Israel Medical Association Journal

Background: Obstructive sleep apnea syndrome (OSAS) is a sleep-related breathing disorder characterized by excessive daytime sleepiness, accidents and high medical expenses. The first line of treatment for OSAS is continuous positive airway pressure (CPAP).

Objectives: To examine attitudes and beliefs as well as physiological and sociodemographic factors affecting OSA patients' decision whether or not to purchase a CPAP device.

Methods: The study was divided into two stages; in the first, 83 subjects completed self-administered questionnaires prior to sleep examination (polysomnographic study). The questionnaires related to sleep habits, sleep disorders, questions organized around health belief model (HBM) concepts, sociodemographic information, health status and PSG[1] examination. In the second stage, 3 months later, 50 OSAS patients were interviewed by telephone, which included questions about their reasons for purchasing/not purchasing the CPAP device.

Results: Only 48% of the OSAS patients purchased the CPAP device. The significant factors positively affecting the decision included higher levels of physiological factors such as body mass index (coefficient 0.36, P < 0.05) and respiratory disturbance index (coefficient 0.16, P < 0.05), higher income levels (coefficient 3.26, p < 0.05), and higher levels of knowledge about OSAS (coefficient -2.98, P < 0.1).

Conclusions: Individuals who are more aware of their own health condition, are better informed about OSAS and have higher incomes are more likely to purchase the device. We suggest reducing the level of co-payment and providing patients with more information about the severe effects of OSAS.

Background: Survival in T cell lymphoblastic lymphoma has improved over the past 30 years, largely due to treatment protocols derived from regimens designed for children with acute lymphoblastic leukemia.

Objectives: To assess the outcome of the NHL-BFM-95 protocol in children and adolescents hospitalized during the period 1999–2006.

Methods: We conducted a retrospective multi-institutional, non-randomized study of children and adolescents up to age 21 with T cell lymphoma admitted to pediatric departments in six hospitals in Israel, with regard to prevalence, clinical characteristics, pathological characteristics, prognostic factors, overall survival (OS) and event-free survival (EFS). All patients had a minimal follow-up of one year after diagnosis. The study was based on the NHL[1]-BFM[2]-95 protocol.

Results: At a median follow-up of 4 years (range 1–9 years), OS and EFS for all patients was 86.5% and 83.8%, respectively. OS was 86.7% and 83.3% for patients with stage III and stage IV, respectively, and EFS was 83.3% and 83.3%, respectively. EFS was 62.5% for Arab patients and 89.7% for Jewish patients (P = 0.014). Patients who did not express CD45 antigen showed superior survival (P = 0.028). Five (13.5%) patients relapsed, four of whom died of their disease. Death as a consequence of therapy toxicity was documented in one patient while on the re-induction protocol (protocol IIA).

Conclusions: Our study shows that OS and EFS for all patients was 86.5% and 83.8%, respectively.

Background: During the last few decades much effort has been invested into lowering smoking rates due to its heavy burden on the population's health and on costs for the health care services.

Objectives: To compare trends in smoking rates between adult Arab men and Jewish men and women during 2000–2008.

Methods: Six random telephone surveys were conducted by the Israel Center for Disease Control in 2000–2008 to investigate smoking rates. The number of respondents was 24,976 Jews men and women and 2564 Arab men. The percent of respondents reporting being current smokers was calculated for each population group (Jews and Arabs) by age, gender and education, and were studied in relation to time.

Results: Among Jewish men aged 21–64 smoking declined during 2000–2008 by about 3.5%. In the 21–44 age group this decline occurred only among respondents with an academic education. Among Jewish women this decline also occurred at ages 21–64, and in the 45–64 age group this decline was due only to a decline in smoking among those with an academic education. Among Arab men aged 21–64 an increase in smoking rates of about 6.5% was observed among both educated and less educated respondents.

Conclusions: Smoking prevalence is declining in Israel among Jews, but not among Arab men. The larger decrease in smoking rates among academics will, in the future, add to the inequalities in health between the lower and higher socioeconomic status groups and between Arabs and Jews. This calls for tailored interventions among the less educated Jews and all Arab men.

Background: Although the presence of bacteria in the cervix is not a sign of disease, the majority of pathogens involved in pelvic inflammatory disease originate from this "normal" flora.

Objectives: To assess the distribution of cervical non-gonococcal and non-chlamydial bacteria in hospitalized women with PID[1] and the bacteria's antibiotic sensitivity.

Methods: We retrospectively evaluated the cultures obtained from the uterine cervix over a 1 year period (2008) at Wolfson Medical Center, Holon. The distribution of cervical non-gonococcal and non-chlamydial bacteria in women with PID and the bacteria's antibiotic sensitivity was compared to that in our previous 1 year study that was performed at Kaplan Medical Center, Rehovot (1988–89). 

Results: In 2008, a total of 412 cultures were obtained of which 126 (30.5%) were sterile. The prevalence of negative cultures was similar in 2008 and in 1988, namely, 30.5% and 33.7%, respectively (P = 0.23). PID was finally diagnosed in 116 patients with positive cultures. The most prevalent bacteria in the 2008 study were Enterococcus species and Escherichia coli – 24.0 % and 26.4% respectively compared to 18.0% and 38.1% in the 1988 study, with the decrease in E. coli isolates being significant (P = 0.0003). In 2008 the antimicrobial sensitivity for various antibiotics ranged from 44.3% to 100.0% (median 90.2%) while in 1988 it ranged from 2.9% to 80.1% (median 51.9%).

Conclusions: The cervical bacterial flora in hospitalized women with PID did not vary significantly between 1988 and 2008. However, antimicrobial sensitivity of the isolated bacteria increased dramatically, probably due to a decrease in resistance to antibiotics.

Background: While family presence during resuscination has been researched extensively in the international and especially American medical literature, in Israel this subject has rarely been researched. Because such policies have become common practice in many countries, it is important to investigate the attitudes of health care staff in Israeli emergency departments to better understand the potential implication of adopting such policies.

Objectives: To examine the attitudes of the physicians and nurses in the ED of Soroka Medical Center to FPDR[1]. 

Methods: The methods we used were both qualitative (partly structured open interviews of 10 ED staff members from various medical professions) and quantitative (an anonymous questionnaire that collected sociodemographic, professional, and attitude data).

Results: The qualitative and quantitative results showed that most staff members opposed FPDR. The main reasons for objecting to FPDR were concern about family criticism, the added pressure that would be put on the staff members, fear of lawsuits, fear of hurting the feelings of the families, and the danger of losing one’s objectivity while treating patients. Physicians objected more strongly to FPDR than did nurses.  

Conclusions: More research is needed on FPDR in Israel, including an examination of its medical, ethical, legal and logistic aspects. In addition to the views of the medical staff, the attitudes of patients and their families should also be examined.

[1] FPDR = family presence during resuscitation

 

Pancreatic cancer is not a common malignancy in Israel, but it is the third most common cause of cancer mortality, attributable to a lack of screening tests, inaccessibility of the pancreas, and late cancer stage at diagnosis. We reviewed the epidemiology, known risk factors and screening methods available in Israel and describe the Israeli national consortium that was established to identify persons at risk and decide on screening methods to detect and treat their early-stage pancreatic cancer. In collaboration with the Israel National Cancer Registry, we evaluated the incidence and trends of the disease in the Jewish and non-Jewish populations. The consortium reviewed known lifestyle risk habits and genetic causes, screening methodologies used and available in Israel. Overall, there are about 600 new patients per year, with the highest incidence occurring in Jewish men of European birth (age-standardized rate 8.11/10⁵ for 2003–06). The 5 year survival is about 5%. The consortium concluded that screening will be based on endoscopic ultrasonography. Pancreatic cancer patients and families at risk will be enrolled, demographic and lifestyle data collected and a cancer pedigree generated. Risk factors will be identified and genetic tests performed as required. This concerted national program to identify persons at risk, recommend which environmental risk factors to avoid and treat, and perform endoscopic ultrasound and genetic screening where appropriate, might reduce their incidence of invasive pancreatic cancer and/or improve its prognosis

Background: The role of alcohol in driver fatalities in Israel is unknown, and monitoring blood alcohol concentration among drivers is not routine. Moreover, over the past decade, self-reported access to and consumption of alcohol in Israel has been on the rise.

Objectives: To use available data to characterize alcohol-related driver fatalities.

Methods: The prevalence of alcohol-related driver fatalities were estimated for 443 drivers, ages 17+ years using data from Israel's National Center for Forensic Medicine for 2000–2004.

Results: Between 8% and 17% of driver fatalities had a BAC[1] ≥ 0.05 g/dl. Most drivers with alcohol exceeding this level were males aged 21–30 years who died on weekends. Recreational and/or medicinal drugs were found in 6%–11% of driver fatalities. Mean BAC among driver fatalities with BAC ≥ 0.05 g/dl was threefold higher than the legal driving limit and appears to be increasing with time.

Conclusions: In light of the evidence suggesting an increasing mean BAC over time as well as reported increasing trends in access to alcohol and consumption, this study should serve as a basis for future research to comprehensively characterize the extent of this problem

Background: Current treatment options for acute calculous cholecystitis include either early cholecystectomy, or conservative treatment consisting of intravenous antibiotics and an interval cholecystectomy several weeks later. Percutaneous drainage is reserved for patients in whom conservative therapy failed or as a salvage procedure for high risk patients.

Objective: To identify clinical and radiographic factors leading to failure of conservative treatment.

Methods: We prospectively collected data on consecutive patients admitted with the diagnosis of acute cholecystitis. Parameters were compared between patients who were successfully treated conservatively and those who required percutaneous cholecystostomy. Logistic regression analysis was performed to identify predictors for failure of conservative treatment. 

Results: The study population comprised 103 patients with a median age of 60 who were treated for acute cholecystitis. Twenty-seven patients (26.2%) required PC[1]. On univariate analysis, age above 70 years, diabetes, elevated white blood cell count, tachycardia (> 100 beats/min) at admission, and a distended gallbladder (> 5 cm transverse diameter) were found to be significantly more common in the PC group (P < 0.001). WBC[2] was higher in the PC group throughout the initial 48 hours. On multivariate analysis, age above 70 (odds ratio 3.6), diabetes (OR[3] 9.4), tachycardia at admission (OR 5.6), and a distended gallbladder (OR 8.5) were predictors for cholecystostomy (P < 0.001). Age above 70 (OR 5.2) and WBC > 15,000 (OR 13.7) were predictors for failure of conservative treatment after 24 and 48 hours (P < 0.001). 

Conclusions: Age above 70, diabetes, and a distended gallbladder are predictors for failure of conservative treatment and such patients should be considered for early cholecystostomy. Persistently elevated WBC (> 15,000) suggests refractory disease and should play a central role in the clinical follow-up and decision-making process for elderly patients with acute cholecystitis.

Background: Patients with thick melanomas > 4 mm deep are at great risk for regional and distant metastatic disease. Historically, the appropriate management of thick melanomas has remained unclear and there is no consensus in the literature. Many have taken the nihilistic view that surgical intervention to excise regional nodal basins is not justified in light of the poor overall prognosis and risk of occult distant disease.

Objectives: To review the outcome of patients with thick node negative melanoma treated at a multidisciplinary academic center

Methods: We retrospectively reviewed a database of melanoma patients to identify patients with thick melanomas, > 4 mm, who were either clinically or sentinel node biopsy negative, staged T4N0, stage IIb or IIc. The charts of these patients were reviewed and updated, with a median follow-up of 4 years.

Results: We identified 23 patients who fit these criteria. Of these, 18 (78%) remain alive with a median follow-up of 4 years. Five patients died of metastatic disease. Of the 18 surviving patients, 14 remained with no evidence of disease after initial resection of their primary lesions. The majority of the recurrences were non-nodal.
Conclusions: The overall survival of patients in our study remains above 75%, at median follow-up of 4 years, even with thick initial index tumor depths. Most of the failures were due to hematogenous spread with lymphatic sparing. Tumor biology that may inhibit lymphatic spread could be a target of future investigation