Israel Medical Association Journal

Background: Fine needle aspiration is the main diagnostic tool used to assess thyroid nodules.

Objectives: To correlate FNA[1] cytology results with surgical pathological findings in two teaching medical centers across the Atlantic.

Methods: We retrospectively identified 484 patients at Hadassah University Hospital, Jerusalem and Mount Sinai Hospital, New York, by means of both preoperative FNA cytology and a final histopathological report. Results compared FNA diagnosis, histological findings and frozen section results (Mt. Sinai only).

Results: The sensitivity value of FNA at Hadassah was 83.0% compared with 79.1% at Mt. Sinai (NS). Specificity values were 86.6 vs. 98.5% (P < 0.05), negative predictive value 78.7 vs. 77.6% (NS) and positive predictive value 89.7 vs. 98.6% (P < 0.05), respectively. "Follicular lesion" was diagnosed on FNA in 33.1% of the patients at Hadassah and in 21.5% at Mt Sinai (P < 0.005) with a malignancy rate of 42.5 vs. 23.1% (P < 0.05), respectively. Frozen section was used in 190 patients at Mt. Sinai (78.5%) with sensitivity and specificity values of 72.3% and 100%. Frozen section results altered the planned operative course in only 6 patients (2.5%). Follicular carcinoma was diagnosed in 12 patients at Hadassah vs. 2 patients at Mt. Sinai (P p <0.05).

Conclusion: The sensitivity of FNA at the two institutions was comparable. While malignancy on frozen section is highly specific, it should be used selectively for suspicious FNA results. Follicular lesions and the rate of malignancy in such lesions were more common at Hadassah, favoring a more aggressive surgical approach.

Background: Fracture of the scaphoid is the most common fracture of a carpal bone. Nevertheless, the diagnosis of SF[1] might be challenging. Plain X-rays that fail to demonstrate a fracture line while clinical findings suggest the existence of such a fracture is not uncommon. Currently there is no consensus in the literature as to how a clinically suspected SF should be diagnosed, immobilized and treated.

Objectives: To assess the current status of diagnosis and treatment of clinically suspected scaphoid fractures in Israeli emergency departments

Methods: We conducted a telephonic survey among orthopedic surgeons working in Israeli EDs[2] as to their approach to the diagnosis and treatment of occult SF.

Results: A total of 42 orthopedic surgeons in 6 hospital EDs participated in the survey. They reported performing a mean of 2.45 ± 0.85 clinical tests, with tenderness over the snuffbox area being the sign most commonly used.  A mean of 4.38 ± 0.76 X-ray views were ordered for patients with a clinically suspected SF. The most common combination included posterior-anterior, lateral, semipronated and semisupinated oblique views. All participating surgeons reported immobilizing the wrists of patients with occult fractures in a thumb spica cast based on their clinical findings. Upon discharge from the ED patients were advised to have another diagnostic examination as follows: 29 (69%) repeated X-rays series, 18 (43%) were referred to bone scintigraphy and 2 (5%) to computed tomography; none were referred to magnetic resonance imaging.

Conclusions: No consensus was found among Israeli orthopedic surgeons working in EDs regarding the right algorithm for assessment of clinically suspected SF. There is a need for better guidelines to uniformly dictate the order and set of tests to be used in the assessment of occult fractures.

Background: The forced oscillation technique is a non-invasive and effort-independent technique and is well suited for lung function measurement in young children. FOT[1] employs small-amplitude pressure oscillations superimposed on normal breathing. Therefore, it has the advantage over conventional lung function techniques in that it does not require patient cooperation for conducting respiratory maneuvers.

Objectives: To test the feasibility of the FOT test in preschool children and to compare the results to the commonly used spirometry before and after the administration of bronchodilator therapy.

Methods: Forty-six children (median age 4.9 years, range 1.8–18.3) attending the Pulmonary Clinic at Schneider Children's Medical Center tried to perform FOT and routine spirometry. Results were retrospectively analyzed. 

Results: Of the 46 children 40 succeeded in performing FOT and only 29 succeeded in performing simple spirometry. All but one of the 32 children aged 4 years and above (97%) could perform both tests. Nine of 14 children (64%) aged 4 and less could perform the FOT but only 3 (21%) could perform spirometry. Baseline values of respiratory resistance measured at 6 Hz (R6) negatively correlated with body length (r² = 0.68, P < 0.005). Twenty-four children performed both tests before and after bronchodilator therapy. A significant concordance was found between the measured responses to bronchodilators by FOT and spirometry (P < 0.01). Only one child had a negative response by FOT but a positive response by spirometry.

Conclusions: The FOT is a simple, non-invasive technique that does not require subject cooperation and thus can be utilized for measuring lung function in children as young as 2 years of age. Furthermore, the FOT was shown to reliably measure response to bronchodilator therapy.

Background: Uncorrected refractive error is the leading cause of visual impairment in children. In 2002 a screening project was launched in Israel to provide data on the effectiveness of the illiterate E-chart in identifying Jewish and Arab schoolchildren in need of a comprehensive eye examination.

Objectives: To present the aims, design and initial results of the visual screening project and the prevalence of vision abnormality in the study population.

Methods: A cross-sectional population-based study was conducted during 2002–2003 among first- and eighth-graders in 70 schools in northern Israel. The nurse's test included use of the illiterate E-chart to measure visual acuity. The medical examination included vision history, clinical eye examination, VA[1] and retinoscopy. The ophthalmologist's evaluation as to whether a child needed a referral for diagnostic procedures, treatment and/or follow-up was recorded and compared with explicit referral criteria formulated after data collection.

Results: Of 1975 schoolchildren, 31% had abnormal VA, defined as VA worse than 6/6 in at least one eye, and a quarter had VA equal or worse than 6/12 in both eyes. The prevalence of vision abnormality among the children was 22.4% when based on the evaluation of the field ophthalmologist and 26.1% when based on two sets of explicit severity scores and referral criteria.

Conclusions: Vision abnormality is a significant health problem among northern Israeli schoolchildren. This project is unique in scope and importance, providing evidence to assist policy making with regard to vision screening for schoolchildren (including data on test reliability and validity) and optimal VA cutoff level, and confirming the need for clinical guidelines regarding referral criteria.

Background: Foodborne Salmonella enterica outbreaks constitute both a threat to public health and an economic burden worldwide.

Objectives: To characterize the pathogen(s) involved and possible source of infection of an outbreak of acute gastroenteritis in a banqueting hall in Jerusalem.

Methods: We conducted interviews of guests and employees of the banqueting hall, and analyzed food items, samples from work surfaces and stool cultures.

Results: Of 770 persons participating in three events on 3 consecutive days at a single banqueting hall, 124 were interviewed and 75 reported symptoms. Salmonella enterica, serovar Enteritidis, phage type C-8, was isolated from: 10 stool cultures (eight guests, one symptomatic employee and one asymptomatic employee) and a sample of a mayonnaise-based egg salad. Pulsed-field gel electrophoresis[c1]  of the isolates revealed an identical pattern in the outbreak isolates, different from SE C-8 controls. A culture-positive, asymptomatic employee was linked to all three events. After a closure order, allowing for cleaning of the banqueting hall, revision of food preparation procedures and staff instruction on hygiene, the banqueting hall was reopened with no subsequent outbreaks.

Conclusions: It is often difficult to pinpoint the source of infection in S. enterica outbreaks. Using molecular subtyping methods, a link was confirmed between patients, a food handler, (presumably a carrier) and a food item – all showing an identical specific Salmonella enterica serovar Enteritidis. Testing asymptomatic as well as symptomatic food handlers in outbreak investigations is imperative. Pre- and post-hiring screening might be considered as preventive measures; hygiene and sanitation education are essential.

Background: Due to extensive activity at sea, certain human populations, especially fishermen, are exposed to direct contact with the sea's inhabitants, including dangerous marine animals.

Objectives: To characterize and assess the extent of injuries caused by marine organisms along the Mediterranean coast of Israel, their type, severity and medical treatment given.

Methods: Data were obtained from a survey on injuries from marine organisms conducted among professional fishermen along the Mediterranean coast of Israel and from medical records reporting toxicological consultations provided by the Israel Poison Information Center.

Results: Injuries caused by marine organisms are not rare in Israel, but most cases are not severe. The most common injuries reported by fishermen were caused by stingrays (30%), weaver fish (22%), rabbit fish, (13%) and marine catfish (10%) – a new Red Sea immigrant. Most fishermen tend to treat such injuries themselves and sought medical help only when an unknown venomous fish was involved. Most cases of severe toxicity were due to secondary infection. Data from the IPIC[1] indicated that 64% of the calls were from the general public and the rest came from physicians in health care facilities. Four sources of injuries were identified: cleaning and preparing fish for consumption, during leisure water sport activities, handling marine aquaria, and fishing. Most cases from the IPIC were graded as minor severity (85%) and were treated symptomatically.
Conclusions: We recommend that medical facilities be installed at the fishing anchorages and that a separate category be established for injuries by marine organisms to facilitate epidemiological data collection from health care facilities

Background: Scombroid fish poisoning is an acute illness caused by consumption of fish containing high concentrations of histamine. Improper handling of fish leads to bacterial contamination. Bacterial enzymes convert histidine to histamine. Symptoms develop quickly and resemble an immunoglobulin E-mediated allergic reaction. The diagnosis is often missed. Serious complications (e.g., bronchospasm, hypotension) are infrequent.

Objectives: To evaluate the prevalence and characteristics of scombroid fish poisoning in Israel as reported to the National Poison Information Center.

Methods: We conducted a retrospective poison center chart review from January 2005 to December 2007.

Results: During the study period, 21 events of scombroid poisoning involving 46 patients were recorded. Tuna was the commonest fish consumed (84.7%). Clinical manifestations developed within 20 minutes in 65.2% of the patients. The main clinical manifestations included rash (41%), flushing (37%), gastrointestinal complaints (37%) and headache (30.4%). About 25% had abnormal vital signs; two patients developed hypotension. Treatment was supportive and included mainly H₁-antagonists (65.2%) and fluids (13%). Five patients were initially misdiagnosed as having an allergic reaction and were treated with corticosteroids (four patients) and epinephrine (one patient).

Conclusions: Scombroid fish poisoning should be suspected in patients with histamine-like manifestations that are temporally related to fish (mainly tuna) consumption, especially in outbreaks. Although scombroid poisoning is often self-limited and responds well to antihistamines, prolonged observation may be required as severe toxicity can supervene. Proper handling of fish and urgent notification of the Ministry of Health are mandatory in order to prevent this potentially serious public heath problem.
 

Background: Intrapartum risk is based mainly on obstetric history, which is lacking in primiparous women.

Objectives: To ascertain whether the traditional known risk of primiparity is an independent variable for both maternal and neonatal outcome.

Methods: All women admitted to labor during March-April 2002 were canvassed for eligibility for participation in the study based on an obstetric risk scoring system developed and validated for our population. During the study period, 1473 women presented for delivery. Of these, 298 women (20%) were eligible according to the exclusion criteria as "low risk" parturients: 135 (45%) were primiparous and 163 (55%) were multiparous (2–5 births).

Results: After correction for significant confounding factors, primiparity was revealed as an independent significant risk factor for instrumental delivery (odds ratio 15.5, 95%confidence interval 1.88–125) and for early postpartum hemorrhage (OR[1] 5.6, 95%CI[2] 1.9–16.6).

Conclusions: This study highlights early postpartum hemorrhage as a significant risk for primiparous women, independent of mode of delivery, and also confirms previous reports of maternal complications requiring transfer from birth centers/home deliveries to tertiary centers.

Since the beginning of medical history, ethics has interested medical practitioners. The subject has become particularly important in recent years due to the huge advancements in medicine and medical technology and has elicited much public interest. While international ethical principles and guidelines have been established, classical Jewish tradition has always placed great emphasis on bioethics. Prof. Avraham Steinberg’s monumental Encyclopedia of Jewish Medical Ethics presents the subject comprehensively and in depth. We propose a bioethics syllabus, to be integrated into the medical curriculum in three stages: i) preclinical – covering basic ethical concepts and principles, relevant history, and ethical codes; ii) clinical  – covering bioethical topics relating to the human life cycle; iii) prior to students' final examinations and further specialization – covering bioethical topics relating to their personal interests. Steinberg’s Encyclopedia is an ideal basis for the development of a professional course, including Jewish traditional aspects. Such a course would provide future physicians with a varied cultural and intercultural background, help shape their image, and improve the quality of medical care.