Israel Medical Association Journal

Objectives: To assess the effects of the recently introduced co-payment for consultant specialist services on patients' utilization of these services in southern Israel.

Methods: Computerized utilization data on specialists' services for 6 months before and 6 months after initiation of co-payment were retrieved from the database of Israel's largest health management organization.

Results: A decrease of 4.5% was found in the total number of visits to Soroka Medical Center outpatient clinics and of 6.8% to community-based consultants. An increase of 20.1% was noted in the number of non-actualized visits at the outpatient clinics. A decrease of 6.2% in new visits was found in the hospital outpatient clinics and of 6.5% in community clinics. A logistic regression model showed that the residents of development towns and people aged 75+ and 12–34 were more likely not to keep a prescheduled appointment.

Conclusion: After introduction of a modest co-payment, a decrease in the total number of visits to specialists with an increase in "no-shows" was observed. The logistic regression model suggests that people of lower socioeconomic status are more likely not to keep a prescheduled appointment.

Objectives: To compare the neonatal outcome (survival, intraventricular hemorrhage and bronchopulmonary dysplasia) of inborn and outborn very low birth weight infants, accounting for sociodemographic, obstetric and perinatal variables, with reference to earlier published data.

Methods: We compared 129 premature infants with birth weights of 750–1250 g delivered between 1996 and 2000 in a hospital providing neonatal intensive care to 99 premature babies delivered in a referring hospital. In the statistical analysis, variables with a statistical significant association with the outcome variables and dissimilar distribution in the two hospitals were identified and entered together with the hospital of birth as explanatory variables in a logistic regression.

Results: Accounting for the covariates, the odds ratios (outborns relative to inborns) were 0.31 (95% confidence interval = 0.11–0.86, P = 0.03) for mortality, 1.37 (95%CI[1] = 0.64–2.96, P = 0.42) for severe intraventricular hemorrhage, and 0.86 (95%CI = 0.38–1.97, P = 0.78) for bronchopulmonary dysplasia. The odds ratio for survival without severe intraventricular hemorrhage was 1.10 (95%CI = 0.55–2.20, P = 0.78). Comparing the current results with earlier (1990–94) published data from the same institution showed that mortality decreased in both the outborn and inborn infants (OR[2] = 0.23, 95%CI = 0.09–0.58, P = 0.002 and 0.46; 95%CI = 0.20–1.04, P = 0.06, respectively), but no significant change in the incidence of severe intraventricular hemorrhage or brochopulmonary dysplasia was observed. Increased survival was observed also in these infants receiving surfactant, more so among the outborn. The latter finding could be attributed to the early, pre-transport surfactant administration, implemented only during the current study.

Conclusions: Our data suggest that very low birth weight outborn infants may share an outcome comparable with that of inborn babies, if adequate perinatal care including surfactant administration is provided prior to transportation to a tertiary center.

Background: The evaluation of influenza vaccine activity and potency are based on the immune response to hemagglutinin, and protection is indicated when a ≥ 1:40 titer of hemagglutination inhibition serum antibody is present. Neuraminidase, the second surface glycoprotein, may also have a role in protection, but little information on the immunologic response to this component is available.

Objectives: To determine whether any response to neuraminidase is evoked by intranasal immunization with a novel, whole, inactivated anti-influenza vaccine.

Methods: This study was part of a more comprehensive study of mucosal and serum immune response to this vaccine. Fifty-four young adults were immunized intranasally, 9 intramuscularly and 18 received a placebo. Twenty-three elderly people were immunized intramuscularly, and 21 elderly and 17 children were immunized intranasally. Serum and nasal antibodies to antigens N1 and N2 were determined by the lectin neuraminidase test.

Results: Serum response following intranasal vaccination was lower than after intramuscular vaccination, and ranged from 21.4 to 35.3% and 33.3 to 64.7% following intranasal vaccination and 52.2 to 77.8% and 47.8 to 88.9% after intramuscular vaccination, to N1 and N2 respectively. Nasal antibody response was low and was found only after intranasal vaccination, and response to N2 was better than to the N1 antigen.

Conclusions: It may be beneficial if future vaccines would include competent hemagglutinin and neuraminidase, which would afford a higher level of protection.
 

Background: During the last decade, Israel, a country with low tuberculosis rates, absorbed some 900,000 new immigrants from TB[1]-endemic countries.

Objectives: To analyze the specific impact of our screening procedures on active TB among children in Israel.

Methods: We conducted a retrospective analysis of epidemiologic and clinical data of all children (aged 0–17) with TB notified to the Ministry of Health between 1990 and 1999.

Results: There were 479 children with TB (male/female ratio 1.36). Most cases (81.8%) were foreign born, predominantly (88.2%) immigrants from Ethiopia and, therefore, huge differences existed in TB incidence rates according to countries of origin. Some 80% were diagnosed within 3 years of arrival, mainly due to active case-finding. Pulmonary TB, with infiltrates on chest X-ray, was found in 49.5%. Extra-pulmonary TB sites were: intra-thoracic lymphadenitis (31.1%), extra-thoracic lymphadenitis (12.5%), bones (3.6%), pleura (1.3%), meninges (1%), and others (1%). Seventy percent had a tuberculin skin test reaction ≥10 mm in size. Two (non-immigrant) children died of TB meningitis.

Conclusions: Most of the pediatric TB cases occurred in recent immigrants and were diagnosed within 3 years of immigration. These data support our policy of active case-finding among new immigrants from Ethiopia and extensive contact evaluation for all TB cases.

Background: Heat shock proteins are highly conserved immunodominant antigens found in various species. Humoral immune responses to mycobacterial HSP65[1] and human HSP60 have been established in a number of human autoimmune diseases.

Objective: To assess the prevalence of antibodies to HSP60 kDa and HSP65 kDa in patients with Sjogren's syndrome as compared to normal subjects.

Methods: Thirty-seven patients with SS[2] were compared with normal controls. The antibodies against human HSP60 were measured by the Anti-Human (IgG/IgM) HSP60 ELISA kit. IgGs[3] and IgMs to mycobacterial HSP65 were determined using an enzyme-linked immunosorbent assay with mycobacterial recombinant HSP65 antigens.

Results: The levels of both anti-HSP60 and -HSP65 were lower among patients compared with controls. IgG autoantibodies to HSP60 were significantly different between groups: 162 ± 55.1 ng/ml in controls versus 112.3 ± 30.6 ng/ml in SS patients (P < 0.001). The levels among controls of anti-HSP65 IgM isotype were also significantly higher than among patients: 111.6 ± 33.4 U/ml versus 96.1 ± 8.9 U/ml (P = 0.01).

Conclusions: The results of the present study show that the levels of different isotypes of anti- HSP60 and HSP65 antibodies were lower in patients with SS than in normal subjects. Additional studies on larger patient populations are required to evaluate the prevalence of these autoantibodies in SS patients.

Epidemiologic data demonstrate a long-linear realationship between low density lipoprotein-cholesterol levels and risk of coronary heart disease.

Objectives: To investigate the effect of low calcium dialysis on post-dialysis hypertension in view of an evident link between serum calcium and blood pressure in both normal renal function and chronic renal failure patients.

Methods: We evaluated 19 chronic hemodialysis patients in whom both post-dialysis hypertension and PDHCa[1] were observed. We investigated changes in serum total calcium, ionized calcium, intact parathormone levels and arterial blood pressure in response to 4 weeks low calcium dialysis as a treatment for PDHCa.

Results: When PDHT[2] patients were treated with low calcium dialysis, post-dialysis blood pressure was significantly decreased compared to pre-dialysis values (155.3 ± 9.7/82.2 ± 7.9 mmHg pre-dialysis vs. 134.1 ± 20.8/80 ± 8.6 mmHg post-dialysis, P = 0.001). Additionally, post-dialysis blood pressure was significantly lower than post-dialysis blood pressure prior to the low calcium dialysis treatment (176.1 ± 15/86 ± 10.8 mmHg post-standard dialysis, 134.1 ± 20.8/80 ± 8.6 mmHg after low calcium dialysis, P = 0.001). A decline in post-dialysis serum calcium (2.34 ± 0.2 vs. 2.86 ± 0.12 mmol/L, P = 0.04) and ionized calcium (1.17 ± 0.12 vs. 1.3 ± 0.06 mmol/L, P = 0.03) compared to pre-dialysis levels was also achieved by this treatment, with no significant changes in iPTH[3] levels.

Conclusions: These data suggest a role for low calcium dialysis in treating acute serum calcium elevation and post-dialysis hypertension in patients receiving maintenance hemodialysis.

Objectives: To report our experience with three patients who developed autoimmune disease following prostatectomy.

Patients: Three patients presented with autoimmune phenomenon soon after a prostectomy for BPH[1] or prostatic carcinoma: one had clinically diagnosed temporal arteritis, one had leukocytoclastic vasculitis, and the third patient developed sensory Guillian-Barré syndrome following prostatectomy.

Conclusions: In view of the temporal association between the removal of the prostate gland and the autoimmune process, combined with previously known immunohistologic features of BPH, a cause-effect relationship probably exists.

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[1] BPH = benign prostatic hypertrophy

Objectives: To examine whether the treatment recommendations given to ischemic heart disease patients at hospital discharge are compatible with the guidelines of the Israeli Medical Societies and the U.S. National Cholesterol Education Program for coronary artery disease prevention; and to study the effects of brief educational sessions on the adherence of physicians with the guidelines.

Methods: We included consecutive IHD[1] patients admitted to four central hospitals in Israel between 1998 and 2000. The study was conducted in two phases. In phase 1, we reviewed discharge letters to document treatment recommendations given to each patient. In phase 2 we educated the practitioners by reviewing the Israeli Medical Societies and the NCEP[2] guidelines and the quality of their recommendations in phase 1, after which we reevaluated the discharge letters.

Results: The study included 2,994 patients: 627 in phase 1 and 2,367 in phase 2. Of the patients who needed cholesterol-lowering according to their low density lipoprotein levels, 37.4% were not prescribed such drugs at discharge (under-treatment group). This proportion was reduced by education to 26.6% (P < 0.001) in phase 2. Of the treated patients, 65.6% did not reach the target LDL[3] goal in phase 1 (under-dosage group) as compared to 60.2% in phase 2 (P = 0.23). In phase 2 there was an increase in the percent of patients reaching LDL levels <130 mg/day (69.3% vs. 63.8% of patients prescribed medication, P = 0.01), but the percent of patients reaching LDL levels <100 was not different in phase 2 after adjusting for age and gender (the odds ratio for reaching target LDL was 1.16, with 95% confidence interval of 0.95–1.43).

Conclusions: Physician recommendations to IHD patients discharged from hospital were suboptimal. We documented a high proportion of under-treated and under-dosage patients. Brief educational sessions have a beneficial effect on the usage of statins; however, additional effort in guideline implementations is needed.

Objective: To assess the prevalence of diabetes in an Arab community, the contribution of obesity to diabetes development, and the therapeutic potential of a preventive program.

Methods: Data were obtained from the medical files of diagnosed diabetes patients attending a primary care clinic in an Arab village in northern Israel.

Results: Type 2 diabetes was diagnosed in 323 patients of whom 63% were women. The prevalence of diabetes below age 65 years was significantly higher among women than men. Diabetic women were younger than men at diagnosis (48.27 vs. 59.52 respectively) and were found to have higher body mass index (34.35 vs. 30.04 respectively) at diagnosis. The age at diagnosis of diabetes was strongly correlated with BMI[1] (r = 0.97, P < 0.0001).

Conclusions: Women of Arab origin are at higher risk of developing type 2 diabetes compared to men. Obesity in women seems to be associated with higher diabetes risk as well as earlier appearance of the disease. Therefore, they will have the disease for longer and, consequently, a higher risk for complications.