Israel Medical Association Journal

Background: Despite the controversy regarding the risks and benefits of hormone replacement therapy, studies in various countries indicate a two- to threefold increase in the use of HRT[1] during the last decade.

Objectives: To estimate the prevalence of HRT use among post-menopausal Jewish women in Israel and to determine the variables predicting current HRT use.

Methods: A cross-sectional telephone survey was conducted in 1998 on a random sample of Jewish women aged 45–74. Of 935 women who were located and eligible, 704 (75%) were interviewed by means of a structured questionnaire.

Results: A total of 589 women (85%) were peri-menopausal or post-menopausal.  Ninety-nine of them (16.8%) were currently using HRT and 78 (13.2%) were past users. Higher rates of current use were found among women who had undergone hysterectomy and/or oophorectomy (38%) than among all other women (13.5%).  Among naturally menopausal women the highest rate of current use (25.6%) was found in those aged 55–59.  A multiple logistic regression showed that the variables associated with current HRT use among naturally menopausal women  were: having a regular gynecologist (odds ratio 3.6, 95% confidence interval 1.7–7.5), visiting a gynecologist during the past year (OR[2] 2.9, 95% CI[3] 1.4–6.0), experiencing symptoms of menopause (OR 2.0, 95% CI 1.01–3.8), having more than a high-school education (OR 1.9, 95% CI 1.04–3.6), and a lower body mass index (OR 0.91, 95% CI 0.85–0.99).

Conclusions: The factors associated with HRT use may be markers for other socioeconomic or psychological characteristics. The disparities noted between population subgroups may be indicative of differences in awareness or in the delivery of preventive healthcare services to women in Israel, and as such need to be addressed by the health system.

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Background: Low density lipoprotein apheresis is used as a complementary method for treating hypercholesterolemic patients who cannot reach target LDL[1]-cholesterol levels on conventional dietary and drug treatment. The DALI system (direct absorption of lipoproteins) is the only extracorporeal LDL-removing system compatible with whole blood.

Objective: To describe our one year experience using the DALI[2] system.

Methods: LDL apheresis was used in 13 patients due to inability to reach target LDL-C levels on conventional treatment. They included seven patients with familial hypercholesterolemia, three who had adverse reactions to statins, and three patients with ischemic heart disease who did not reach LDL-C target level on medical treatment.

Results: The average triglyceride, total cholesterol, high density lipoprotein-C and LDL-C levels before and after treatment in all patients were: 170 ± 113 vs. 124 ± 91, 269 ± 74 vs. 132 ± 48, 42 ± 8 vs. 37 ± 7.9, and 196 ± 77 vs. 80 ± 52 mg/dl, respectively. Comparing the results of a subgroup of seven patients who had previously been treated with plasma exchange, it is noteworthy that while the reduction in triglyceride, total cholesterol and LDL-C are comparable, the effect on HDL[3]-C concentration was less apparent: from an average of 39.7 ± 8.7 and 23 ± 5.7 mg/dl before and after plasma exchange to an average of 43.9 ± 8.1 and 38.4 ± 7 mg/dl before and after LDL apheresis, respectively. Five patients developed treatment-related adverse events: three experienced allergic reactions manifested as shortness of breath, urticaria and facial flushing; one patient developed rhabdomyolysis, an adverse reaction that was not reported previously as a result of LDL apheresis; and one patient had myopathy with back pain. All untoward effects occurred during the first few treatment sessions.

Conclusions: LDL apheresis using the DALI system is highly efficacious for the treatment of hypercholesterolemia. It is associated with a significant number of side effects occurring during the first treatment sessions. In patients not experiencing adverse effects in the early treatment period, it is well tolerated, and can provide remarkable clinical benefit even after short-term therapy.

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Background: Fine-needle aspiration is a widely accepted method in the preoperative evaluation of head and neck tumors. However, its effectiveness in the interpretation of salivary gland disorders is controversial.

Objectives: To evaluate the effectiveness of FNA[1] as a preoperative diagnostic tool of parotid lesions.

Methods: Reports of 52 FNA from various parotid gland lesions were compared with the final pathologic diagnoses.

Results: We noted 31 true-positive, 5 true-negative and 16 false-negative results. There were no false-positive FNA reports. The calculated sensitivity, specificity and accuracy of FNA diagnosis in this study were 66%, 100%, and 69.2% respectively.

Conclusions: The high rate (30.8%) of false-negative FNA results was partly explained by sampling errors, therefore specificity of the procedure could be improved by the precise selection of a representative aspiration site.

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Background: Previous studies have shown a low prevalence of diabetes and other cardiovascular risk factors among Bedouins living in the Negev Desert. New evidence suggests that diabetes is becoming highly prevalent.

Objectives: To estimate the prevalence of diabetes in the town of Rahat, describe the cardiovascular risk factor profile and therapeutic modalities for diabetes and related conditions in this population, and compare these findings with those in the Jewish population.

Methods: A complete record review of all known diabetic individuals aged 35 and older registered at the Rahat Clinic (Clalit Health Services) was carried out by a trained nurse and a research assistant. Information on demographic, anthropometric and clinical characteristics was abstracted. Data on prescribed hypoglycemic agents and other medications were also obtained.

Results: Of the 316 known diabetic patients in the clinic, complete data were available for 271 (85.8 %). The prevalence of known diabetes was 7.3% in males and 9.9% in females. Females had a significantly higher body mass index than males (30.9 vs. 29, P < 0.002), but lower levels of HBA1c and microalbuminuria. Oral hypoglycemic medications were taken by 69% of women and 76% of men, and insulin by 19% of women and 15% of men.

Conclusions: Compared with data on Jewish diabetic patients in the Negev and Israel, the overall prevalence of diabetes in the population of Rahat is higher, but their cardiovascular risk profile is better, except for obesity. These findings support the hypothesis that diabetes and obesity have become major public health problems among Bedouins.
 

Background: The prevalence of clinical manifestations and laboratory parameters in systemic lupus erythematosus differ among various ethnic groups. Few studies have reported on SLE[1] in Arabs.

Objectives: To summarize the demographic, clinical and laboratory features of Arab SLE patients and to compare them with other series from different Arab countries.

Methods: We reviewed the charts of all Arab SLE patients who had been seen at the Carmel Medical Center in Haifa, the Nazareth Hospital and the Holy Family Hospital in Nazareth, and a professional clinic (a referral outpatient clinic of the largest health maintenance organization in Israel) in Acre – all cities in northern Israel. Only patients with symptoms of more than one year were included. Demographic, clinical and laboratory parameters were documented and compared with those of four series from different Arab countries.

Results: The study group comprised 34 patients. The majority of the patients was Moslem; there were a few Druze and one Christian. There was no statistical difference between our patients and any of the other Arab series in terms of arthritis, neuropsychiatric manifestations and VDRL. The presence of serositis and mucocutaneous manifestations was significantly lower in our series compared to some of the other series. However, there was significantly less renal involvement in our patients compared to each of the other series.

Conclusions: The prevalence of most clinical and laboratory parameters in Israeli Arab SLE patients is comparable to that of other series of SLE patients from different Arab countries. The prevalence of renal involvement in Israeli Arab SLE patients seems to be lower than in SLE patients from different Arab countries.

Background: The use of an automated biopsy system for renal biopsy has recently gained popularity, but its safety in single functioning kidneys is unclear.

Objective: To report our experience with the automated system for closed renal biopsy during a 5 year period.

Methods: Eighty-five patients underwent percutaneous native renal biopsy with the automated biopsy gun (16G needle) under real-time ultrasound. They were chronologically divided into two groups: 41 patients (group A), using an older ultrasound machine; and 44 patients (group B), using a newer ultrasound machine. Nine patients biopsied with a manual 14G Tru-cut needle served as the control (group C).

Results: The number of "attempted" passes at the kidney was 4.0 ± 0.1 in group B, 4.7 ± 0.3 in group A (P < 0.05 vs. group B), and 5.8 ± 0.5 in group C (P < 0.01 vs. group B). The number of successful passes did not differ (3.3 ± 0.1, 3.3 ± 0.1, 3.1 ± 0.2). The ratio of "attempted/successful" was 1.28 ± 0.07 in group B, 1.95 ± 0.38 in A, and 1.90 ± 0.21 in C (P < 0.01 vs. B). The number of glomeruli obtained was similar in the three groups. Adequate tissue was obtained in 95%, 98%, and 100%, respectively. Hemoglobin decreased by 4.3 ± 1.1% in group B, 6.9 ± 1.3% in group A, and 11.3 ± 1.8% in group C (P < 0.05 vs. B). Perinephric/subcapsular hematoma occurred in 5 patients (11.4%) in group A (2 taking aspirin), in 2 patients (4.9%) in group B, and in none in group C. The necessity for blood transfusion post-biopsy was similar in all groups. Four of five patients with single functioning kidneys (one in group A and four in group B) had uneventful biopsies, and adequate tissue was obtained in three.

Conclusions: The use of the automated biopsy gun is effective, safe and has a low rate of major complications. It may be used safely in single functioning kidneys.

Recent studies have implicated the dying cell as a potential reservoir of modified autoantigens that may initiate and drive systemic autoimmunity in susceptible hosts. The uridine-rich small nuclear ribonucleoprotein complex is a common target for autoantibodies present in the serum of patients with systemic lupus erythematosus and SLE[1]-overlap syndromes. Four modifications occurring in this complex during apoptosis have been described to date: the caspase-mediated cleavage of the U1-70K protein, the U1 RNA and the Sm-F protein, and the association with hyperphosphorylated SR proteins. In addition, the U1 snRNP[2] complex has been shown to translocate from its normal subcellular localization to apoptotic bodies near the surface of cells undergoing apoptosis. This redistribution might facilitate exposure of the modified components of the U1 snRNP complex to the immune system when the clearance of apoptotic cell remnants is somehow disturbed. The modifications in the U1 snRNP components during apoptosis might represent the initial epitopes to which an immune response is generated and may be the trigger for the production of autoantibodies to this complex in patients with SLE or SLE-overlap syndromes. Therefore, it can be hypothesized that the exposure of elevated levels of apoptotically modified U1 snRNP to the immune system of a genetically susceptible individual might lead to the breaking of immunologic tolerance towards the U1 snRNP complex.

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Pressure sores are a well-recognized problem, with an etiology that is multifactorial and not solely a consequence of pressure itself. Malnutrition is one of the factors involved, namely low calorie and protein intake. Mainly elderly patients, patients after hip fracture, but also patients after trauma, burns or extended surgery require additional nutritional support to reduce the possibility of pressure ulcers developing. Evidence has shown the efficacy of percutaneous endoscopic gastrostomy in elderly patients with malnutrition and dementia. Nutritional support should include sufficient calories, protein, fat, carbohydrates, vitamins and minerals. Arginine is the main amino acid required and is essential for collagen deposition and wound healing. Vitamin A and zinc should be added to nutritional support.