Israel Medical Association Journal

Background: During 2013–2014 Israel experienced a continuous circulation of wild poliovirus type 1 (WPV1) but with no clinical cases. WPV1 circulation was gradually terminated following a national vaccination campaign of bivalent oral poliovirus vaccine (bOPV) for 943,587 children < 10 years. Four cases of children with neurological manifestations that appeared following bOPV vaccinations were reported during the campaign: three of Guillain-Barré syndrome (GBS) and one of acute disseminated encephalomyelitis (ADEM). 

Objectives: To present an analysis of these cases, the rapid response and the transparent publication of the results of this analysis. 

Methods: The clinical, laboratory and epidemiological data of these four patients were available during the analysis. In addition, data regarding the incidence of GBS and ADEM during previous years, and reported cases of acute flaccid paralysis (AFP) and the incidence of Campylobacter jejuni enteritis were collected from the Epidemiology Department of the Israel Ministry of Health.

Results: The incidence of GBS among bOPV-vaccinated children was not higher than among bOPV-unvaccinated children. For all the cases reviewed the "incubation period" from vaccination to the event was longer than expected and other more plausible causes for the neurologic manifestations were found. There is no evidence in the literature of a causal relationship between bOPV and ADEM. 

Conclusions: There was no association between the bOPV vaccine and the reported neurological manifestations. We believe that our experience may assist other public health professionals when confronting a similar problem of alleged side effects during a mass medical intervention.

 

Background: The search for the presence of vegetations in patients with suspected infective endocarditis is a major indication for trans-esophageal echocardiographic (TEE) examinations. Advances in harmonic imaging and ongoing improvement in modern echocardiographic systems allow adequate quality of diagnostic images in most patients.

Objectives: To investigate whether TEE examinations are always necessary for the assessment of patients with suspected infective endocarditis. 

Methods: During 2012–2014 230 trans-thoracic echo (TTE) exams in patients with suspected infective endocarditis were performed at our center. Demographic, epidemiological, clinical and echocardiographic data were collected and analyzed, and the final clinical diagnosis and outcome were determined. 

Results: Of 230 patients, 24 had definite infective endocarditis by clinical assessment. TEE examination was undertaken in 76 of the 230 patients based on the clinical decision of the attending physician. All TTE exams were classified as: (i) positive, i.e., vegetations present; (ii) clearly negative; or (iii) non-conclusive. Of the 92 with clearly negative TTE exams, 20 underwent TEE and all were negative. All clearly negative patients had native valves, adequate quality images, and in all 92 the final diagnosis was not infective endocarditis. Thus, the negative predictive value of a clearly negative TTE examination was 100%.

Conclusions: In patients with native cardiac valves referred for evaluation for infective endocarditis, an adequate quality TTE with clearly negative examination may be sufficient for the diagnosis.

 

There has been a dramatic increase in the number of female physicians in all fields and specializations of medicine, but this increase has not resulted in a redistribution of domestic tasks and responsibilities. Reviewing the literature of the last two decades (April 1994 to April 2014) on how female physicians cope with the challenge of balancing their family and professional lives for the duration of their professional careers revealed that they suffer from the work-family conflict more than other professionals and that it has a more negative effect on women than on men. Women physicians consider work-family balance significantly when making career choices. These considerations affect their career success, their productivity as faculty members, their marital life, and parenthood. Having a supportive spouse at home and a facilitating mentor at work are important for a positive work-family balance among female physicians. Special career-supporting measures, such as flexible work schedules and expanded support for childcare over the course of work and when taking part in academic activities, are critical for female physicians.

Background: Obesity causes specific sexual problems, including diminished sexual desire, poor performance and avoidance of sexual encounters.

Objectives: To systematically evaluate the effect of bariatric surgery on patients' sexual function as compared to their preoperative status.

Methods: Bariatric surgery candidates were given a validated sexual function questionnaire the day before surgery and again 1 year after surgery. Females were polled with the Female Sexual Function Index (FSFI) and males with the Brief Sexual Function Inventory (BSFI). Statistical analysis was performed to elucidate differences in response to the questionnaires.

Results: The study population included 34 females and 14 males. Mean age and body mass index (BMI) were 40.2 ± 10.2 years and 43.4 ± 5.3 kg/m2, respectively. Postoperative BMI was 31.4 ± 4.9 kg/m2 (P < 0.001). Laparoscopic sleeve gastrectomy was performed in 36 patients and laparoscopic Roux-y gastric bypass in 12. In females, the FSFI index rose significantly from 24 to 30 (P = 0.006), indicating increased sexual performance and satisfaction. In males the BSFI increased from 40.2 to 43.9 but did not reach statistical significance (P = 0.08). However, general satisfaction, desire and erection were each significantly improved within the BSFI.

Conclusions: In addition to the well-documented medical and quality-of-life benefits of bariatric surgery, there is also clear improvement in patients' sexual function, both physical and psychosexual.

 

Background: In recent years several reports have been published describing dogs’ ability to detect, by scent, patients with cancer. This ability is based on the sniffing of volatile organic elements that are secreted by malignant cells, react to them. 

Objectives: To evaluate the ability of trained dogs to detect (i) breast cancer cell cultures (MCF7) compared to the control pseudo-normal keratinocyte cell line (HaCaT), and then (ii) melanoma (BG) and (iii) type 2 epithelial lung carcinoma (A549) malignant cell cultures to which they were not previously exposed in the course of their training.

Methods: Cell cultures were prepared in a standard manner. Two Belgian Shepherd dogs were trained and then tested in a single-blind test (for dogs and trainers) on their ability to detect the "target specimen," a MCF7 breast cancer cell culture. Following this, the ability of the dogs to detect cancer cell cultures that they were not previously exposed to (i.e., A549, BG) was tested. In each test round, four specimens placed in identical blocks were arranged in a line with one meter between them: one target specimen (MCF7, A549, BG), two control specimens (HaCaT), and a sample containing cell culture medium only.

Results: The two dogs picked out all the target specimens of MCF7 breast cancer cell cultures that they were trained to detect (10/10) as well as all the target specimens that they were not previously exposed to [A549 (5/5) and BG (5/5)], but did not pick out the control specimens or the cell culture medium. Thus, the sensitivity, specificity, and positive and negative predictive values for both dogs were 100%.

Conclusions: The results of this study support the assumption that cancer cells have a unique odor pattern, and that this odor pattern is common to different types of cancer.

 

Abstract:

Background: Waterpipe tobacco smoking (WTS) is common in some populations and may add increased risk for tobaccorelated diseases.

Objectives: To assess the rates of WTS and risk practices associated with WTS in three distinct populations in Israel: long-term Jewish residents (LTJR), immigrants from the former Soviet Union (fSU), and Arabs.

Methods: We conducted a cross-sectional survey of 899 randomly selected participants, age 30–65 years, using face-toface interviews with subjects from the three population groups in Israel. Respondents reported WTS, cigarette smoking, alcohol consumption, and socioeconomic characteristics.

Results: Among men, WTS at least once a week was reported by 4.8% of LTJR, 3.2% of fSU immigrants and 20.3% of Arabs. Lower rates were reported among women of all groups. The younger, less educated men and the younger unmarried women had higher odds of WTS. LTJR who smoked cigarettes and drank alcohol had higher odds of WTS [odds ratio (OR) 32.6, confidence interval (CI) 9.36–113.6; OR = 3.57, CI =1.48–8.63, respectively], compared to non-smokers and non-drinkers. fSU immigrants who smoked cigarettes had higher odds of WTS (OR = 3.40, CI = 0.99–11.7) compared to non-smokers. Among Arabs, cigarette smoking and alcohol consumption were not associated with WTS.

Conclusions: Arabs are more likely than other Israeli populations to engage in WTS. This behavior may add to increased inequalities in rates of tobacco-induced diseases between Arabs and Jews in Israel. Including WTS in the policies for smoke-free public places is called for.

Background: The Syntax score (SS) is a helpful tool for determining the optimal revascularization strategy regarding coronary artery bypass surgery (CABG) vs. percutaneous coronary intervention (PCI) in patients with complex coronary disease. While an association between higher SS and mortality was found for PCI patients, no such association was found for CABG patients.

Objectives: To assess whether the SS predicts late mortality in patients undergoing CABG in a real-world setting.

Methods: The study included 406 consecutive patients referred for CABG over a 2 year period. Baseline and clinical characteristics were collected. Angiographic data SS were interpreted by an experienced angiographer. Patients were divided into three groups based on SS tertiles: low ≤ 21 (n=205), intermediate 22–31 (n=138), and high ≥ 32 (n=63). Five year mortality was derived from the National Mortality Database.

Results: Compared with low SS, patients with intermediate and high scores were significantly older (P = 0.02), had lower left ventricular ejection fraction (64% vs. 52% and 48%, P < 0.001) and greater incidence of acute coronary syndrome, left main disease, presence of chronic total occlusion of the left anterior descending and/or right coronary artery, and a higher EuroSCORE (5% vs. 5% and 8%, P < 0.01). Patients with intermediate and high SS had higher 5 year mortality rates (18.1% and 19%, respectively) compared to patients with low score (9.8%, P = 0.04). On multivariate analysis, SS was not an independent predictor of late mortality.

Conclusion: Patients with lower SS had lower mortality after CABG, which is attributable to lower baseline risk. SS is not independently predictive of late mortality in patients with multi-vessel coronary artery disease undergoing CABG.

Background: Gaucher disease is the most prevalent inherited disorder among Ashkenazi Jews (carrier frequency of about 6%) and six mutations account for about 96% of their mutant alleles. Two mutations, N370S and R496H, have been reported only in mildly affected or asymptomatic patients, Due to the rarity of R496H, it was recommended that it be excluded from screening programs. 

Objectives: To verify the frequency and trace the origin of Gaucher mutations in screened individuals whose Ashkenazi ethnicity was confirmed by the birthplace of their grandparents.

Methods: We conducted a retrospective analysis of the screened results for the period 2006–2011. Mutations were identified by restriction analysis, Tag-It^TM detection system, Pronto® diagnostic kit and Nanogen technology (NanoChip® 400).

Results: The heterozygote frequency of eight mutations was estimated in a cohort of 16,910 alleles. Two mutations, N370S and R496H, were the most frequent in our population. However, while the occurrence of N370S carriers was similar to other reports (1:19.4), that of R496H carriers was considerably elevated (1:207). Examination of the screened individuals' ethnicity showed a significant difference in the distribution pattern of the country of origin between the carriers of these two mutations.

Conclusions: The origin pattern differences between the two groups of heterozygotes might reflect a separate geographic region of introduction for various mutations. As a result, secondary subgroups could be formed within the Ashkenazi population. This might clarify the dissimilarities in the occurrence of R496H mutation reported by various centers. 

Thrombosis is a common phenomenon in patients with malignancies. It is believed that thrombosis is multifactorial and that in addition to mechanisms directly associated with cancer and its treatment, it may also be related to the interaction between the immune system and clotting. The present work describes four cancer patients (three adults and one child) whose clinical course was characteristic of catastrophic antiphospholipid syndrome (CAPS) in intensive care units of the National Cancer Institute of Rio de Janeiro. The presence of findings similar to those in CAPS can be attributed to an unbalanced interaction between the immune system and coagulation.

Background: Late nephrology referral, before initiation of dialysis treatment, is associated with adverse outcome.

Objectives: To investigate the implications of late nephrology referral on mortality among dialysis patients in Israel.

Methods: We retrospectively analyzed 200 incident dialysis patients. Patients were defined as late referrals if they started dialysis less than 3 months after their first nephrology consultation. Survival rates and risk factors for mortality were analyzed

Results: The early referral (ER) group comprised 118 patients (59%) and the late referral (LR) group 82 patients (41%). The mortality rate was 44.5% (53 patients) in the ER and 68% (n=56) in the LR group. The 4 year survival rate was 41.1% in the ER and 18.7% in the LR group (P < 0.0001). The mortality rate increased with late nephrology referral (HR 1.873, 95%CI 1.133–3.094), with age (HR 1.043 for each year, 95%CI 1.018–1.068), with diabetes (HR 2.399, CI 1.369-4.202), and with serum albumin level (HR 0.359 for an increase of each 1 g/dl, 95%CI 0.242–0.533). The median survival time was higher for the ER group in women, in patients younger than 70, and in diabetic patients. A trend for longer survival time was found in non-diabetic patients. Survival time was not increased in early referred patients older than 70 and in male patients.

Conclusions: Late nephrology referral is associated with an overall higher mortality rate in dialysis patients. The survival advantage of early referral may have a different significance in specific subgroups. The timing of nephrology referral should be considered as a modifiable risk factor for mortality in patients with end-stage renal disease.