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This column describes an innovative, government-sponsored, countrywide mental health reform focusing on rehabilitation and community integration of persons with serious mental illness, which was enacted into law in Israel in 2000. The reform was part of the country's efforts to shift the locus of treatment and care from psychiatric institutions to the community. The authors review preliminary evidence of the impact of reform and offer cautionary notes regarding the future direction of its implementation. The decade after the law's enactment saw an impressive increase in rehabilitation services, a significant reduction in the number of psychiatric beds, and major changes in government budget allocations. The authors examine factors that may endanger the viability of reform and discuss lessons to be learned from the Israeli experience. 相似文献
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Shiri Skolnik Alexander Ioscovich Leonid A. Eidelman Atara Davis Anat Shmueli Amir Aviram 《The journal of maternal-fetal & neonatal medicine》2019,32(8):1262-1266
Introduction: Amniotic fluid embolism (AFE) is a rare and potentially lethal obstetric complication, commonly occurring during labor, delivery, or immediately postpartum. There is a paucity of data regarding incidence, risk factors, and clinical management. Our primary objective in this study was to evaluate clinical presentation of AFE and delineate anesthesia management of these cases.Methods: This 10 years retrospective multi-center cohort study was performed in five tertiary university-affiliated medical centers, between the years 2005 and 2015. All documented cases of AFE identified according to the ICD guidelines were reviewed manually to determine eligibility for AFE according to Clark’s criteria. All cases confirming Clark’s diagnosis were included in the cohort.Results: Throughout the study period, 20 cases of AFE were identified, with an incidence of 4.1 per 100,000 births. Average age at presentation was 35?±?5 years. Seventy percent of cases presented during vaginal delivery, 20% occurred throughout a cesarean delivery, and 10% occurred during a dilation and evacuation procedure. The most common presenting symptom was sudden loss of consciousness in 12 parturients (66.7%), fetal bradycardia in 11 parturients (55%), and shortness of breath in 10 parturients (50%). Perimortem cesarean section was performed in 55% of cases, although only one case was performed in the delivery suite, while all others were performed in the operating room. Echocardiography was performed in 60% of the cases and all were pathological. Furthermore, 20% of cases were connected to an extracorporeal membrane oxygenation machine. There was a 15% mortality rate of 15%. A further 15% suffered major neurological disability, 25% suffered minor neurological morbidity, and 45% survived without severe complications.Conclusion: AFE is associated with significant maternal morbidity. This study highlights the importance of providing advanced training for the delivery suite staff for cases of maternal cardiovascular collapse secondary to AFE and increasing awareness for this rare and devastating obstetric condition. 相似文献
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Eyal?Krispin Amir?Aviram Lina?Salman Rony?Chen Arnon?Wiznitzer Rinat?Gabbay-BenzivEmail author 《Archives of gynecology and obstetrics》2017,296(5):877-883
Objective
To determine the perinatal outcome associated with cup detachment during vacuum-assisted vaginal delivery (VAVD).Methods
A retrospective cohort study of all women attempting VAVD in a tertiary hospital (2012–2014). Singleton-term pregnancies were included. Antepartum fetal death and major fetal structural or chromosomal abnormalities were excluded. Primary outcome was neonatal birth trauma (subgaleal hematoma, subarachnoid hematoma, subdural hematoma, skull fracture, and/or erb’s palsy). Secondary outcomes were maternal complications or other neonatal morbidities. Outcomes were compared between women after ≥1 cup detachment (study group) and the rest (control group). Logistic regression analysis was utilized to adjust results to potential confounders.Results
Overall, 1779 women attempted VAVD during study period. Of them, in 146 (8.2%), the cup detached prior to delivery; 130/146 (89%) had a single detachment. After detachment, 4 (2.7%) delivered by cesarean section, 77 (52.7%) delivered after cup reapplication, and 65 (44.6%) delivered spontaneously. Women in the study group were more likely to undergo VAVD due to prolonged second stage, and were characterized by lower rates of metal cup use. Neonates in the detachment group had higher rates of subarachnoid hematoma and composite neonatal birth trauma (2.7 vs. 0.1% and 4.8 vs. 1.8%, respectively, p < 0.05). This remained significant after adjustment to potential confounders (subarachnoid hematoma aOR = 45.44, 95% CI 6.42–321.62 and neonatal birth trauma aOR = 2.62, 95% CI 1.1–6.22, p < 0.05 for all). Other neonatal and maternal morbidities were similar between groups.Conclusion
Cup detachment is associated with a higher rate of adverse neonatal outcome. Cup reapplication should be considered carefully.96.
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Amir Aviram Ami Fishman Maya Steinberg Ido Solt Rami Aviram 《International journal of gynaecology and obstetrics》2014
Objective
To compare approval rates of late termination of pregnancy (LTOP) requests before and after a policy change in Israel in late 2007.Methods
In a retrospective study, LTOP requests and board decisions from 2002–2007 (group 1) were compared with those from 2007–2012 (group 2) at 3 university-affiliated medical centers in Israel. Reasons for application, approval, or rejection were compared between the groups.Results
There were 552 applications for LTOP. The overall approval rate for LTOP and the specific approval rate per medical indication did not differ significantly between the groups. The rate of requests due to confirmed genetic anomalies decreased from 18.4% in group 1 to 11.3% in group 2 (P = 0.03). Compared with group 1, the rate of rejection for intrauterine infection increased from 8.3% to 26.3% (P = 0.2), and that for pregnancy complications decreased from 62.5% to 35.0% (P = 0.2) in group 2 but these differences were not statistically significant. Requests due to structural anomalies were declined because they were considered to be minor cardiac, renal, cerebral, or skeletal anomalies.Conclusion
The more stringent 2007 criteria for approving requests for LTOP did not affect the rate of rejection of requests due to structural anomalies between the 2 time periods. 相似文献100.
Sharon Orbach-Zinger Carolyn F. Weiniger Amir Aviram Alexander Balla Shai Fein Leonid A. Eidelman 《The journal of maternal-fetal & neonatal medicine》2018,31(9):1171-1176
Purpose: Placenta previa (PP) is a major cause of obstetric hemorrhage. Clinical diagnosis of complete versus incomplete PP has a significant impact on the peripartum outcome. Our study objective is to examine whether distinction between PP classifications effect anesthetic management.Methods and materials: This multi-center, retrospective, cohort study was performed in two tertiary university-affiliated medical centers between the years 2005 and 2013. Electronic delivery databases were reviewed for demographic, anesthetic, obstetric hemorrhage, and postoperative outcomes for all cases.Results: Throughout the study period 452 cases of PP were documented. We found 134 women (29.6%) had a complete PP and 318 (70.4%) had incomplete PP. Our main findings were that women with complete PP intraoperatively had higher incidence of general anesthesia (p?=?.017), higher mean estimated blood loss (p?.001), increased blood components transfusions (p?.001), and significant increase in cesarean hysterectomy rate (p?.001) than women with incomplete PP. Additionally, complete PP was associated with more postoperative complications: higher incidence of admission to the intensive care unit (ICU) (p?.001), more mechanical ventilation (p?=?.02), a longer median postoperative care unit (PACU) (p?=?.02), ICU (p?=?.002), and overall length of stay in the hospital (p?.001).Conclusions: Complete PP is associated with increased risk of hemorrhage compared with incomplete PP. Therefore distinction between classifications should be factored into anesthetic management protocols. 相似文献