dietary intake are governmental subsidy for the essential foods, correction of wages and increase in social security payments thus maintaining the buying power, as well as the educational effect of the preventive services--the Mother and Child Health Stations on feeding practices.