Israel Medical Association Journal

Background: The association of carpal tunnel syndrome with occupational risk factors is well established. However, in clinical practice these factors are only rarely considered and evaluated. Managing these risk factors could prevent the occurrence of future cases and alleviate treatment of the afflicted individuals.

Objectives: To estimate the role of occupational risk factors in a large group of patients diagnosed by electro­physiological studies as suffering from CTS.

Methods: A group of 396 subjects (204 women, 165 men) who were tested in one laboratory by electrophysiological studies were further evaluated (by questionnaire) to determine the possible role of occupational and other risk factors in the etiology of their syndrome.

Results: Persons employed in high force — low repetitive or low force — high repetitive jobs, harbor an extra risk for developing CTS as compared with controls, OR=3.21 (95% C1 = 1.5-6.9) and OR=4.72 (95%C1 = 1.8-12.5), respectively. These jobs include typists/secretaries, nursing personnel, production workers and housewives.

Conclusion: Evaluation of a general group of examinees referred for electrophysiological studies on sympatology compatible with CTS may show that occupational risk factors play a substantial role in the development of symptoms. By increasing the awareness of clinicians and the public to these risk factors, appropriate preventive measures can be intro­duced and the burden of the disease reduced.

Background: Fixed dose combination therapy varies among countries.

Objective: To compare the list of fixed-dose combination therapies used in the USA, UK and Israel.

Methods: The total list of drugs and FDC drugs were counted manually from a list of generic names. We also counted the number of drugs in four characteristic subgroups:

cardiovascular, anti-infective, gastrointestinal, and dermatolo­gical. Data for drugs in the USA, UK and Israel were taken from the Physician’s Desk Reference (PDR 1997), the British National Formulary (BNF March 1997) and the Monthly Ethical Drug Indexed Compilation (MEDIC July 1997) respectively.

Results: The global percentage of FDC drugs in the USA and UK was higher than in Israel (20%, 25% and 15% respectively). A similar trend was found in all subclasses of FDC drugs except for the anti-infective category in which the percentage of FDC drugs was low and similar in all countries.

Conclusion: The list of FDC drugs varies greatly between the USA, UK and Israel. reflecting the differences in the outcome of debate between the pharmaceutical companies and the regulatory authorities.

Background: It is not clear to what extent the drug economy in Israel's health maintenance organizations is responsive to major healthcare reforms.

Objective: To provide information on how drug expendi­tures, revenues, net costs and drug utilization have changed in the wake of the 1995 National Health Insurance Law in Israel.

Methods: This study compares trends in aggregate sick fund expenditures, revenues (patient co-payment) and net costs (expenditures less revenues) in Israel's four health maintenance organizations for the 3 year period 1992-1994 prior to the introduction in 1995 of the NHI Law, with that of the 4 year period 1995-1998 following its introduction. This analysis is similarly carried out for Israel’s largest HMO, Clalit Health Services, and for the three smaller HMOs combined.

Results: The pace of growth in the pre-NHI era in drug expenditures and particularly in drug revenues was drastically reduced in the NHI era - whether measured as totals or as per insured person (age-adjusted) or in real terms at constant medicine prices. These trends were mirrored to a large extent in

Conclusions: The impact of the NHI Law on the HMO drug economy has been substantial. The evidence suggests a decline in both the qualitative (basket of drugs consumed) and quantitative (volume of drugs consumed) elements of growth. These changes in expenditure and revenue trends are discussed in the light of the evolving involvement of the Israel Ministry of Health in drug policy within the framework of the NHI, with emphasis on the basket of drugs reimbursed and co­payments for prescriptions.

Objectives: To assess mortality causes and trends over time and identify target groups with excessive mortality rates among Israeli youth aged 10-24, in order to formulate an intervention policy for prevention of adolescent mortality.

Methods: Mortality data for Israeli residents aged 10-24 were extracted from the Central Bureau of Statistics compu­terized death certificate file for the period 1984-95. Trends were evaluated by cause of death and demographic char­acteristics.

Results: The crude mortality rate among Israeli youth aged 10-24, during 1993-1995, was 39.6 per 100000. Rates were 2.7 times higher among males, increased with age, and reached a peak among 18-21 year olds. Rates were 1.4 times higher among Arabs than among Jews. The sharp increase in mortality among Jewish males of military service age (18-21 years) was due mainly to motor vehicle crashes and suicide. Although overall mortality decreased by 9.4% from 1984-86 to 1993-95, the gap between the subgroups increased. MVC­related mortality increased over time by 100% among Arab males. The rate of completed suicide among Jewish males increased by 110%. Although injury-related mortality is lower in Israel compared with the U.S., similar demographic differen­tials and trends were found in both countries.

Conclusions: Suicide among Jewish males of military service age, as well as MVC fatalities among Arab males, present a growing public health issue. Intervention strategies should therefore be targeted towards these subgroups in order to minimize the rates of preventable death.

Background: Cryosurgery is a minimally invasive treat­ment option for prostate cancer.

Objectives: To report on the first series of cryosurgical ablation for prostate cancer performed in Israel.

Methods: Cryosurgical ablation of the prostate was undertaken in 2 patients aged 53-72 diagnosed with adenocarcinoma of the prostate. The procedures were performed percutaneously and were monitored by real-time trans-rectal ultrasound. The CRYOHIT machine applying Argon gas was used with standard or ultra-thin cryoprobes. The average follow-up was 12.8 months postsurgery (range 1- 24 months).

Results: No rectal or urethral injuries occurred and all patients were discharged from hospital within 24-48 hours. The duration of suprapubic drainage was 14 days in 10 patients and prolonged in 2. Early complications included penoscrotal edema in four patients, perineal hematoma in three, hemorrhoids in two and epidydimitis in one. Long-term complications included extensive prostatic sloughing in one patient and a perineal fistula in another, both of whom required prolonged suprapubic drainage. Minimal stress incontinence was noted in two patients for the first 8 weeks after surgery. None of the patients has yet regained spontaneous potency. A prostate-specific antigen nadir of less than 0.5 ng/ml was achieved in eight patients and an undetectable PSA level below 0.1 ng/ml in five patients.

Conclusion: Cryoablation for prostate cancer is safe and feasible, and the preliminary results are encouraging. Further study is needed to elucidate the efficacy of the procedure.

Background: Familial nephritis is a heterogeneous group of disorders caused by several genetic conditions such as Alport syndrome, glomerulonephritic syndromes, and unclas­sified nephritis without deafness or ocular defects.

Objectives: To describe a family of Iraqi Jewish origin, several of whose members suffer from non-syndromic renal failure without deafness or ocular defects and where transmis­sion is by autosomal dominant inheritance. We present the case histories of four family members and describe the molecular analysis performed in order to seek a possible linkage to one of the genes causing Alport or Alport-like syndromes.

Methods: We investigated all family members over the age of 18 for evidence of renal failure. We also extracted DNA and carried out molecular linkage analysis with polymorphic markers in each of the known loci involved in Alport and Alport­like syndromes.

Results: Histology of the renal biopsy specimens showed non-specific findings. Linkage was excluded for all the Alport and Alport-like syndrome loci.

Conclusions: The condition suffered by several members of this family seems to represent a unique autosomal dominant type of progressive hereditary nephritis, characterized by hypertension and progressive renal failure without significant hematuria or proteinuria. The main histological changes are non-specific in the early stage of the disease. Our study rules out all the currently known genes that cause Alport syndrome as being responsible for the basic defect in this type of nephritis.

Background: Spinal dural arteriovenous fistulae comprise the majority of spinal vascular malformations. The most common clinical presentation is that of progressive myelor­adicuiopathy, probably related to venous hypertension, which may lead to permanent disability and even death.

Objective: To report our clinical experience with spinal dural arteriovenous fistulae.

Methods: Nine patients with spinal dural AVF were managed at our center during a one year period (1998-1999). The patients, eight men and one woman ranging in age from 46 to 75 years, presented with initially fluctuating and eventually permanent and progressive paraparesis, sensory disturbances and sphincter dysfunction. The neurological signs generally began symmetrically and progressed from the distal to proximal limb regions. The duration of symptoms before diagnosis ranged from 6 to 36 months during which the patients underwent an extensive but fruitless work-up and even unnecessary operations due to misdiagnosis. All patients finally underwent magnetic resonance imaging and spinal angiography, which demonstrated the pathological vascular fistula. Interruption of the AVF was achieved by embolization or by surgical resection.

Results: Following treatment, six patients experienced improvement of gait and sphincter control, and the severe neurological deficits stabilized in the other three patients with long duration of illness. There was no further deterioration in any of the treated patients.

Conclusions: The history, neurological findings and radiological changes on MRI scan should alert clinicians to the possibility of spinal dural AVF, leading to diagnostic spinal angiography. Early diagnosis and treatment may significantly improve outcome and prevent permanent disability and even mortality.

Background: Lower urinary tract symptoms are highly prevalent in older men, have been shown to affect men’s quality of life, and may be associated with more serious outcomes.

Objectives: To determine the prevalence of LUTS among men aged 50 years or older registered at family practice centers in Israel and to assess the effect of these complaints on different aspects of their life.

Methods: In a random sample cohort of men aged 50 years and older, fluent in Hebrew, drawn from those registered in four family clinics in Israel, patients identified with LUTS were interviewed by phone using a structured questionnaire.

Results: The prevalence of LUTS in our study was 21%. Less than a third of these patients had low severity LUTS (28%), 59% were rated moderate, and 13% had severe symptoms. Age had a positive correlation with the severity of LUTS, and increasing severity of symptoms had a negative effect on the daily function and quality of life of patients.

Conclusions: Our community-based study shows that LUTS is a common finding among men above the age of 50 (21%) and has a significant negative effect on their quality of life and daily function. Knowledge of these data should make primary care physicians more aware of this common problem and thus improve the treatment and quality of life of these patients by better identification and prompt treatment.