Israel Medical Association Journal

Background: Valved holding chambers with masks are commonly used to deliver inhaled medications to young children with asthma. Optimal mask properties such as their dead space volume have received little attention. The smaller the mask the more likely it is that a greater proportion of the dose in the VHC[1] will be inhaled with each breath, thus speeding VHC emptying and improving overall aerosol delivery efficiency and dose. Masks may have different DSV[2] and thus different performance.

Objectives: To compare both physical dead space and functional dead space of different face masks under various applied pressures.

Methods: The DSV of three commonly used face masks of VHCs was measured by water displacement both under various pressures (to simulate real-life application, dynamic DSV) and under no pressure (static DSV).

Results: There was a great variability of both static and dynamic dead space among various face mask for VHCs, which is probably related to their flexibility.

Conclusions: Different masks have different DSV characteristics. This variability should be taken into account when comparing the clinical efficacy of various VHCs. 

The lethal poisoning of Alexander Litvinenco with the radioactive element polonium-210, and the risk that many civilians (including Israeli citizens) who were in the same location in London at the same time were exposed to radiation, was an unprecedented event in the western world. This was only the second known death due to ²¹⁰Po[1], a natural alpha radiation-emitting element. A task team was created to handle the event. The team comprised representatives from the Ministry of Health's advisory committee for radiological events (which includes the Israel Defense Force, the Israeli Atomic Energy Commission and the Ministry of Environmental Protection), the Public Health Services Central District, and a public relations expert. Forty-seven people were located and underwent an epidemiological inquiry, and urine samples for detection of ²¹⁰Po were sent abroad to a specialized laboratory. The radiotoxicological results were analyzed and evaluated by the expert team and follow-up recommendations were made. This unfamiliar and potentially stressful scenario was handled successfully by a multi-organizational multidisciplinary task team. The joint work of the task team was a real-life "exercise" simulating a radiological event in Israel. This team has recommended further evaluation of various vital missions in the event of any possible future radiological event, with special emphasis on a proactive communication approach to the media and the public.

Background: Many centers in Israel still use pre-1970 reference data for neonatal weight, length and head circumference. A recently published population-based reference overestimated the weight of premature infants.

Objective: To develop a national reference for birth weight, birth length, and head circumference by gestational age for singleton infants in Israel.

Methods: Data were collected on all singleton live births documented in the neonatal registry of Rabin Medical Center from 1991 to 2005 (n=82,066). Gestational age estimation was based on the last menstrual period until 1977 and early fetal ultrasound thereafter. Neonates with an implausible birth weight for gestational age (identified by the rule of median ± 5 standard deviations or expert clinical opinion) were excluded. Reference tables for fetal growth by gestational age were created for males and females separately.

Results: The growth references developed differed markedly from the Usher curves currently used in our department. Compared to the recently published population-based birth weight reference, our data were free of the problem of differential misclassification of birth weight for gestational age for the premature infants and very similar for the other gestational age groups. This finding reinforced the validity of our measurements of birth weight, as well as of birth length and head circumference.

Conclusions: Use of our new (birth length and head circumference) and improved (birth weight) gender-specific hospital-based reference for fetal growth may help to define normal and abnormal growth in the neonatal population of Israel and thereby improve neonatal care and public health comparisons.
 

Background: Non-operative management following abdominal stab wounds is possible in selected patients who are both hemodynamically stable and do not have signs of peritonitis. However, the rate of failure of non-operative management is higher in Israel than in western countries.

Objectives: To assess the patterns of injury following abdominal stabbing.

Methods: Data from the Israeli Trauma Registry were used to identify all patients with abdominal stab injury admitted to eight different trauma centers between 1997 and 2004.

Results: The number of patients admitted per year more than doubled between 1997 and 2004, from 257 to 599. The percentage of patients with severe injury (Index Severity Score ≥ 16) increased from 9.4% to 19.0%. The incidence of multiple stab injuries almost doubled, from 37% to 62%.

Conclusions: Review of the data in the Israeli Trauma Registry indicates an increase in both absolute rate and relative incidence of serious stab injuries. This indicates that patterns of injury following stab wounds are not necessarily similar, not even within the same geographical area over time.
 

Management of asthma is currently based on symptoms (in children, usually a second-hand report from parents) and lung function measurements. Inhaled steroids, targeted at controlling airway inflammation, are the mainstay of asthma management. Due to possible side effects they should be used at the lowest possible doses while asthma is adequately controlled. Fractional exhaled nitric oxide is a simple non-invasive method to assess inflammation in asthma and its role in asthma management is increasing in popularity. The present review summarizes recent research on the use of FeNO[1] in monitoring airway inflammation and optimizing asthma management. The addition of FeNO measurements to the conventional assessment of asthma control appears promising. The practicability of including this measuring method into everyday clinical practice is currently being evaluated.

Background: Pulmonary tuberculosis continues to be a major cause of mortality, particularly in developing countries. Despite modern anti-TB[1] treatment, the elderly and immigrants from TB-endemic countries are at risk. Multidrug resistance has yet to be resolved..

Objectives: To determine the mortality rate and predictors of mortality among patients hospitalized with TB in Israel.

Methods: We evaluated the medical records of 461 patients with active pulmonary TB who were hospitalized in the department of respiratory care during the 5 year period 2000–2004. Data included demographic, clinical, laboratory and radiological findings, drug resistance as well as adverse reactions to anti-TB treatment.

Results:| Three main ethno-geographic groups were observed: 253 patients from the former USSR, 130 from Ethiopia, and 54 of Israeli origin (as well as 24 residents of other countries). Of the 461 patients 65 patients (13%) died in hospital. The factors that were best predictors of mortality were older age, ischemic heart disease, cachexia, prior corticosteroid treatment, hypoalbuminemia and pleural effusion (P < 0.005 for all). The ethno-geographic factor and the presence of multidrug-resistant bacteria had no significant effect on mortality in our study group.

Conclusions: The mortality rate in our study was relatively low, and there was no significant difference between the three ethno-geographic groups.

Background: Chronic obstructive pulmonary disease is an increasing cause of chronic morbidity and mortality around the world. The major cause of the disease is smoking. Despite the gravity of the problem there is no knowledge of its rate in the Israeli smoking population.

Objectives: To assess the prevalence of COPD[1]and early lung cancer among smokers.

Methods: People aged 45 up to 75 with a history of at least 20 pack-years cigarette smoking, including quitters, were screened for COPD. They were interviewed and a spirometry was performed.

Results: Of the 1150 people recruited 92% underwent and performed acceptable spirometry; 22% of these subjects had airflow limitation and were diagnosed with COPD according to the GOLD classification. Only 4% had been diagnosed as COPD prior to this screening. The majority of those tested were unaware of or unconcerned about developing the disease. There was no correlation between pack-years smoking and development of COPD, but there was a relative correlation of pack-years smoking and severity of COPD, particularly in the older group only (r = 0.42).

Conclusions: About one-fifth of the smokers aged 45 and up developed COPD. There is a significant gap between the disease distribution and its awareness in the population at risk. The need for a national screening program and early diagnosis of COPD in people at risk is needed.

Background: In an era of increasing antimicrobial resistance, knowledge of local antimicrobial susceptibility patterns of common uropathogens is essential for prudent empiric therapy of community-acquired urinary tract infections.

Objectives: To define antimicrobial susceptibility of Gram-negative uropathogens in northern Israel over a 10 year period and to compare it with antibiotic-use patterns in the same community.

Methods: We tested the susceptibility of all Gram-negative urinary isolates from outpatients at HaEmek Medical Center over the years 1995, 1999, 2002 and 2005 to common antimicrobial agents. MIC₉₀ of Escherichia coli to some of these agents was determined and antibiotic consumption data over the years 2000–2005 (DDD/1000/day) were obtained.

Results: We observed a rise in susceptibility rates of E. coli to amoxicillin-clavulanate, trimethoprim-sulfamethoxazole and nitrofurantoin and of other Gram-negative isolates to amoxicillin-clavulanate, ceftriaxone and cephalothin. Susceptibility rates of all Gram-negative uropathogens to ciprofloxacin decreased significantly. MIC₉₀ of E. coli for all drugs tested remained stable. There was a significant decrease in the use nitrofurantoin and TMP-SMX[1] and a significant increase in the use of ampicillin, cephalothin and ceftriaxone.

Conclusions: Antibiotic resistance patterns mostly remained unchanged or improved slightly. There was, however, a constant decrease in susceptibility of all Gram-negative uropathogens to ciprofloxacin. Antibiotic use patterns could not explain the changes seen in antibiotic susceptibility patterns.

Research findings have shown the protective effect of religiosity – among both Christians and Israeli Jews – in terms of morbidity and mortality. To explore the relationship between religiosity and health behavior as a possible explanation for these findings we conducted 3056 telephone interviews, representing the Israeli adult urban Jewish population. Health status, health behavior, frequency of medical checkups, and eating habits were measured. Logistic regressions were used to estimate the religiosity gradient on health behavior, controlling for other personal characteristics. We found a lower prevalence of stress and smoking among religious persons; we also found that religious women exercise less than secular women and that religious people – both men and women – are more obese than their secular counterparts. While no religiosity gradient was found with relation to the frequency of blood pressure, cholesterol and dental checkups, religious women are less likely to undergo breast examinations and mammography. Finally, religious people generally follow a healthier dietary regime, consuming less meat, dairy products and coffee, and much more fish. The lower smoking rates, lower levels of stress, and the healthier dietary regime are consistent with the previously shown longer life expectancy of religious people; however, obesity might become a risk factor in this community.

Background: With the development of computer technology and the high-tech electronic industry over the past 30 years, the technological age is flourishing. New technologies are continually being introduced, but questions regarding the economic viability of these technologies should be addressed.

Objectives: To identify the medical technologies that are currently in use in different rehabilitation medicine settings in Israel

Methods: The TECHNO-R 2005 survey was conducted in two phases. Beginning in 2004, the first survey used a questionnaire with open questions relating to the different technologies in clinical use, including questions on their purpose, who operates the device (technician, physiotherapist, occupational therapist, physician, etc.), and a description of the treated patients. This questionnaire was sent to 31 rehabilitation medicine facilities in Israel. Due to difficulties in comprehension of the term “technology,” a second revised standardized questionnaire with closed-ended questions specifying diverse technologies was introduced in 2005. The responder had to mark from a list of 15 different medical technologies which were in use in his or her facility, as well as their purpose, who operates the device, and a description of the treated patients.

Results: Transcutaneous electrical nerve stimulation, the TILT bed, continuous passive movement, and therapeutic ultrasound were the most widely used technologies in rehabilitation medicine facilities. Monitoring of the sitting position in the wheelchair, at the bottom of the list, was found to be the least used technology (with 15.4% occurrence). Most of the technologies are used primarily for treatment purposes and to a lesser degree for diagnosis and research.

Conclusions: Our study poses a fundamental semantic and conceptual question regarding what kind of technologies are or should be part of the standard equipment of any accredited rehabilitation medicine facility for assessment, treatment and/or research. For this purpose, additional data are needed.
 

Background: Trauma management includes the care provided both in hospital and by emergency medical systems in the community. In many cases it is the parents who decide where to take an injured child for care, depending on the circumstances and severity of the injury, the personal characteristics of the injured or the carer and the availability and accessibility of services.

Objectives: To examine the use of pre-hospitalization services and reasons for their use by children and adolescents according to the injury and personal characteristics.

Methods: The study group comprised 924 Israeli citizens aged 0–17 years hospitalized for injuries in six hospitals across Israel. Carers were interviewed in the hospital regarding the circumstances of the injury event, the use of pre-hospitalization services, and sociodemographic characteristics. Data on the cause and nature of the injury were obtained from the hospital records.

Results: The proportion of severe injuries (Injury Severity Score 16+) was higher in Arab children than Jewish children (15% and 9% respectively). Sixty-three percent of the Arab children and 39% of the Jewish children used community services prior to hospitalization. The odds ratio of proceeding directly to the hospital was 0.44, 95% confidence interval 0.29–0.69, for the Arab compared to the Jewish children, controlling for severity, cause and nature of the injury, sociodemographic characteristics, and the reported availability of ambulance services.

Conclusions: More Arab than Jewish carers tended to seek care in the community for an injured child, but the effect of personal characteristics on seeking care was similar in both population groups. Issues of availability and accessibility of services may explain the differences.