Israel Medical Association Journal

Background: Acute rheumatic fever is considered a relatively uncommon disease in developed countries. Although cases are encountered in the Nazareth area in Israel, no systematic study of this disease has been done in the last 20 years.

Objective: To study the incidence and characteristics of acute rheumatic fever cases in the Nazareth area during the last decade.

Methods: Cases of acute rheumatic fever diagnosed according to the modified Jones criteria were identified in two hospitals in the Nazareth area during the 10 years. These two hospitals receive about 75% of non-obstetric referrals to the emergency room. Clinical, laboratory and treatment data of these patients were documented and the incidence of disease calculated. The population census in the Nazareth area was obtained from the Central Bureau of Statistics.

Results: Forty-four patients, with a mean age of 18 years, were identified. The mean annual incidence was 5 cases/100,000 population. Arthritis was found in 98% of the patients (migratory in 52%) and carditis in 34%, but only one patient had a subcutaneous nodule, and none had either erythema marginatum or chorea. Only one patient with carditis developed heart failure a few months later due to severe mitral stenosis.

Conclusion: Rheumatic fever in the Nazareth area is still manifest. The mean age of the patients was higher than found previously. In only half of the patients was the arthritis migratory, with other major manifestations of rheumatic fever found only rarely.
 

Background: The more patients know about their medications the higher their compliance with drug therapy, reflecting an effective communication between health professionals and their patients. Numerous studies on this subject have been published, but none has been conducted in Israel.

Objectives: To evaluate patients’ perceptions of drug counseling by health professionals – the prescribing physician and dispensing pharmacist – and to determine whether there is a difference in the patient’s perception according to his or her place of birth and mother tongue.

Methods: A total of 810 patients were interviewed following receipt of their medications from in-house pharmacies at two community clinics of Israel’s largest sick fund. Each patient was interviewed in his or her mother tongue according to a constructed questionnaire, which included the patient’s demographic background, type of medications received, the patient’s perceptions of drug counseling given by both the physician and the pharmacist, and the patient’s perception of non-prescription drug counseling given by the dispensing pharmacist.

Results: Of the 810 patients enrolled in this study, 32% received three or more medications at each physician visit. The main therapeutic classes of medications prescribed and dispensed were for neurological disorders, cardiovascular diseases, gastrointestinal problems and respiratory diseases. While 99% of the patients claimed that they knew how to use their medications, only 96% reported receiving an explanation from either physician or pharmacist. The quality of counseling, as evaluated by the patients, was ranked above average for 75% of the consultations with the prescribing physician and 63% with the dispensing pharmacist.

Conclusions: Although few conclusions can be drawn from this study based on the initial statistical analysis of the data, the major findings were that patients value highly the counseling they receive and that 99% believe they have the requisite knowledge for using their medications. Compared to the international literature, our results – based on the patients' perceptions – indicate that counseling by pharmacists is a common and well-accepted activity in Israel and occurs at a high rate.
 

Background: Cigarette smoking is a major contributor to the risk of acute myocardial infarction and the subsequent morbidity and mortality. Physicians can play an important role in smoking cessation among patients with AMI because of their frequent contact with the patient during the event.

Objectives: To study the prevalence of smoking, age, localization of coronary occlusion, mortality and rate of smoking cessation in consecutive patients who were diagnosed with a first AMI in our center in 1989–93.

Methods: The study included 1,510 consecutive patients with first AMI: 973 men (512 smokers, 52.6%) and 537 women (215 smokers, 40%), whose mean age was 64.1±6.7 and 68.6±5.2 years respectively.

Results: The median age at the first AMI in non-smoking and smoking men differed significantly (70.4±6.8 vs. 56.6±6.1 years, P<0.001) while the difference in the women was smaller (70.4±6.9 vs. 66.8±7.2). The proportion of smokers/non-smokers among men was greater at a younger age and decreased proportionally with age. The overall mortality was 11.3% with a significant difference in mortality rate in the younger age groups between smokers and non-smokers (1% vs. 0% in the age group 31–40 years, P<0.05, and 6.1% vs. 0.8% in the 41–50 year age group, P<0.001). Only 62% of the smokers who survived the AMI declared that they had received anti-smoking advice from a physician during hospitalization. The cessation rate in this group was significantly higher than in smokers who had not been cautioned against smoking (56% vs. 18%).

Conclusions: Current smokers sustained their first AMI more than one decade earlier than non-smokers, and the younger smokers had a higher mortality rate. The majority of the smokers who received anti-smoking advice during their hospitalization for AMI quit smoking in the year following the acute event. 

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AMI= acute myocardial infarction

Background: The beneficial effect of aprotinin, a naturally occurring protease inhibitor, on preservation of organs such as the liver, kidney and lung has been documented.

Objective: To explore the effects of hepatic ischemia and reperfusion on both liver and myocardial function, using a dual isolated perfused organ model with and without aprotinin.

Methods: Isolated rat livers were stabilized for 30 minutes with oxygenated modified Krebs-Henseleit solution at 37°C. Livers were then perfused continuously with KH or KH + aprotinin 10⁶ KIU/L for an additional 135 min. Livers of two other groups were made globally ischemic for 120 min, then perfused for 15 min with KH or with KH + aprotinin. Isolated hearts (Langendorff preparation) were stabilized for 30 min and then reperfused with KH or KH + aprotinin exiting the liver for 15 min.  The liver’s circuit was disconnected, and hearts were re-circulated with the accumulated liver + heart effluent for an additional 50 min.

Results: In the ischemia and ischemia + aprotinin groups, portal vein pressure (1 and 15 min reperfusion) was 331±99% and 339±61% vs. 308±81% and 193±35% of baseline, respectively (P<0.03 vs. ischemia). There were no other differences in the enzyme leakage  between aprotinin-treated or untreated ischemic livers. Left ventricular pressure was stable in the controls.

However, LV pressure in groups perfused with ischemic liver effluent declined within 65 min reperfusion, whether aprotinin treated or not (84±8% and 73±5% of baseline, respectively, P<0.004 only for ischemia vs. control)

Conclusion: When aprotinin was used, LV pressure was inclined to be higher while liver portal vein pressure was lower, thus providing protection against liver and heart reperfusion injury. 

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* These authors contributed equally to the article

KH = Krebs-Henseleit

LV = left ventricular

Background: A high rate of consanguineous marriages exists within the Israeli Arab community, with approximately half occurring between first cousins. This contributes towards a high incidence of congenital malformations and autosomal recessive diseases, many of which are detectable at prenatal diagnosis.

Objectives: To assess the levels of both awareness and acceptance regarding prenatal diagnosis and termination of pregnancy among a group of Arab women in order to devise the optimal means of providing genetic counseling and general health services.

Methods: A total of 231 Arab women of childbearing age were interviewed 3 days postpartum to assess their knowledge of prenatal diagnosis and termination of pregnancy, their willingness to undergo prenatal diagnosis, and their opinions on termination of pregnancy in the event of a severely affected fetus.

Results: Half the women believed that prenatal testing is not an effective (or accurate) tool for diagnosing an affected fetus. A quarter had poor knowledge on prenatal diagnosis, and a quarter believed that prenatal diagnosis does provide the correct diagnosis. Ninety-five percent said they would agree to undergo prenatal diagnosis; and in the event of a severely affected fetus, 36% said they would agree to a termination of pregnancy, 57% said they would not, and 7% were undecided.

Conclusions: There is a need for special intervention programs, with guidance by health professionals, geneticists and religious authorities, that will inform this population on the increased risk associated with consanguinity, stress the importance and effectiveness of prenatal testing to identify severe congenital malformations, and help them to accept prenatal diagnosis and termination of pregnancy if indicated.

Background: Smoking rates have decreased in western countries as well as in Israel during the past 20 years.

Objectives: To estimate current rates of smoking and smoking cessation, and to assess factors associated with smoking and smoking cessation in family practice.

Methods: Prospective face-to-face interviews were conducted with 1,094 subjects, aged 16 years or older, registered in a family practice.

Results: Of all subjects studied, 746 (68.2%) were non-smokers, 237 (21.7%) were current smokers, and 111 (10.1%) had stopped smoking. Overall, 31.8% of the males and 13.8% of the females were current smokers, and 20.1% males and 2.4% females had stopped smoking. Current smoking and smoking cessation rates were significantly and inversely associated with age among males and females. Smoking rates were higher among males and females who were married, had 10-12 years of education, and among males of North African origin and females of Israeli origin. The number of cigarettes smoked per day was associated with smoking and smoking cessation in males, but not in females. The highest rate of quitting occurred among males who smoked 25 cigarettes per day. In a multiple regression analysis, gender and the number of cigarettes smoked per day were the most significant factors that predicted smoking cessation. The most common reason for stopping was the appearance of new signs of illness or the development of a new chronic disease, followed by a physician's recommendation to quit smoking.

Conclusions: Female smokers and male smokers who smoke less than 25 cigarettes per day are the least likely to quit smoking. Future programs should be designed for and targeted at these groups of patients.

Background: Osteoporosis is the most common human bone disease. It affects millions of persons throughout the world and its prevalence will increase as the population ages worldwide.

Objective: To assess Israeli physicians' attitudes and knowledge with regard to management of osteoporosis.

Methods: A questionnaire was mailed to 1,900 Israeli physicians concerning their attitudes to the management of osteoporosis, their prescribing habits, and their knowledge on the pharmacological treatment of the disease.

Results: Replies were received from 19% of the physicians. The respondents encouraged physical activity and cessation of smoking for all women, and prescribed estrogen replacement as the main treatment for 50-year-old women. A relatively low level of knowledge was found regarding the adequate dosage of several of the pharmacological treatments.

Conclusions: The findings of the present study stress the need to provide clear guidelines and to extend physicians' knowledge regarding the management of osteoporosis.

Background: Exposure of newborn animals to high concentrations of oxygen leads to diffuse alveolar damage similar to that seen in bronchopulmonary dysplasia in human infants. Therefore, neonatal rats are a suitable practical model of hyperoxic lung damage in human infants.

Objective: To determine the involvement of tumor necrosis factor-alpha and interleukin-6 in lung injury in neonatal rats exposed to 100% O2 concentration.

Methods: A randomized controlled study was designed in which litters of term Sprague-Dawley rat pups were assigned to experimental or control groups. The pups in the experimental group were placed in 100% O2 from birth for 9 days, while the control pups were placed in room air. Twelve to 15 pups from each group were sacrificed on day 1, 3, 6, 9 and 13 after birth for bronchoalveolar lavage collection and lung histologic study. The bronchoalveolar lavage fluid was assayed for TNFα and IL-6.

Results: Newborn rats exposed to 100% O2 for the first 9 days of life showed severe pulmonary edema and hypercellularity on days 1 and 3, which then improved to nearly complete resolution on days 6 and 9. Pulmonary TNFα was produced early on O2 exposure (day 3) and pulmonary IL-6 later (days 6 and 9).

Conclusions: Hyperoxia induces sequential production of pulmonary TNFα and IL-6, which corresponds to the severity of the pathological findings and the known inflammatory and anti-inflammatory role of these cytokines.

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TNFα= tumor necrosis factor-alpha

IL-6= interleukin-6