Israel Medical Association Journal

Background: The fish-eating habits of Israelis who present with impacted fish bones in the aerodigestive tract are unknown.

Objectives: To retrospectively investigate the relation between an impacted fish bone in the aerodigestive tract, the species of fish, and the place of occurrence in an Israeli population.

Methods: The current prospective observational study included all patients with aerodigestive impacted fish bones who were treated in our emergency department from 1 September 2008 to 30 September 2009. The data retrieved from their medical records included age, gender, place of event (at home or elsewhere), species of fish, and method of removing the bone.

Results: A total of 108 patients aged 1.5–87 years (median 48 years), 52.8% female, met the study criteria. Most (87%) of the events occurred at home, and 50.9% occurred during the weekend (Friday- Saturday). The bones were from low-priced fish (e.g., carp, hake) in 62% of the cases, high-priced fish (e.g., salmon, red snapper) in 30.5%, and of unknown species in 10.2%. The proportion of cases in which the fish bone belonged to a high-priced fish eaten out of the home was significantly higher than the cases in which a low-priced fish was eaten at home (64.3% vs. 22.3%, P = 0.04). One hundred bones were removed during direct oral inspection and 8 bones were removed under general anesthesia by endoscopy.

Conclusions: Most fish bone impactions in the aerodigestive tract in central Israel involve low-priced fish and take place at home over the weekend.
 

Background: Infertility is one of the most prevalent health disorders in young adults.

Objectives: To study the distribution of causes of infertility in couples referred to primary infertility clinics in Israel.

Methods: Data for a 9 year period were derived from two clinics of major women's hospitals run by the country's largest health insurance funds. All patients were treated by one physician. Laparoscopy was not performed to rule out endometriosis.

Results: Of the 2515 couples identified, 1991 (79.2%) had a definitive diagnosis following complete workup (including hysterosalpingography). Mean age was 29.6 ± 6.0 years; mean duration of infertility was 1.7 ± 1.8 years. Primary infertility accounted for 65% of cases. Causes of infertility were male factor (45%), oligo-ovulation disorders (37%), and tubal damage (18%). Infertility factors were identified in the woman alone in 30.6% of cases and the man alone in 29.2%. Two combined infertility factors were found in 18% of patients, and three combined factors in 0.5%. The rate of unexplained infertility (which probably includes non-tubal endometriosis) was 20.7%.

Conclusions: As male factor accounts for almost half of all cases of infertility in couples, sperm analysis is mandatory before any treatment.
 

Background: Traditionally, medication dosage was based on clinical and demographic parameters, but drug metabolism was recently recognized as an important factor for proper dosing and prediction of side effects. Metabolic considerations are crucial when administering drugs with a narrow therapeutic index, such as those of the thioguanides family (azathioprine and 6-MP). These can cause life-threatening myelosuppression due to low activity of a critical metabolic enzyme, thiopurine S-methyl transferase. A number of single nucleotide substitutions encoding variant enzymes account for most enzyme deficiencies.

Objectives: To determine the frequency of individuals from different Israeli ethnic groups who may be at risk for drug toxicity from drugs of the thioguanide family due to enzymatic variants.

Methods: DNA analysis was performed using polymerase chain reaction methods. We tested TPMT[1] allelic variants TPMT*3A (G460A, A719G), TPMT*3B (G460A) and TPMT*3C (A719G) in five subpopulations in Israel: mixed-origin Israeli Jews, Arabs, Druze, Jews of Kurdish extraction, and Ethiopian Jews.

Results: The Druze (P = 0.0002) and Ethiopian Jewish (P = 0.015) subpopulations had a significantly unique distribution of allelic variants compared to the rest of the Israeli population. The Druze subpopulation showed a high number of TPMT variants with decreased activity, and a homozygote for TPMT*3A/ *3A was detected.  Ethiopian Jews were found to carry mainly the TPMT*3C variant, also observed in other studies of African populations.

Conclusions: It is advisable that Druze patients be tested for the TPMT enzyme before starting treatment with 6-MP or azathioprine. Such testing may also be considered for other Israeli ethnic subgroups.

Background: Appropriate antibiotic use is of both clinical and economic significance to any health system and should be given adequate attention. Prior to this study, no in-depth information was available on antibiotic use patterns in the emergency department of Hadassah Medical Center.

Objectives: To describe the use and misuse of antibiotics and their associated costs in the emergency department of Hadassah Medical Center.

Methods: We analyzed the charts of 657 discharged patients and 45 admitted patients who received antibiotics in Hadassah Medical Center’s emergency department during a 6 week period (29 April – 11 June 2007). A prescription was considered appropriate or inappropriate if the choice of antibiotic, dose and duration by the prescribing physician after diagnosis was considered suitable or wrong by the infectious diseases consultant evaluating the prescriptions according to Kunin’s criteria.

Results: The overall prescribing rate of antibiotics was 14.5% (702/4830) of which 42% were broad- spectrum antibiotics. The evaluated antibiotic prescriptions numbered 1105 (96 prescriptions containing 2 antibiotics, 2 prescriptions containing 3 antibiotics), and 54% of them were considered appropriate. The total inappropriate cost was 3583 NIS[1] (1109 USD PPP[2]) out of the total antibiotic costs of 27,300 NIS (8452 USD PPP). The annual total antibiotic cost was 237,510 NIS (73,532 USD PPP) and the annual total inappropriate cost was 31,172 NIS (9648 USD PPP). The mean costs of inappropriate prescriptions were highest for respiratory (112 NIS, 35 USD PPP) and urinary tract infection (93 NIS, 29 USD PPP). There were more cases when the optimal cost was lower than the actual cost (N=171) than when optimal cost was higher than the actual cost (N=9). In the first case, the total inappropriate costs were 3805 NIS (1,178 USD PPP), and in the second case, -222 NIS (68.7 USD PPP).

Conclusions: The use of antibiotics in emergency departments should be monitored, especially in severely ill patients who require broad-spectrum antibiotics and for antibiotics otherwise restricted in the hospital wards. Our findings indicate that 12% of the total antibiotic costs could have been avoided if all prescriptions were optimal.

Background: Professional volunteers play a crucial role in reinforcing emergency medical services in Israel. In order to encourage volunteers to return for additional shifts, the organization should provide conditions that will assure the return, particularly at a time of self-risk such as war. In 2009 Israeli emergency medical services (Magen David Adom) were required to increase preparedness in the southern part of the country due to missile attacks on civilian populations, while continuing their routine activities, i.e., responding promptly to emergency events. In order to perform these multiple functions, MDA[1] stations in the towns under attack were strengthened with volunteers from other regions of the country. These volunteers, trained as paramedics, served in 24–48 hour shifts.

Objectives: To identify the factors influencing the willingness of volunteers to return.

Methods: A questionnaire was used to assess the satisfaction of volunteers participating in the reinforcement with regard to their physical environment, job assignment and the actual activity they were involved in. Data were analyzed using SPSS statistical software.

Results: During the 10 days of the study, 121 volunteers reinforced southern MDA stations and 99 (81%) of them responded to the questionnaire. We found that volunteers' willingness to return to do more shifts was affected by their welcome and reception at the station, their job assignment, and their training and preparation for performing the necessary tasks. The sleeping conditions and the number of events they participated in were also contributing factors.

Conclusions: Factors that contribute to the willingness of volunteers to re-volunteer should be taken into account by organizations that rely on them.

Background: Trans-aortic pressure gradient in patients with aortic stenosis and left ventricular systolic dysfunction is typically low but occasionally high.

Objectives: To examine the distribution of trans-aortic PG[1] in patients with severe AS[2] and severe LV[3] dysfunction and compare the clinical and echocardiographic characteristics and outcome of patients with high versus low PG.

Methods: Using the echocardiographic laboratory database at our institution, 72 patients with severe AS (aortic valve area ≤ 1.0 cm²) and severe LV dysfunction (LV ejection fraction ≤ 30%) were identified. The characteristics and outcome of these patients were compared.

Results: PG was high (mean PG ≥ 35 mmHg) in 32 patients (44.4%) and low (< 35 mmHg) in 40 (55.6%). Aortic valve area was slightly smaller in patients with high PG (0.63 ± 0.15 vs. 0.75 ± 0.16 cm² in patients with low PG, P = 0.003), and LV ejection fraction was slightly higher in patients with high PG (26 ± 5 vs. 22 ± 5% in patients with low PG, P = 0.005). During a median follow-up period of 9 months 14 patients (19%) underwent aortic valve replacement and 46 patients (64%) died. Aortic valve replacement was associated with lower mortality (age and gender-adjusted hazard ratio 0.19, 95% confidence interval 0.05–0.82), whereas trans-aortic PG was not (P = 0.41).

Conclusions: A large proportion of patients with severe AS have relatively high trans-aortic PG despite severe LV dysfunction, a finding partially related to more severe AS and better LV function. Trans-aortic PG is not related to outcome in these patients.

Background: It is currently recommended that capillary glucose levels of non-critically ill hospitalized diabetic patients be maintained at between 140 and 180 mg/dl. Implementation of these recommendations and evaluation of their effectiveness require that data regarding the glucose control of these hospitalized patients be accessible.

Objective: To analyze glucose control and monitoring of all the diabetic patients hospitalized in the general medicine wards of our medical center.

Methods: Capillary glucose measurements of all diabetic patients hospitalized in our departments of medicine between June and December 2008 were recorded by a central computerized institutional glucometer. Median glucose values and frequency of daily glucose checks per patient were analyzed in the internal medicine wards.

Results: We evaluated 14,366 capillary measurements from 2475 patients; 43% were taken before breakfast and 25% before dinner. A median of one daily determination per patient was obtained. This number increased 1.4-fold in patients with hyperglycemia > 200 mg/dl and 2.5-fold in patients with hypoglycemia. Seventy-five percent of the recorded glucose values were within the recommended target range, with a median daily level of 161 mg/dl and median fasting glucose of 142 mg/dl. A significant variance was found between wards.

Conclusions: The frequency of capillary glucose measurements in diabetic patients hospitalized in general medicine wards was low; most capillary glucose values, however, were within the recommended target range. The optimal monitoring of glucose in these patients remains to be determined.

Pathological gambling is classified in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders) and in the ICD-10 (International Classification of Disease) as an impulse control disorder. The association between impulsivity and pathological gambling remains a matter of debate: some researchers find high levels of impulsivity within pathological gamblers, others report no difference compared to controls, and yet others even suggest that it is lower. In this review we examine the relationship between pathological gambling and impulsivity assessed by various neurocognitive tests. These tests – the Stroop task, the Stop Signal Task, the Matching Familiar Figures Task, the Iowa Gambling Task, the Wisconsin Card Sorting Test, the Tower of London test, and the Continuous Performance Test – demonstrated less impulsivity in gambling behavior. The differences in performance between pathological gamblers and healthy controls on the neurocognitive tasks could be due to addictive behavior features rather than impulsive behavior.

Background: Parallel to increased life expectancy, the number of very elderly patients hospitalized in internal medicine departments is growing rapidly, although clinical data on hospital care are lacking.

Objectives: To investigate the sociodemographic data, hospitalization characteristics and outcomes of nonagenarian patients, as these measures are necessary for evaluating prognostic information and predictors of mortality.

Methods: We reviewed the medical records of all patients aged ≥ 90 hospitalized in our institute's Department of Internal Medicine. The data comprised 482 admissions of 333 patients hospitalized over a one year period.

Results: Half of the study patients were residents of nursing institutions. A high rate of atrial fibrillation was documented (106 patients, 32%). Acute infectious diseases constituted the leading diagnosis (276/482 admissions, 57%), followed by acute coronary syndrome (17% of admissions). In-hospital mortality occurred in 74 patients (22%). Chronic therapy with statins or acetylsalicylic acid was inversely related to mortality (P < 0.05). The main predictors for in-hospital death of nonagenarians were pressure sores, older age, atrial fibrillation, malignant disease, and admission due to an acute infection, especially Clostridium difficile-associated diseases. In addition, mental decline, permanent urinary catheter, leukocytosis, renal failure and hypoalbuminemia predicted post-discharge mortality. Admission due to an infectious disease but not acute coronary syndrome was significantly correlated to in-hospital and post-discharge mortality (P < 0.001).

Conclusions: Hospitalized nonagenarians comprise a growing group with distinct characteristics and increasing significance in the daily practice of internal medicine departments. Comprehensive assessment of the elderly at admission together with identification of the above clinical and laboratory risk factors for mortality will help determine in-hospital management, discharge planning and rehabilitation programs.

Pancreatic cancer is not a common malignancy in Israel, but it is the third most common cause of cancer mortality, attributable to a lack of screening tests, inaccessibility of the pancreas, and late cancer stage at diagnosis. We reviewed the epidemiology, known risk factors and screening methods available in Israel and describe the Israeli national consortium that was established to identify persons at risk and decide on screening methods to detect and treat their early-stage pancreatic cancer. In collaboration with the Israel National Cancer Registry, we evaluated the incidence and trends of the disease in the Jewish and non-Jewish populations. The consortium reviewed known lifestyle risk habits and genetic causes, screening methodologies used and available in Israel. Overall, there are about 600 new patients per year, with the highest incidence occurring in Jewish men of European birth (age-standardized rate 8.11/10⁵ for 2003–06). The 5 year survival is about 5%. The consortium concluded that screening will be based on endoscopic ultrasonography. Pancreatic cancer patients and families at risk will be enrolled, demographic and lifestyle data collected and a cancer pedigree generated. Risk factors will be identified and genetic tests performed as required. This concerted national program to identify persons at risk, recommend which environmental risk factors to avoid and treat, and perform endoscopic ultrasound and genetic screening where appropriate, might reduce their incidence of invasive pancreatic cancer and/or improve its prognosis

Background: Low back pain is a common problem managed by primary care physicians and orthopedic specialists.

Objectives: To evaluate the outcome of new LBP[1] episodes in patients who chose to visit either an orthopedist or a general practitioner.

Methods: All patients visiting the orthopedist or physician during the study period were screened for a new complaint of LBP. After the initial visit the patients were interviewed by phone by means of a structured questionnaire, with a follow-up interview one month later. The study was performed at Clalit Health Services primary care and consultation clinics. A random sample of 125 GPs[2] and 17 orthopedists were chosen. Consecutively recruited were 166 patients who visited the GP and 75 the orthopedist. The main outcome measures evaluated were perceived complaint severity and degree of disturbance to everyday functioning, problem resolution, and health services utilization.

Results: Patients who decided to first visit the orthopedist indicated a higher disturbance to everyday functioning (75% vs. 70%, P < 0.01), were invited for further follow-up visits (6% vs. 51%, P < 0.05) and had more computed tomography and bone scans (20 vs. 3%, P < 0.001 and 9 vs. 2%, P < 0.05, respectively). Health status after one month showed that patients who chose the GP were more likely to have their problem solved (36 vs. 17%, P < 0.05).

Conclusions: Symptom resolution for a new LBP complaint was significantly higher in patients who decided on the GP, even when controlling for severity of illness and degree of disturbance to everyday functioning.

Background: Although febrile urinary tract infections are very common in young children, the need for antimicrobial prophylaxis and evaluation following a first event is controversial.

Objectives: To assess the approach of leading pediatric specialists throughout Israel.

Methods: A questionnaire regarding the approach to antibiotic prophylaxis and diagnostic evaluation following a first event of febrile UTI[1], according to age and underlying renal abnormality, was sent to all 58 directors of departments of pediatrics, units of pediatric infectious diseases and pediatric nephrology in Israel.

Results: Fifty-six directors (96%) responded. Most prescribed prophylactic antibiotics after UTI. Heads of infectious disease departments prescribed less prophylaxis following UTI at the age of 18 months than heads of pediatrics or heads of pediatric nephrology units (34% vs. 72–75%, P = 0.018), but more often in cases of severe vesico-ureteral reflux without UTI. Cephalosporins were used prophylactically more often by directors of pediatrics compared to heads of pediatric nephrology units (71% vs. 38%, P = 0.048); the latter used non-beta-lactam prophylaxis (61% vs. 23%, P = 0.013) more often. Most pediatricians used renal sonography for evaluation; renal scan was used more commonly by pediatric nephrologists.

Conclusions: The administration of prophylactic antibiotics after UTI is still common practice among pediatric opinion leaders, although the specific approach differs by subspecialty. According to up-to-date evidence-based data, educational efforts are needed to formulate and implement judicious guidelines.