Daniel Chemtob, MD, MPH, DEA, Leon Epstein, MD, MPH, Paul E. Slater, MD, MPH and Daniel Weiler-Ravell, MD
Background: Sensing an inadequacy of tuberculosis control due to an influx of TB associated with immigration, we analyzed TB treatment outcome in Israel by population groups.
Objectives: To provide an epidemiological basis necessary for any new national TB control policy, and to bring it to the attention of the medical profession in Israel and abroad since its results led to a change in Israel’s TB control policy.
Methods: We reviewed all TB cases notified during the period 1990 to September 1992. New cases” (820 cases, 93.5%) and “re-treatment cases” (57 cases, 6.5%) were analyzed according to three mutually exclusive groups: “successful outcome,” “death” and “potentially unsatisfactory outcome” (according to WHO/IUATLD definitions).
Results: Of 820 “new cases,” 26.6% had a satisfactory outcome,” 68.5% had a “potentially unsatisfactory outcome” and 4.9% died compared to 47.4%, 45.6% and 7% among 57 “re-treatment cases,” respectively. Using logistic regression analysis, outcome was associated with the district health office (P<0.0001), the TB experience” of the notifying clinic (P<0.0001), and the form of TB (P=0.02). No significant relationships were obtained for population groups, gender and age, interval between arrival in Israel and TB notification, and bacteriological results.
Dan Leibovici, MD, Amnon Zisman, MD, Yoram I. Siegel, MD and Arie Lindner, MD
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.
Tsafra Ilan, MSc, Tamy Shohat, MD, Ana Tobar, MD, Nurit Magal, PhD, Michal Yahav, BSc, Gabrielle J. Halpern, MB, ChB, Gidi Rechavi, MD and Mordechai Shohat, MD
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.
Daniel Chemtob, MD, MPH, DEA, Leon Epstein, MD, MPH, Paul E. Slater, MD, MPH and Daniel Weiler-Ravell, MD
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.
Pesach Shvartzman, MD, Howard Tandeter, MD, Aya Peleg, MD, Hava Tabenkin, MD, Nakar Sasson, MD and Jeffrey Borkan, MD, PhD
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.
Manuel Katz, MD, Sheila S. Warshawsky, MSc, Avi Porat, MD and Joseph Press, MD
Background: Appropriateness of hospital admission has both clinical and economic relevance, especially in light of the growing pressure for increased efficiency of health services utilization. In Israel, the number of referrals and use of the emergency room continue to rise along with an increase in hospital admissions and the number of inappropriate admissions. Using evaluation protocols, such as the Pediatric Appropriateness Evaluation Protocol, international studies have shown that 10-30% of hospital admissions are medically unnecessary. Inappropriate hospitalizations have an economic impact as well as medical and psychological effects on the child and the family.
Objectives: To assess the extent and characteristics of inappropriate pediatric admissions to a tertiary care facility in Israel.
Methods: We conducted a prospective study using chart review of pediatric admissions to Soroka University Medical Center on 18 randomly selected days in 1993, and evaluated the appropriateness of admissions using the PAEP.
Results: Of the 221 pediatric admissions 18% were evaluated as inappropriate. The main reason for such an evaluation was that the problem could have been managed on an ambulatory basis. Inappropriate admissions were associated with hospital stays of 2 or less days, children older than 1 year of age, Jewish children, and self-referrals to the pediatric emergency room.
Conclusions: The assessment and identification of characteristics of inappropriate hospital admissions can serve as indicators of problems in healthcare management and as a basis for improving quality of care and developing appropriate medical decision-making processes.
Boaz Meijer, MD, David Branski, MD and Eitan Keren, MD
Background: Prevention of cigarette smoking is an important issue in public health policy. Since most adult smokers began smoking in childhood, understanding behavorial factors associated with smoking initiation would contribute to smoking initiation programs. Health-related behavior may vary between different ethnic groups.
Objectives: To determine the prevalence of smoking among Jewish and Arab adolescents in Jerusalem, and whether there are differences in smoking initiation between the two ethnic groups.
Methods: We carried out a cross-sectional survey of all students in the 6th to 11th grades (age range 11-17 years) of a Jewish school and an Arab school in the Jerusalem area, using an anonymous self-completion questionnaire. A total of 791 questionnaires was analyzed, 479 from the Jewish students and 312 from the Arab students.
Results: The lowest prevalence of smoking was found among Arab female students and the highest among Jewish female students (9% vs. 41%, P<O.OO1). The prevalence of smoking among Jewish and Arab males was similar. More Arab female students smoked than their mothers. Peer pressure seemed to be a more important factor among Jewish students.
Conclusions: This study demonstrated the presence of ethnic differences in smoking prevalence and the reasons for smoking among adolescents in Israel. These results suggest the need for specific smoking prevention policies for different ethnic groups.
Rachel Dankner, MD, MPH, Dipl Sports Medicine, Giora Kaplan, MA and Vita Barell, BA
Background: Israel lacks a systematic surveillance of sports injuries, and knowledge of risk factors and specific patterns of injury is inadequate. In order to promote prevention of sports-related injuries, the magnitude of the problem must first be identified and the incidence and severity of sports injuries described.
Objective: To conduct a survey on previous sports injuries among a sample of Israeli athletes.
Methods: A convenience sample of Israeli amateur athletes participating in the 1997 15th Maccabiah Games was randomly selected. The study group answered an anonymous self-administered questionnaire that included sociodemographic data, and information regarding their sports activity and sports-related injuries that had occurred during the previous 2 years.
Results: The study group, aged 12-3 years (median age 21), comprised 301 consenting athletes in 28 different sports. Of these athletes 56.1% reported having had at least one injury. Most injuries (75.6%) involved the upper and lower extremities, and 37.8% of the injured sportsmen had received medical attention from a physician. Half of the athletes participated in contact sports - both collision and limited impact. This group had a much greater proportion of reported injuries in all age groups.
Conclusion: Surveillance of sports injuries should be expanded in order to develop appropriate prevention programs in Israel.
Michael D. Lockshin, MD
Autoimmune diseases are said to have high female/male (F/M) ratios, but these ratios are imprecise. Published definitions and classifications of autoimmune diseases differ substantially, as do the F/M ratios themselves. Imputed causality of auto-immune diseases requires better precision. Some thyroid, rheumatic and hepatic diseases consistently have high F/M ratios, but marked differences exist in the reported quantity of the ratios. Other autoimmune diseases have low F/M ratios. Because F/M ratios reflect incidence and not severity of disease, gonadal hormones, if they play a role, must do so through a threshold or permissive mechanism. Sex differences related to environmental exposure, X-inactivation, imprinting, X or Y chromosome genetic modulators, and intrauterine influences remain as alternate, theoretical, explanations for sex differences of incidence. The epidemiology of the sexdiscrepant autoimmune diseases - young, female - suggests that an explanation for sex discrepancy lies in differential exposure, vulnerable periods, or thresholds, rather than in quantitative aspects of immunomodulation.
Yosef S. Haviv, MD and Jerry Blackwell, PhD
Michael Mullerad, MD, Tzipora Falik, MD, Ralph Madeb, MD and Ofer Nativ, MD
Noberto Krivoy, MD, Lili Struminger, MSc, Regina Bendersky, MD, Irit Avivi, MD, Manuela Neuman, PhD and Shimon Pollack, MD
Alberto Kurzbaum, MD, Claudia Simsolo, MD, Ludmilla Kvasha, MD and Arnon Blum, MD