Israel Medical Association Journal

Background: Exclusive breastfeeding is recommended through six months as it supports infant growth and development. Yet, many mothers do not exclusively breastfeed in early postpartum.

Objectives: To examine factors associated with exclusive breastfeeding at hospital discharge among culturally diverse women.

Methods: This cross-sectional study used data of women who gave birth at a major medical center in Israel in 2015–2017. Descriptive statistics and regression analysis were conducted to examine maternal characteristics and associated breastfeeding outcomes by hospital discharge.

Results: Among 10,978 women, 17.8% (n=1958) exclusively breastfed, 57.9% (n=6357) partially breastfed, and 24.3% (n=2663) did not breastfeed. Among Israeli-born and former Soviet Union-born Jewish women, breastfeeding intention (odds ratio [OR] 19.59, 95% confidence interval [95%CI] 10.27–37.35 and OR 15.92, 95%CI 5.79–43.80, respectively) and early breastfeeding (OR 2.415, 95%CI 1.91–3.05 and OR 2.04, 95%CI 1.57–2.64, respectively) were associated with exclusive breastfeeding. The only significant factor associated with exclusive breastfeeding among refugees and Israeli-born Muslim women was early breastfeeding (OR 1.61, 95%CI 1.20–2.16). For Ethiopian-born Jewish women, not married (OR 0.330, 95%CI 0.114–0.955) and cesarean delivery (OR 0.481, 95%CI 0.232–0.998) were negatively associated with exclusive breastfeeding.

Conclusions: Despite having access to the same hospital-based breastfeeding support, there were differences among ethno-culturally diverse women in Israel. In this study, we identified maternal characteristics associated with early breastfeeding among women of diverse ethno-cultural backgrounds. Study findings highlight the importance of ethno-cultural considerations in breastfeeding practices and inform health professionals of factors associated with exclusive breastfeeding in early postpartum.

Background: Sperm banks initially focused on providing sperm donation (SD) to heterosexual couples grappling with severe male infertility. Notable advancements in fertility treatments and sociological trends have broadened the scope of SD toward single women and same sex female couples.

Objectives: To evaluate SD recipient characteristics over the last three decades in Israel according to demographic parameters.

Methods: This retrospective cohort study included 5489 women who received SD between January 1992 and December 2021 from a tertiary referral center. We divided the overall period into six groups of five years each. A comparison of demographic characteristics of women who received SD in different periods was performed according to age at the beginning of the treatment, marital status (single women and same sex female couples, heterosexual couples), and ethnic origin.

Results: The average age of women who received SD was 37.02 ± 5.36 years. The average patient age rose from 35.08 years in 1992–1997 to 37.43 years in 2017–2021 (P-value < 0.01). The use of SD was more common among single women and same sex female couples compared to heterosexual couples in later years. Regarding single and same sex female couple, the percentage of SD recipients increased radically from 33% to 88.1% (P-value < 0.01).

Conclusions: Modern sperm banks treat older patients in non-heterosexual relationships. These trends encompass not only medical implications (e.g., in vitro fertilization vs. intrauterine insemination) but also delve into the personal and sociological impact experienced by both patients and offspring.

Background: Helicobacter pylori (H. pylori) prevalence varies according to both geographical region and ethnicity. The interplay between these two factors has been poorly studied.

Objectives: To determine the positivity rate of H. pylori infection among Jewish and Arab patients who live in a mixed urban center in Israel.

Methods: Between November 2009 and September 2014, dyspeptic patients referred to a gastroenterology clinic in Lod, Israel, were enrolled in a prospective study. For each patient, clinical and epidemiological data were collected and a noninvasive or endoscopy-based test for H. pylori was performed.

Results: A total of 429 consecutive patients (322 Jewish and 107 Arabs), mean age 45 years (range 15–91 years) were included; 130 males. Overall positivity for H. pylori was 42.4% (182/429). The positivity rate of H. pylori was 38.8% for Jews (125/322) and 53.2% for Arabs (57/107) in Lod (P < 0.01). When immigrants were excluded, the difference in H. pylori positivity did not reach statistical significance (45.0% [77/171] vs. 53.2% [57/107], P = 0.217, in Jews and Arabs, respectively).

Conclusions: H. pylori infection was more common in Arabs that Jews in the mixed city of Lod, Israel. This finding may suggest that non-environmental factors were responsible for the observed difference in H. pylori positivity.

Background: Little is known about phenotypical variations among ethnic groups in patients with Parkinson's disease (PD) in Israel. Clinical characteristics of non-Ashkenazi Jews (NAJ) are scantly described.

Objectives: To describe clinical aspects of PD in ethnic groups in Israel, focusing on NAJ and Ashkenazi Jews (AJ).

Methods: In this cross-sectional retrospective study, we collected demographic, genetic, and clinical characteristics of patients from different ethnic Jewish backgrounds. Ethnic groups included AJ; North African Jews (NAFJ); oriental Jews (OJ) originating from Iran, Iraq, and Buchara; Balkan Jews; Yemenite Jews (YJ); and Jews of mixed origin. Clinical characteristics included hyposmia, urinary complaints, constipation, and rapid eye movement sleep behavioral disorder. Cognitive complaints, motor features, levodopa-induced dyskinesia, and motor fluctuations were collected. Motor part of the MDS-UPDRS and Hoehn and Yahr scores were collected.

Results: The study comprised 174 PD Jewish patients (63.2% AJ, 56.4% males). The age at onset was 65.3 ± 10.2 years; 106 patients (60.9%) were genotyped (17 glucocerebrosidase [16.0%], 13 leucine-rich repeat kinase 2 [LRRK2] [12.3%]). Rates of hyposmia were significantly higher in AJ than NAJ (56.6% vs. 39.5%, respectively, P = 0.003). No significant differences were found in motor features in all variables. Of 13 AJ patients carrying the LRRK2 mutation, only one had hyposmia. Three patients with LRRK2 were NAJ.

Conclusions: Hyposmia is less prevalent in PD patients of NAJ origin than in AJ. The rate of hyposmia in NAFJ patients is particularly low. The rate of other non-motor features is similar between NAJ and AJ patients.

Background: Implantable loop recorders (ILRs) are a central tool in the evaluation of unexplained syncope. These devices record and store electrocardiograms, both automatically and on patient-dependent activation. Therefore, obtaining optimal diagnostic results relies on a patient's comprehension and collaboration.

Objectives: To evaluate the effect of ethnic background and mother-tongue language on the diagnostic yield (DY) of ILRs.

Methods: Patients at two medical centers in Israel, who had ILRs as part of syncope workup were included. Inclusion criteria were age over 18 years and an ILR for at least one year (or less if the cause of syncope was detected). Patient demographics, ethnic background, and previous medical history were recorded. All findings from ILR recordings, activation mode (manual vs. automatic), and treatment decisions (none, ablation, device implantation) were collected.

Results: The study comprised 94 patients, 62 Jews (i.e., ethnic majority) and 32 non-Jews (i.e., ethnic minority). While baseline demographic characteristics, medical history, and drug therapy were similar in both groups, Jewish patients were significantly older at the time of device implantation: 64.3 ± 16.0 years of age vs. 50.6 ± 16.9, respectively; (P < 0.001). Arrhythmias recorded in both groups as well as treatment decisions and device activation mode were similar. Total follow-up time from device implantation was longer in the non-Jewish vs. the Jewish group (17.5 ± 12.2 vs. 24.0 ± 12.4 months, respectively; P < 0.017).

Conclusions: The DY of ILR implanted for unexplained syncope did not seem to be influenced by patient's mother-tongue language or ethnicity.

Background: Epidemiological studies have shown a connection between ethnic origin and the incidence and outcome of systemic lupus erythematosus (SLE).

Objective: To evaluate the SLE outcomes among Ashkenazi Jews, non-Ashkenazi Jews, and Arabs.

Methods: We conducted a retrospective study of patients who were diagnosed with SLE and followed in lupus clinics at two large tertiary medical centers. The data were obtained from patient medical records. Patients were stratified into three ethnic origins: Ashkenazi Jews, non-Ashkenazi Jews, and Arabs. The primary outcomes were all-cause mortality, development of end-stage kidney disease (ESKD), and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) 2K ≤ 4 at last visit.

Results: We included 570 patients in this study. The Arab group showed the highest number of SLE classification criteria at diagnosis and last encounters compared to non-Ashkenazi and Ashkenazi Jewish groups (6.0 vs. 5.0 and 4.0, respectively at diagnosis, P < 0.001; 8.0 vs. 7.0 and 6.0 at last visit, P = 0.01). In multivariate models, Arab patients had three times higher risk of all-cause mortality than Ashkenazi Jews (hazard ratio 2.99, 95% confidence interval [95%CI] 1.32–6.76, P = 0.009). ESKD was similar among the study groups. Low disease activity (SLEDAI 2K ≤ 4) at last visit was lower in the Arab group than the Ashkenazi Jews (odds ratio 0.50, 95%CI 0.28–0.87, P = 0.016), depicting a medium-to-high disease activity among the former.

Conclusions: Physicians should consider the influence of the ethnicity of the SLE patient when deciding on their care plan.

Background: Up to 60% of inflammatory bowel disease (IBD) patients treated with infliximab develop antibodies to infliximab (ATI), which are associated with low drug levels and loss of response (LOR). Hence, mapping out predictors of immunogenicity toward infliximab is essential for tailoring patient-specific therapy. Jewish Sephardi ethnicity, in addition to monotherapy, has been previously identified as a potential risk factor for ATI formation and infliximab failure.

Objectives: To explore the association between Jewish sub-group ethnicity among patients with IBD and the risk of infliximab immunogenicity and therapy failure. To confirm findings of a previous cohort that addressed the same question.

Methods: This retrospective cohort study included all infliximab-treated patients of Jewish ethnicity with regular prospective measurements of infliximab trough levels and ATI. Drug and ATI levels were prospectively measured, clinical data was retrieved from medical charts.

Results: The study comprised 109 Jewish patients (54 Ashkenazi, 55 Sephardi) treated with infliximab. There was no statistically significant difference in proportion of ATI between Sephardi and Ashkenazi patients with IBD (32% Ashkenazi and 33% Sephardi patients developed ATI, odds ratio [OR] 0.944, P = 0.9). Of all variables explored, monotherapy and older age were the only factors associated with ATI formation (OR 0.336, 95% confidence interval 0.145–0.778, P = 0.01, median 34 vs. 28, interquartile range 28–48, 23–35 years, P = 0.02, respectively).

Conclusions: Contrary to previous findings, Sephardi Jewish ethnicity was not identified as a risk factor for ATI formation compared with Ashkenazi Jewish ethnicity. Other risk factors remained unchanged.

Background: Lung cancer is the most common cause of cancer-related death.

Objectives: To identify changing patterns of lung cancer and its histologic subtypes among different population groups in Israel over a 25 year period.

Methods: Primary lung cancers, all types and all stages, diagnosed during 1990–2014 were recorded in the Israel National Cancer Registry database. Demographic information was retrieved from the National Population Register. Age-standardized rates for the different subgroups were calculated for each year. Joinpoint software was used to analyze trends in incidence.

Results: We identified 42,672 lung cancer cases. The most common histology was adenocarcinoma (34%), followed by squamous cell carcinoma (19%), large cell/not-otherwise-specified (19%), other histologies (15%), and small cell lung cancer (11%). The adenocarcinoma incidence rose from 25.7% to 48.2% during the examined period. Large cell/not-otherwise-specified incidence peaked around 2005–2006 and declined after. Lung cancer incidence increased significantly for the population overall and specifically in Arab females, followed by Jewish females and by Arab males. Adenocarcinoma and small cell lung cancer increased in Jewish females and in Arab males. A younger age of diagnosis was seen in Arab compared to Jewish patients.

Conclusions: Jewish females and Arab males and females living in Israel demonstrated a constant increase in lung cancer incidence, mostly in adenocarcinoma and small cell lung cancer incidence. In addition, a younger age of diagnosis in Arabs was noted. Smoking reduction interventions and screening should be implemented in those populations.

Background: Survivors of acute myocardial infarction (AMI) are at increased risk for recurrent cardiac events and tend to use excessive healthcare services, thus resulting in increased costs.

Objectives: To evaluate the disparities in healthcare resource utilization and costs throughout a decade following a non-fatal AMI according to sex and ethnicity groups in Israel.

Methods: A retrospective study included AMI patients hospitalized at Soroka University Medical Center during 2002–2012. Data were obtained from electronic medical records. Post-AMI annual length of hospital stay (LOS); number of visits to the emergency department (ED), primary care facilities, and outpatient consulting clinics; and costs were evaluated and compared according sex and ethnicity groups.

Results: A total of 7685 patients (mean age 65.3 ± 13.6 years) were analyzed: 56.8% Jewish males (JM), 26.6% Jewish females (JF), 12.4% Bedouin males (BM), and 4.2% Bedouin females (BF). During the up-to 10-years follow-up (median 5.8 years), adjusted odds ratios [AdjOR] for utilizations of hospital-associated services were highest among BF (1.628 for LOS; 1.629 for ED visits), whereas AdjOR for utilization of community services was lowest in BF (0.722 for primary clinic, 0.782 for ambulatory, and 0.827 for consultant visits), compared with JM. The total cost of BF was highest among the study groups (AdjOR = 1.589, P < 0.01).

Conclusions: Long-term use of hospital-associated healthcare services and total costs were higher among Bedouins (especially BF), whereas utilization of ambulatory services was lower in these groups. Culturally and economically sensitive programs optimizing healthcare resources utilization and costs is warranted.

Background: Crohn’s disease and ulcerative colitis are the two major classic presentations of inflammatory bowel diseases (IBD). Studies have shown a wide variation in the incidence and prevalence attributed to different geographic and ethnic populations.

Objectives: To assess the clinical characteristics of IBD among Arabs in Israel and to compare them to characteristics of IBD among Ashkenazi Jews.

Methods: This retrospective, comparative study compared the clinical characteristics of IBD among 150 Arabs from the Holy Family Hospital and the Nazareth Hospital EMMS, both located in Nazareth, Israel, to those of 97 age- and sex-matched Ashkenazi Jewish patients from Shaare Zedek Medical Center, Jerusalem, Israel.

Results: The Arab cohort, which included 106 patients (70%) with Crohn's disease and 44 (29%) with ulcerative colitis, was compared to 97 Ashkenazi patients (81% with Crohn's disease and 17% with ulcerative colitis) (P < 0.05). Alcohol consumption was found in both groups, but Arabs smoked more (46% vs. 12%, respectively, P < 0.05). Obstructive phenotype was lower in Arabs (10% vs. 32%, P < 0.05). 5-aminosalicylic acid and anti-tumor necrosis factor alpha were prescribed for the Arab and Ashkenazi groups (89% and 21%, respectively). The need for surgical intervention due to disease severity and/or complications was not significant (22% vs. 24%).

Conclusions: Despite similar reports of NOD2/CARD15 mutations, Crohn's disease is more common than ulcerative colitis within the Arab-Israeli population. Increased smoking rates may explain milder disease severities in Arabs, as reflected by lower obstructive pattern and frequent use of milder therapeutic modalities.

Background: In Israel, coronary heart disease mortality rates are significantly higher among the Arab population than the Jewish population. Dyslipidemia prevention should begin in childhood.

Objectives: To identify sociodemographic disparities in the preventive health measurement of lipid profile testing and lipoprotein levels among Israeli children and adolescents.

Methods: A cross-sectional analysis of 1.2 million children and adolescents insured by Clalit Health Services between 2007 and 2011 was conducted using sociodemographic data and serum lipid concentrations.

Results: Overall, 10.1% individuals had undergone lipid testing. Those with male sex (odds ratio [OR] = 0.813, 95% confidence interval [95%CI] 0.809–0.816), Arab ethnicity (OR = 0.952, 95%CI 0.941–0.963), and low socioeconomic status (SES) (OR = 0.740, 95%CI 0.728–0.752) were less likely to be tested. By 2010, differences among economic sectors narrowed and Arab children were more likely to be tested (OR = 1.039, 95%CI 1.035–1.044). Girls had higher total cholesterol, triglyceride, low-density lipoprotein-cholesterol, and non-high-density lipoprotein-cholesterol levels compared to boys (P < 0.001). Jewish children had higher cholesterol and low-density and high-density lipoprotein-cholesterol, as well as lower triglyceride levels than Arabs (P < 0.001). Children with low SES had lower cholesterol, low-density and high-density lipoprotein-cholesterol, and non-high-density lipoprotein-cholesterol levels (P < 0.001).

Conclusions: We found that boys, Arab children, and those with low SES were less likely to be tested. Over time there was a gradual reduction in these disparities. Publicly sponsored healthcare services can diminish disparities in the provision of preventive health among diverse socioeconomic groups that comprise the national population.

Background: The prevalence of Helicobacter pylori varies geographically by age, race, and socioeconomic status (SES). However, the impact of ethnicity on endoscopic outcomes in infected individuals is not well known.

Objectives: To assess the impact of ethnicity among Israelis with biopsy-proven H. pylori infection.

Methods: A retrospective study, including patients who underwent gastroscopy and were diagnosed histologically with H. pylori infection, was conducted. Information on demographics, SES, medications, and co-morbidities were extracted from medical records. Univariate (Student's t-test, chi-square test) and multivariate (multinomial and logistic) regression analysis were conducted to examine the predictors of the clinical outcome.

Results: The study included 100 Israeli Jews and 100 Israeli Arabs diagnosed with biopsy-proven H. pylori infection. At univariate analysis, the number of households was higher among Arabs (P < 0.001), whose family income and parental education were lower than among Jews (P < 0.001 for both variables). The response to amoxicillin and clarithromycin differed between the two groups, being higher among Jews (P < 0.001).In clinical outcomes (gastritis severity, gastric and duodenal ulcer, intestinal metaplasia, atrophic gastritis, and MALT), no statistically significant differences could be detected between Jews and Arabs. Concerning intestinal metaplasia, lack of consumption of nonsteroidal anti-inflammatory drugs resulted a statistically significant protective factor (odds ratio 0.128, 95% confidence interval 0.024–0.685, P = 0.016).

Conclusions: Although in the literature ethnicity seems to be a risk factor for H. pylori colonization, no statistical significance was detected in various endoscopic and histological findings related to H. Pylori infection between Israeli Arabs and Jews.

Background: Mortality and decrease in function after hip fracture are significantly related to patient factors including age, gender, co-morbidities, and mental status. Several studies demonstrated ethnic disparities in incidence, mortality, and functional outcome after hip fractures in the United States.

Objectives: To assess the relationship between ethnicity and hip fracture incidence and outcomes of mortality, functional change, and perioperative complications in the Israeli population.

Methods: We reviewed our institutional hip fracture registry for all patients from 2014–2015. Patients with incomplete data, < 60 years of age, or pathologic and periprosthetic fractures were excluded. Our study comprised 693 patients. Ethnicity was based on country of birth. Specifically, for those born in Israel, the nationality of either Jewish or Arab was further dichotomized. Perioperative complications, mortality, and mobility status at 1 year follow-up were recorded. The ethnicities of 27,130 patients admitted to the medicine and surgical wards during the same time interval served as a control group for the hip fracture cohort.

Results: Immigrants from Europe and America had the highest incidence of hip fractures. Fracture types varied in incidence in groups with 70% of extracapsular hip fractures occurring in Arabs and immigrants from Eastern countries, compared to 60% in immigrants from Western countries and the former Soviet Union. Mortality, perioperative complications, and mobility at 1 year were similar in all ethnic groups.

Conclusion: Our study demonstrated significant differences in incidence and fracture characteristic among ethnicities, but no difference in patient outcome. These findings differed from the available North American studies.

Background: Coronary artery disease (CAD) has known risk factors. Individual risks related to specific ethnicities are complex and depend on genetic predisposition and lifestyle.

Objectives: To compare the nature and prevalence of risk factors in Arab and non-Arab ethnic patients with symptomatic obstructive CAD referred for coronary angiography.

Methods: CAD, defined as coronary angiography with a ≥ 50% narrowing in ≥ 1 vessel, was diagnosed in 1029 patients admitted to a medical center between April 2014 and October 2015. Patients were divided into two groups according to ethnic origin: Arab vs. non-Arab. Demographics, clinical presentation, and coronary risk profiles were compared.

Results: The diagnosis of CAD was made during ST-elevation myocardial infarction (STEMI) in 198 patients (19%) who arrived at the clinic, 620 (60%) with unstable angina/non-STEMI, and 211 (21%) with stable angina. Patients with symptomatic CAD and Arab ethnicity were 47% more prevalent than non-Arab patients presenting with CAD. The Arab patients were appoximately 5 years younger, 50% more likely to be active smokers, 25% more likely to be obese, and more likely to have a family history of CAD. Other coronary risk factors were similar between the two groups.

Conclusions: Smoking and obesity, which are potentially modifiable CAD risk factors, stood out as major risk factors, in addition to genetic disposition, among Arab and non-Arab patients with symptomatic CAD. Screening and educational interventions for smoking cessation, obesity control, and compliance to treatment of co-morbidities should be attempted in order to decrease CAD in the Arab population.

Background: Little is known about the incidence of urinary tract infections (UTI) in the dispersed Bedouin population. UTIs are routinely treated empirically according to local resistance patterns, which is important when evaluating the risk factors and antibiotic resistance patterns in the Bedouin population.

Objectives: To analyze risk factors, pathogens, and antibiotic resistance patterns of UTIs in the Bedouin population compared to the general population in southern Israel. To compare data from this study to that from a previous study conducted at our center.

Methods: We prospectively followed all patients hospitalized with community acquired UTIs during a 4 month period at Soroka Medical Center. We also compared results from this study to those from a study conducted in 2000.

Results: The study comprised 223 patients: 44 Bedouin (19.7%), 179 (80.3) non-Bedouin; 158 female (70.9%), 65 male (29.1). The Bedouin were younger (51.7 vs. 71.1 years of age, P < 0.001) and had a lower Charlson Comorbidity Index (2.25 vs. 4.87, P < 0.001). Enterobacteriaceae were the most common pathogens identified, and Escherichia coli (E. coli) was the most common with 156 (70%) strains identified, followed by Klebsiella spp. with 29 (13%), Proteus spp. with 18 (8%), pseudomonas with 9 (4%), and other bacteria including enterococci with 11 (5%). The prevalence of E. coli increased significantly from 56% in 2000 to 70% in this study. We also noted an increase in community acquired extended spectrum beta lactamase (ESBL) pathogens from 4.5% in 2000 to 25.5% in the present study. No statistically significant difference was observed between the Bedouin and general populations in the causal pathogens, resistance to antibiotics, length of therapy, and readmission rate within 60 days. 

Conclusions: The Bedouin population hospitalized for UTIs is younger and presents with fewer co-morbidities. Isolated pathogens were similar to those found in the general population as was the presence of drug resistant infections. Overall, a substantial percentage of pathogens were resistant to standard first-line antibiotics, driving the need to change from empiric therapy to aminoglycoside therapy.