Israel Medical Association Journal

Background: Concomitant bacterial and viral infection is a well-known phenomenon, however only very rarely has a bacterial infection been reported during hepatitis A virus infection.

Objective: To evaluate retrospectively the clinical records of children hospitalized with HAV infection for a concomitant infection proved or presumed to be bacterial.

Method: A retrospective study was conducted on all the children hospitalized with hepatitis A infection from 1988–96 in our center. The records were evaluated for a concomitant infection.

Results: Of 40 children hospitalized with HAV infection, 13 were found to have a concomitant infection: these included 6 with pneumonia, 4 with pyelonephritis and 1 case each of purulent otitis media, osteomyelitis and staphylococcal bacteremia.

Conclusion: In areas where hepatitis A is endemic, a simultaneous infection with hepatitis A and other common bacterial infection during childhood may co-exist. A permissive role for HAV infection is suggested.

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HAV = hepatitis A virus

Background: A high rate of consanguineous marriages exists within the Israeli Arab community, with approximately half occurring between first cousins. This contributes towards a high incidence of congenital malformations and autosomal recessive diseases, many of which are detectable at prenatal diagnosis.

Objectives: To assess the levels of both awareness and acceptance regarding prenatal diagnosis and termination of pregnancy among a group of Arab women in order to devise the optimal means of providing genetic counseling and general health services.

Methods: A total of 231 Arab women of childbearing age were interviewed 3 days postpartum to assess their knowledge of prenatal diagnosis and termination of pregnancy, their willingness to undergo prenatal diagnosis, and their opinions on termination of pregnancy in the event of a severely affected fetus.

Results: Half the women believed that prenatal testing is not an effective (or accurate) tool for diagnosing an affected fetus. A quarter had poor knowledge on prenatal diagnosis, and a quarter believed that prenatal diagnosis does provide the correct diagnosis. Ninety-five percent said they would agree to undergo prenatal diagnosis; and in the event of a severely affected fetus, 36% said they would agree to a termination of pregnancy, 57% said they would not, and 7% were undecided.

Conclusions: There is a need for special intervention programs, with guidance by health professionals, geneticists and religious authorities, that will inform this population on the increased risk associated with consanguinity, stress the importance and effectiveness of prenatal testing to identify severe congenital malformations, and help them to accept prenatal diagnosis and termination of pregnancy if indicated.

Background: Osteoporosis is the most common human bone disease. It affects millions of persons throughout the world and its prevalence will increase as the population ages worldwide.

Objective: To assess Israeli physicians' attitudes and knowledge with regard to management of osteoporosis.

Methods: A questionnaire was mailed to 1,900 Israeli physicians concerning their attitudes to the management of osteoporosis, their prescribing habits, and their knowledge on the pharmacological treatment of the disease.

Results: Replies were received from 19% of the physicians. The respondents encouraged physical activity and cessation of smoking for all women, and prescribed estrogen replacement as the main treatment for 50-year-old women. A relatively low level of knowledge was found regarding the adequate dosage of several of the pharmacological treatments.

Conclusions: The findings of the present study stress the need to provide clear guidelines and to extend physicians' knowledge regarding the management of osteoporosis.

Background: Chickenpox is a highly contagious childhood infection caused by varicella zoster virus, a virus of the herpes family. Although a mild and self-limiting disease in otherwise healthy children, chickenpox can be a complicated and even life-threatening disease in adults, pregnant women and immunosuppressed individuals. Among infants whose mothers had varicella during the first trimester of pregnancy, 2-3% will develop a congenital VZV syndrome that includes a combination of scarring, limb deformation, central nervous system impairment and ocular injury. In 1974, a live attenuated virus vaccine against VZV was developed in Japan and has been thoroughly tested for safety, efficacy and long-term effects. In March 1995 the vaccine was licensed in the U.S. for use in healthy children only.

Objectives: To determine the rate of immunity to VZV in young Israeli adults.

Methods: On the assumption that a randomly picked sample of 18-year-old army recruits in Israel is representative of the general Jewish population, 900 sera samples were taken for 3 years (1985,1988,1992). The sera were analyzed for IgG to VZV with a commercial ELISA kit using microwells coated with VZV antigens.

Results: A total of 98% of the samples tested positive for VZV antibodies. The difference in serologic values between the recruitment years was not statistically significant.

Conclusion: The majority of the Israeli population reaches adulthood already immunized against VZV, with immigrants having slightly lower immunity rates. Nonetheless, a few dozen cases of chickenpox are diagnosed in the IDF annually. These data should be taken into account when a vaccination program is devised. Should such a program be implemented, it would be interesting to repeat the serosurvey for comparison. A shift in the peak occurrence age might necessitate the administration of a booster vaccine at an older age.

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VZV= varicella zoster virus

IDF= Israel Defense Forces

Background: Most countries today are experiencing an accelerated pace of population aging. The management of the elderly housebound patient presents a special challenge to the family physician.

Objectives: To investigate a series of home visits to housebound patients, the therapeutic procedures used, the equipment needed, and the diagnostic conclusions reached.

Methods: The details of 379 consecutive home visits to housebound patients were recorded by 91 family doctors serving 125,000 patients in Israel.

Results: The average age of the patients was 76.1 years. The vast majority of the visits were during office hours (94%). In 24.1% it was the doctor who decided to make the home visit on his/her own initiative. The most common initial reason for a home visit was undefined general symptoms, but the doctor was usually able to arrive at a more specific diagnosis after the visit. Medications were prescribed in 59.1% of the visits, and in 23.5% the medication was administered directly by the physician. The commonest drugs used were analgesics and antibiotics. In 19.3% of visits no action at all, other than examination and counseling, was undertaken. The equipment needed included prescription pads (73%), a stethoscope (81%), sphygmomanometer (74.9%), and otoscope/torch (30.6%). Only 15% of visits resulted in referral to hospital.

Conclusions: Home visits to housebound patients serve as a support to caregivers, provide diagnostic information, and help the family with the decision as to when hospitalization is appropriate. The specific medical cause for the patient being housebound had little effect on the process of home visiting.
 

Background: The need for aortic valve replacement in children and young adults poses a special problem to cardiologists and surgeons. Replacing the sick aortic valve with the patient’s pulmonary valve as described by Ross has proven to be a good option in this special age group.

Objective: To review our initial experience in order to assess the short-term results.

Methods: From January 1996 to June 1999, 40 patients (age 8 months to 41 years) underwent aortic valve replacement with pulmonary autograft. Indications for surgery were congenital aortic valve disease in 30 patients, bacterial endocarditis in 5, rheumatic fever in 3, and complex left ventricular outflow tract obstruction in 3. Trans-esophageal echocardiography was performed preoperatively and post-bypass in all patients, and transthoracic echocardiography was done prior to discharge and on follow-up.

Results: There was no preoperative or late mortality. All patients remain in functional class I (New York Heart Association) and are free of complications and medication. None showed progression of autograft insufficiency or LVOT obstruction. Homograft insufficiency in the pulmonary position has progressed from mild to moderate in one patient, and three developed mild homograft stenosis.

Conclusions: The Ross procedure can be performed with good results in the young population and is considered an elegant surgical alternative to prosthetic valves and homografts.

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LVOT = left ventricular outflow tract

Background: Hypertension is one of the most prevalent vascular diseases in the adult population. It is an important determinant of atherosclerosis in adolescents and young adults. There is to date no information on blood pressure in children of the Israeli Arab population.

Objectives: To study blood pressure in Israeli Arab children and adolescents.

Methods: Blood pressure measurements were taken in the supine position in 4,488 Israeli Arab children and adolescents of both sexes aged 6–17 years. Height and weight were also determined. Correlation was investigated between systolic and diastolic blood pressure, body mass index, gender, and age.

Results: The systolic and diastolic blood pressures were similar in both sexes for all age groups up to 14 years of age. Systolic blood pressure was significantly (P<0.001) higher in males aged 15–17 years  (120±13 vs. 111±12 mmHg, 123±13 vs. 113±14.0 mmHg, and 123±18 vs. 111±14 mmHg, respectively). Diastolic blood pressure was higher in males aged 15–17, with a statistically significant difference for age 17 only (75±12 vs. 69±13 mmHg). Blood pressure was elevated in 322 students in the initial screening (7.17%), with a decrease to 2.18% when this group was rescreened 2 weeks later. The systolic blood pressure in our group is higher than that in Jewish Israeli children of Asian and North African origin, and in American children. It is similar to the systolic blood pressure of European children and Jewish children born in Israel. The diastolic blood pressure in our group is higher than that in all groups of Israeli Jewish children and American children of different ethnic groups.

Conclusions: Israeli Arab children and adolescents have higher blood pressure levels than their Israeli Jewish counterparts. Further studies are required to confirm this observation.

Background: Erythema nodosum, although uncommon in children, is the most frequent form of panniculitis in pediatrics.  EN has been associated with various infections and chronic inflammations, and its course varies with age, gender, and racial and geographic factors.  There is no information on EN in Israeli children.

Objectives: To examine the clinical course of EN and the conditions with which it is associated in Israeli children.

Methods: We conducted a retrospective study of 24 children with a diagnosis of EN who presented at our Center over a 10 year period (1989–98).

Results: EN was more frequent in females than males (ratio 2:1) due to a cluster of adolescent girls. The mean duration of the skin manifestation was 18 days. The course was benign in all patients. Streptococcal infection was the most common cause (25%), followed by Epstein-Barr virus infection (18%) and inflammatory bowel disease (13%).  In one-third of cases, no specific cause could be identified. Tuberculosis, an important cause of EN in the past, was not found in our patients.

Conclusions: Most cases of EN in Israeli children are related to streptococcal and EBV infections or to chronic inflammatory conditions. Despite the increase in tuberculosis morbidity in Israel during recent years, we found no association of EN and tuberculosis in our study.

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EN = erythema nodosum

EBV = Epstein-Barr virus

Objectives: To assess the structure and the positive and negative job components of family physicians in Israel, as well as the effect of these components on their satisfaction with their work.

Methods: A questionnaire was sent to a random selection of members of the Israel Society of Family Physicians (n=225).

Results: Altogether 183 questionnaires were returned. Specialist family doctors, practice medical directors and salaried doctors were involved in more activities than non-specialist doctors, trainees and self-employed doctors. Overall satisfaction was highest for specialists and lowest for non-specialists. Work overload, insufficient resources and abundant paperwork were most frequently cited as negative work components. The opportunity to utilize medical knowledge, challenging work and work variety scored highest as positive components.

Conclusions: The more professionally active physicians were also the more satisfied. Clinical work and teaching provided the most satisfaction, while administrative work and lack of time were the main causes of dissatisfaction.

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* This article is dedicated to the memory of our dear friend, Dr. michael Herz, who contributed to the writing of it.

Objectives: To assess the risk factors for malignant melanoma among kibbutz members compared to matched healthy controls.

Methods: We conducted a case-control study of 168 malignant melanoma patients and 325 healthy controls, matched by age and gender. Data were collected on three categories of risk: demographic, personal (e.g., skin, eye and hair color), and environmental/behavioral (e.g., sun exposure, use of sunscreens).

Results: There were no differences between the groups regarding sociodemographic data. Significantly more patients than controls had fair, vulnerable skin (P<0.001), light eyes (P<0.05), and fair hair (P<0.001). There was no difference in family history of malignant melanoma or other cancers. Patients with malignant melanoma had significantly more additional skin lesions (e.g., keratoses) (P<0.001). More patients than controls recalled having been exposed to the sun for long periods when they were 6–13 years of age. A conditional logistic regression analysis showed that fair hair, fair vulnerable skin, and additional skin lesions were independently associated with malignant melanoma (P<0.01).

Conclusions: The main target population for interventions to reduce the incidence of malignant melanoma among kibbutz members should be individuals with these risk factors. A history of increased exposure to the sun from age 6 to 13 should also be taken into account as an independent risk factor. 

Objectives: To present a follow-up on tests for use of performance-enhancing drugs among elite Israeli athletes from 1993 until the present.

Methods: Since 1993, 273 drug tests (urine samples) were performed in elite Israeli athletes. These tests were done during major competitions, and at random during the regular training season without prior notice to the athletes. The urine samples were sent for analysis to an official drug laboratory of the Olympic Committee in Cologne, Germany.

Results: Since 1993, seven (2.7%) male Israeli elite athletes (5 weight lifters, a javelin thrower, and a sprinter) tested positive for performance-enhancing drugs — all of them for anabolic steroids, and two for diuretics as well.

Discussion: These findings suggest that the phenomenon of performance-enhancing drug use by elite athletes has also entered Israeli sports, and probably represent the tip of the iceberg among Israeli sportsmen.  Therefore, more drug tests should be performed, especially at random without prior notice and during the regular season. Athletes in the most popular sports such as soccer and basketball should also be tested.  The concern over the use of these agents is both medical and ethical.

Objectives: This article reviews 25 years (1973–98) of experience in bone banking in Israel.

Methods: A nationwide survey on the clinical application of the banked musculoskeletal tissues during 1996 was conducted by means of a written questionnaire sent to all orthopedic departments in Israel.

Results:  The response rate to the questionnaire was 84%. A total of 257 cases were allocated bone allografts: the majority comprised 225 spongy bones, 26 were massive bone allografts and 6 were soft tissue allografts.

Conclusion:  Improvement of quality control and quality assurance of the banked tissues, together with development of skills in the use of osteoinductive and osteoconductive materials, cast the future of musculoskeletal tissue banking.

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 * A Tribute to Professor Henry Horoszowski