E. Bamberger, N. Lahat, V. Gershtein, R. Gershtein, D. Benilevi, S. Shapiro, I. Kassis, L. Rubin and I. Srugo
Background: Whereas the diagnosis of classical pertussis has traditionally been based on clinical criteria, increasing numbers of atypical presentations suggest the need for an extensive laboratory-based approach.
Objectives: To assess the relative efficacy of clinical and laboratory methods in the diagnosis of Bordetella pertussis by patient age and immunization status.
Methods: We compared the clinical and laboratory diagnosis of B. pertussis in 87 pre-vaccinated, 78 recently vaccinated, and 75 post-vaccinated children with suspected pertussis. Serum and nasopharyngeal swabs were obtained for serology, culture and polymerase chain reaction.
Results: PCR[1] and culture identified 41% and 7% of patients with B. pertussis, respectively (P < 0.001). All positive cultures were PCR-positive. Positive PCR was less common among those recently vaccinated than among those in the pre- (P < 0.001) and post-vaccinated groups (P < 0.05). Positive culture was more common among those pre-vaccinated than among those recently vaccinated (P < 0.01). Positive tests for immunoglobulin M and A were more common among the post-vaccinated than the pre- and recently vaccinated (P < 0.001), respectively. Logistic regression analyses revealed that clinical criteria have no significant association with infection in recently and post-vaccinated children. Among the pre-vaccinated children, whoop and cough duration were associated with a positive PCR (odds ratio 7.66 and 0.5, P < 0.001). Seventy-six percent of pre-vaccinated, 39% of recently vaccinated and 40% of post-vaccinated children with positive PCR did not meet the U.S. Centers for Disease Control diagnostic criteria for B. pertussis.
Conclusions: PCR is a useful tool for pertussis diagnosis, particularly in pre-vaccinated infants. The yield of culture and serology is limited, especially among pre- and recently vaccinated children. In pre-vaccinated infants with whoop and less than 2 weeks of cough, PCR testing should be implemented promptly.
D. Harats, E. Leibovitz, M. Maislos, E. Wolfovitz, T. Chajek-Shaul, E. Leitersdorf, D. Gavish, Y. Gerber and U. Goldbourt, for the HOLEM study group
Background: Hypercholesterolemia control status is lacking throughout the western world.
Objectives: To examine whether the treatment recommendations given to ischemic heart disease patients at hospital discharge are compatible with the guidelines of the Israeli Medical Societies and the U.S. National Cholesterol Education Program for coronary artery disease prevention; and to study the effects of brief educational sessions on the adherence of physicians with the guidelines.
Methods: We included consecutive IHD[1] patients admitted to four central hospitals in Israel between 1998 and 2000. The study was conducted in two phases. In phase 1, we reviewed discharge letters to document treatment recommendations given to each patient. In phase 2 we educated the practitioners by reviewing the Israeli Medical Societies and the NCEP[2] guidelines and the quality of their recommendations in phase 1, after which we reevaluated the discharge letters.
Results: The study included 2,994 patients: 627 in phase 1 and 2,367 in phase 2. Of the patients who needed cholesterol-lowering according to their low density lipoprotein levels, 37.4% were not prescribed such drugs at discharge (under-treatment group). This proportion was reduced by education to 26.6% (P < 0.001) in phase 2. Of the treated patients, 65.6% did not reach the target LDL[3] goal in phase 1 (under-dosage group) as compared to 60.2% in phase 2 (P = 0.23). In phase 2 there was an increase in the percent of patients reaching LDL levels <130 mg/day (69.3% vs. 63.8% of patients prescribed medication, P = 0.01), but the percent of patients reaching LDL levels <100 was not different in phase 2 after adjusting for age and gender (the odds ratio for reaching target LDL was 1.16, with 95% confidence interval of 0.95–1.43).
Conclusions: Physician recommendations to IHD patients discharged from hospital were suboptimal. We documented a high proportion of under-treated and under-dosage patients. Brief educational sessions have a beneficial effect on the usage of statins; however, additional effort in guideline implementations is needed.
R. Ben-Ami, Y. Siegman-Igra, E. Anis, G.J. Brook, S. Pitlik, M. Dan and M. Giladi
Background: Short trips to holiday resorts in Mombassa, Kenya, have gained popularity among Israelis since the early 1990s. A cluster of cases of malaria among returned travelers raised concern that preventive measures were being neglected.
Objectives: To characterize the demographic and clinical features of malaria acquired in Kenya, and to assess the adequacy of preventive measures.
Methods: Data were collected from investigation forms at the Ministry of Health. All persons who acquired malaria in Kenya during the years 1999–2001 were contacted by phone and questioned about use of chemoprophylaxis, attitudes towards malaria prevention, and disease course. Further information was extracted from hospital records.
Results: Kenya accounted for 30 of 169 (18%) cases of malaria imported to Israel, and was the leading source of malaria in the study period. Of 30 malaria cases imported from Kenya, 29 occurred after short (1–2 weeks) travel to holiday resorts in Mombassa. Average patient age was 43 ± 12 years, which is older than average for travelers to tropical countries. Only 10% of the patients were fully compliant with malaria chemoprophylaxis. The most common reason for non-compliance was the belief that short travel to a holiday resort carries a negligible risk of malaria. Only 3 of 13 patients (23%) who consulted their primary physician about post-travel fever were correctly diagnosed with malaria. Twenty percent of cases were severe enough to warrant admission to an intensive care unit; one case was fatal.
Conclusions: Measures aimed at preventing malaria and its severe sequelae among travelers should concentrate on increasing awareness of risks and compliance with malaria chemoprophylaxis.
A. Kessler, H. Gavriel, S. Zahav, M. Vaiman, N. Shlamkovitch, S. Segal and E. Eviatar
Background: Fine-needle aspiration biopsy has been well established as a diagnostic technique for selecting patients with thyroid nodules for surgical treatment, thereby reducing the number of unnecessary surgical procedures performed in cases of non-malignant tumors.
Objectives: To evaluate the sensitivity, specificity, accuracy, and positive and negative predictive values of FNAB[1] in cases of a solitary thyroid nodule.
Methods: The preoperative FNAB results of 170 patients who underwent thyroidectomy due to a solitary thyroid nodule were compared retrospectively with the final postoperative pathologic diagnoses.
Results: In cases of a solitary thyroid nodule, FNAB had a sensitivity of 79%, specificity of 98.5%, accuracy of 87%, and positive and negative predictive values of 98.75% and 76.6% respectively. All cases of papillary carcinoma diagnosed by FNAB proved to be malignant on final histology, while 8 of 27 cases of follicular adenoma detected by preoperative FNAB were shown to be malignant on final evaluation of the surgical specimen.
Conclusions: FNAB cytology reduces the incidence of thyroidectomy since this method has excellent specificity and sensitivity and a low rate of false-negative results. It proved to be cost-effective and is recommended as the first tool in the diagnostic workup in patients with thyroid nodules.
R. Krakover, A. Blatt, A. Hendler, I. Zisman, M. Reicher, J. Gurevich, E. Peleg, Z. Vered and E. Kaluski
Background: Coronary sinus is a venous conduit with dynamic and unclear function with regard to coronary circulation.
Objectives: To describe the dynamic changes of the coronary sinus during the cardiac cycle.
Methods: The angiographic feature of the coronary sinus was evaluated in 30 patients undergoing diagnostic and therapeutic coronary angiography.
Results: Prolonged angiographic imaging following coronary injections permitted accurate demonstration of the coronary sinus in all 30 patients. We report, for the first time, that the coronary sinus can be divided into two angiographic functional/anatomic portions, upper and lower. The lower part is prone to a highly dynamic contraction/relaxation pattern, observed in 12 of the 30 patients, while 10 patients had normal and 8 had low contractile pattern on angiography. Clinical assessment of these patients did not identify an association with this motion pattern.
Conclusions: The coronary sinus is an important anatomic/functional structure that should be further investigated in patients with various forms of heart disease.
Z. Laron, H. Lewy, I. Wilderman, A. Casu, J. Willis, M.J. Redondo, I. Libman, N. White and M. Craig
Background: Type 1 childhood-onset diabetes mellitus has a multifactorial origin involving an interplay between genetic and environmental factors. We have previously shown that many children who subsequently develop T1DM[1] have a different seasonality of birth than the total live births of the same population, supporting the hypothesis that perinatal viral infection during the yearly epidemics are a major trigger for the autoimmune process of T1DM.
Objectives: To compare the seasonality of children with T1DM in different populations around the world for which data were available.
Methods: We analyzed large cohorts of T1DM patients with a clinical disease onset before age 14 or 18 years.
Results: We found a seasonality pattern only in ethnically homogenous populations (such as Ashkenazi Jews, Israeli Arabs, individuals in Sardinia and Canterbury, New Zealand, and Afro-Americans) but not in heterogeneous populations (such as in Sydney, Pittsburgh and Denver).
Conclusions: Our findings attempt to explain the controversial data in the literature by showing that ethnically heterogeneous populations with a mixture of patients with various genetic backgrounds and environmental exposures mask the different seasonality pattern of month of birth that many children with diabetes present when compared to the general population.
J.H. Passwell and Z. Spirer