Israel Medical Association Journal

Background: Human milk produced during prolonged lactation (> 1 year) is extraordinarily rich in fat and has a higher energy content than human milk produced during short lactation.

Objectives: To estimate the fatty acid (FA) profile of human milk and to test the hypothesis that the proportion of C12 and C14 (two dietary saturated FA known to most promote hypercholesterolemia) in human milk during prolonged lactation is similar to that in short lactation.

Methods: We conducted a cross-sectional study of 30 mothers of term infants lactating for more than 1 year as compared with 25 mothers of full-term infants who lactated for 2–6 months. Milk was collected by manual expression in mid-breastfeeding.

Results: The two groups did not differ in maternal height, weight, body mass index, diet, infant birth weight and gestational age, but mothers in the prolonged lactation group were significantly older. There was a significant correlation between lactation duration and C12 or C14. The percentage of all FA combined (except for C12 and C14) decreased significantly over time. In contrast, C12:0 and C14:0 combined increased significantly during lactation (R2 = 10.0%, P < 0.03).

Conclusions: Women who lactated for more than 1 year had higher C12 and C14 FA percentages in their milk than women who lactated for 2–6 months.

Background: Maternal exposure to alcohol during pregnancy can lead to a wide range of clinical manifestations in their offspring, termed fetal alcohol spectrum disorder (FASD). In Israel, relatively few cases of FASD have been diagnosed and the prevalence has not been systematically evaluated.

Objectives: To determine the number of children with FASD or at risk for FASD in a select population of high risk patients seen at a clinic evaluating foster and adopted children.

Methods: Israeli children under 2 years old who were candidates for domestic adoption or in foster care were prospectively evaluated for clinical manifestations of FASD, and information was obtained regarding parental use of alcohol or other illicit drugs.

Results: Of the 100 patients prospectively evaluated, 8 had mothers with a known history of alcohol consumption during pregnancy. Two of the children had fetal alcohol syndrome (FAS) without known maternal exposure to alcohol and two had partial FAS. Eleven other children were at risk for development of one of the diagnostic categories of FASD.

Conclusions: In a population of pre-adoption and foster children, 15% either had manifestations of FASD or were at risk for developing FASD. Although this is a select high risk population, the data from this study strongly suggest a greater prevalence of FASD than previously assumed. Under-diagnosis of FASD is detrimental to affected children who could benefit from interventions designed to meet the needs of FASD victims.
 

Background: There is a wide treatment gap between evidence-based guidelines and their implementation in primary care.

Objective: To evaluate the extent to which physicians "literally" follow guidelines for secondary prevention of dyslipidemia and the extent to which they practice "substitute" therapeutic measures.

Methods: We performed a post hoc analysis of data collected in a prospective cluster randomized trial. The participants were 130 primary care physicians treating 7745 patients requiring secondary prevention of dyslipidemia. The outcome measure was physician "literal" adherence or "substitute" adherence. We used logistic regressions to evaluate the effect of various clinical situations on “literal” and “substitute” adherence.

Results: "Literal" adherence was modest for ordering a lipoprotein profile (35.1%) and for pharmacotherapy initiations (26.0%), but rather poor for drug up-titrations (16.1%) and for referrals for specialist consultation (3.8%). In contrast, many physicians opted for "substitute" adherence for up-titrations (75.9%) and referrals for consultation (78.7%). Physicians tended to follow the guidelines “literally” in simple clinical situations (such as the need for lipid screening) but to use "substitute" measures in more complex cases (when dose up-titration or metabolic consultation was required). Most substitute actions were less intense than the actions recommended by the guidelines.

Conclusions: Physicians often do not blindly follow guidelines, but rather evaluate their adequacy for a particular patient and adjust the treatment according to their assessment. We suggest that clinical management be evaluated in a broader sense than strict guideline adherence, which may underestimate physicians' efforts.
 

Pulmonary epithelioid hemangioendothelioma (PEH), previously known as "intravascular bronchoalveolar tumor," is a rare vascular malignancy with an unpredictable prognosis. Treatment can vary from observation in asymptomatic patients to surgery in patients with resectable disease or chemotherapy in patients with disseminated disease. This report describes the clinical, radiological and pathological features of three cases of PEH and a review of the current literature.
 

Background: Little is known of the risk factor disparities in first stroke among Jewish and Arab patients undergoing rehabilitation in Israel.

Objectives: To investigate the age, gender and risk factor disparities in first stroke among Jewish (immigrant and non-immigrant) and Arab patients undergoing rehabilitation and to compare the prevalence and odds ratio of stroke risk factors in these patients.

Methods: The database of the Department of Neurological Rehabilitation C at Loewenstein Rehabilitation Center was used to investigate first ischemic and hemorrhagic stroke patients admitted for hospital rehabilitation over a 15 year period, January 1993 to December 2008. Particular attention was paid to age, gender and risk factor disparities.

Results: The 2000 patients with first stroke who were included in the study were grouped as Jewish (immigrant and non-immigrant) and Arab (237 Arabs, 370 non-immigrant Jews and 1393 immigrant Jews). A high percentage of Arab patients were found to have hypertension and diabetes mellitus, while a high percentage of Jewish immigrants had stenosis of the internal carotid artery.

Conclusions: The study demonstrated some differences in the effect of risk factors between the groups. It may be important to address such differences when developing stroke preventative strategies in this population of Jewish and Arab stroke survivors in Israel.
 

Background: Pediatric functional visual loss (FVL) is the loss of vision in a child that cannot be explained by an organic pathology. In the last decade, only a few studies on pediatric FVL have reported long-term patient follow-up.

Objectives: To report the characteristics of pediatric FVL with long-term follow-up in Israeli children.

Methods: We conducted a retrospective chart review of the medical records of patients with FVL from 2000 to 2010. Only children with adequate follow-up (at least 2 months) were included.

Results: Of the 12 patients identified, 9 were females. Mean patient age was 10.5 ± 4.4 years (range 3.5–17 years). Most children (75%) had bilateral visual loss. One patient had a history of psychiatric illness and in three patients a preceding psychosocial event/trauma was identified. Brain imaging and electrophysiology testing (if done) were normal in all cases. No medications were prescribed to any of the patients, and all were reassured that there was a high chance of spontaneous resolution. The follow-up time was 2–108 months (mean 23.8 months, median 6). During the follow-up period 9 of the 12 had complete resolution and 2 had relief of symptoms. Three patients reported a recurrence of symptoms. No organic disease was ever diagnosed in this group.

Conclusions: FVL may occur in all age groups, including children. In cases of visual loss, it is usually bilateral and can involve both acuity and visual field loss. In the present report most of the patients experienced normalization or relief of their symptoms without medical treatment.
 

The incidence of invasive uterine cervical cancer in Israeli Jewish women is persistently lower than in many other countries, although the frequency of premalignant lesions is similar to that in other populations. Most characteristics, except certain traditional habits, are similar to those in other populations. The incidence among women born in North Africa and their Israeli born descendants is significantly higher than in those born in other continents, possibly due to genetic factors. In view of the similarities to other populations the reason for the low incidence in Israel remains obscure, and whether it may be attributed to genetic reasons or to some traditional habits remains to be confirmed
 

Background: Religiosity has been examined as a mechanism of stress management. Since many studies have shown a high rate of psychological morbidity among medical students during different stages of training, it is important to investigate whether religiosity may serve as a protective factor.

Objectives: To assess the association between religiosity and depression or anxiety in a sample of medical students and to compare the results with a matched sample of students from other fields of study.

Methods: This cross-sectional study examined a sample of Tel Aviv University medical students and compared them with students in other faculties at the same university for any association between religiosity and depression or anxiety. The subjects completed the Beck Depression Inventory, the Beck Anxiety Inventory, a modified religiosity inventory, and a demographic and psychosocial variables inventory.

Results: Findings did not show a significant association between religiosity and depression or anxiety in the general sample (n=119). A positive significant correlation between religiosity and anxiety was found among medical students, with 29.4% of them reporting anxiety and 25.2% depression. While high rates of depression and anxiety were reported by students in the first to third years (pre-clinical years), there was a decrease in depression and anxiety in the fourth to sixth years (clinical years). However, higher anxiety and depression scores were noted among controls as compared to medical students.

Conclusions: In contrast to another recent investigation, a negative correlation between religion and depression/anxiety does not necessarily exist. An association between religiosity and mental health could have many theoretical and practical implications and requires further investigation. Similar to previous studies, the rates of depression and anxiety among Israeli medical students were comparable with those of other countries. These rates are considered higher than those in the general population and emphasize the importance of alertness to mental health issues among students, especially during the early study years.
 

Background: Wounds of the lower extremities are a significant problem, being severe and costly to treat. Adjunctive treatment with hyperbaric oxygenation (HBOT) has proven to be a useful and cost-effective means of treating ischemic wounds, mainly in diabetic patients.

Objectives: To describe patients with ischemic wounds treated at the Rambam and Elisha Hyperbaric Medical Center and their wound improvement following HBOT.

Methods: We conducted a retrospective cohort study of all patients (N=385) treated in the center during 1998–2007 for ischemic non-healing wounds in the lower extremities.

Results: The mean age of the patients was 61.9 years (SD 13.97). Most of them were diabetic (69.6%) and male (68.8%). Half of the subjects had a wound for more than 3 months prior to undergoing pre-HBOT transcutaneous oximetry (TcPO₂) testing. Most of the wounds were classified as Wagner degree 1 or 2 (39.1% and 46.2% respectively). The median number of treatments per patient was 29. Only 63.1% of patients had continuous treatments. Approximately 20% of patients experienced mild side effects. An improvement occurred in 282 patients (77.7%) following HBOT: 15.2% fully recovered, 42.7% showed a significant improvement (and were expected to heal spontaneously), and 19.8% a slight improvement.

Conclusions: HBOT can benefit the treatment of non-healing ischemic wounds (especially when aided by pretreatment TcPO₂ evaluation; data not shown). Our experience shows that this procedure is safe and contributes to wound healing.

Background: Primary liver masses in children may require intervention because of symptoms or concern about malignant transformation.

Objectives: To review the management and outcomes of benign liver masses in children. Methods: We conducted a retrospective chart review of children with liver masses referred to our institution during the period 1997–2009.

Results: Benign liver masses were identified in 53 children. Sixteen of these children (30%) had hemangioma/infantile hepatic hemangioendothelioma (IHH) and 15 (28%) had focal nodular hyperplasia. The remainder had 6 cysts, 4 hamartomas, 3 nodular regenerative hyperplasia, 2 adenomas, 2 vascular malformations, and one each of polyarteritis nodosa, granuloma, hepatic hematoma, lymphangioma, and infarction. Median age at presentation was 6 years, and 30 (57%) were female. Masses were initially noticed on imaging studies performed for unrelated symptoms in 33 children (62%), laboratory abnormalities consistent with liver disease in 11 (21%), and palpable abdominal masses in 9 (17%). Diagnosis was made based on characteristic radiographic findings in 31 (58%), but histopathological examination was required for the remaining 22 (42%). Of the 53 children, 27 (51%) were under observation while 17 (32%) had masses resected. Medications targeting masses were used in 9 (17%) and liver transplantation was performed in 4 (8%). The only death (2%) occurred in a child with multifocal IHH unresponsive to medical management and prior to liver transplant availability.

Conclusions: IHH and focal nodular hyperplasia were the most common lesions. The majority of benign lesions were found incidentally and diagnosed radiologically. Expectant management was sufficient in most children after diagnosis, although surgical intervention including liver transplant was occasionally necessary.
 

Background: Patients with heart failure (HF) have a poor prognosis. Heart failure centers with specialized nurse-supervised management programs have been proposed to improve prognosis.

Objectives: To evaluate the clinical outcome of patients with HF treated at a multidisciplinary HF center of Clalit Health Services in Jerusalem in collaboration with Hadassah University Hospital.

Methods: We evaluated clinical outcome including hospitalizations and death in all HF patients followed at the HF center for 1 year.

Results: Altogether, 324 patients were included and followed at the HF center; 58% were males with a mean age of 76 ± 11 years, and 58% were in New York Heart Association (NYHA) functional class 3-4. The overall 1 year survival rate was 91% and the 1 year hospitalization rate 29%. Comparing patients in the HF center to the whole cohort of patients with a diagnosis of HF (N=6618) in Clalit Health Services in Jerusalem demonstrated a similar 1 year survival rate: 91% vs. 89% respectively but with a significantly reduced hospitalization rate: 29% vs. 42% respectively (P < 0.01). Cox regression analysis demonstrated that treatment in the HF center was a significant predictor of reduced hospitalization after adjustment for other predictors (hazard ratio 0.65, 95% confidence interval 0.53–0.80, P < 0.0001). A subset of patients that was evaluated (N=78) showed significantly increased compliance. NYHA class improved in these patients from a mean of 3.1 ± 0.1 to 2.6 ± 0.1 after treatment (P < 0.0001).

Conclusions: Supervision by dedicated specialized nurses in a HF center increased compliance, improved functional capacity in HF patients, and reduced hospitalization rate. HF centers should be considered part of the standard treatment of patients with symptomatic HF.