Israel Medical Association Journal

Background: Following the recent drought in Ethiopia, the Jewish Agency, aided by the Israel Ministry of Foreign Affairs, launched a medical relief mission to a rural district in Ethiopia in May-August 2000.

Objectives: To present the current medical needs and deficiencies in this representative region of Central Africa, to describe the mission’s mode of operation, and to propose alternative operative modes.

Methods: We critically evaluate the current local needs and existing medical system, retrospectively analyze the mission’s work and the patients’ characteristics, and summar­ize a panel discussion of all participants and organizers regarding potential alternative operative modes.

Results: An ongoing medical disaster exists in Ethiopia, resulting from the burden of morbidity, an inadequate health budget, and insufficient medical personnel, facilities and supplies. The mission operated a mobile outreach clinic for 3 months, providing primary care to 2,500 patients at an estimated cost of $48 per patient. Frequent clinical diagnoses included gastrointestinal and respiratory tract infections, skin and ocular diseases (particularly trachoma), sexually trans­mitted diseases, AIDS, tuberculosis, intestinal parasitosis, malnutrition and malaria.

Conclusions: This type of operation is feasible but its overall impact is marginal and temporary. Potential alternative models of providing medical support under such circum­stances are outlined.
 

Background: The incidence of spinal failure necessitating general anesthesia and endotracheal intubation following spinal anesthesia for cesarean section is extremely low. Aspiration prophylaxis prior to spinal anesthesia is often recommended in case of spinal failure or excessive spinal block requiring the emergency administration of general anesthesia.

Objectives: To determine the incidence of endotracheal intubation following spinal anesthesia for cesarean section.

Methods: We retrospectively reviewed the pen-operative course of parturients undergoing cesarean section under spinal anesthesia at our institution from February 1991 to December 1993. If spinal failure occurred, 10 ml of sodium bicarbonate was administered by mouth prior to induction of general anesthesia.

Results: Among the 743 cases that we reviewed, spinal failure occurred in 15 patients (2%) because of inadequate analgesia in 14 patients (1.9%) and unexpected prolonged surgery for hysterectomy in one patient (0.1%). No patient required intubation due to excessive spinal block. In none of the patients was a record of pulmonary aspiration identified.

Conclusions: The extremely low incidence of spinal failure or excessive block necessitating endotracheal intuba­tion suggests that routine aspiration prophylaxis may not be necessary prior to spinal anesthesia. However, these results should be confirmed by a prospective, controlled study on larger populations. An antacid should be readily available and administered whenever general anesthesia is required.
 

Background: Breast cancer is one of the most prevalent malignancies in women, yet one of the most treatable. Early detection is essential to obtain the desired remission and longevity. Numerous studies have shown that periodic screen­ing for breast cancer can reduce mortality by 20-30%.

Objective: To assess the rates, compliance, character­istics as well as barriers in women regarding mammography screening.

Methods: The study group comprised a random sample of 702 women aged 50 or older from 5914 eligible women in two teaching clinics in southern Israel. Phone interviews using structured questionnaires were conducted.

Results: The mean age of the study population was 61 years. The vast majority of the women were not born in Israel. Sixty-three percent of the women had undergone a mammo­graphy screening, 48% in the past 2 years. Monthly self-breast examinations were performed by 12% of the women in the last 2 years. Significant factors associated with undergoing mammography were: more than 7 years since immigration, married, a higher education level, adequate knowledge about breast cancer and mammography, presence of past or current cancer, and cancer in relatives. The main reasons for not being screened was no referral (54%) and a lack of knowledge about breast cancer and mammography (19%) - conditions easily remedied by physician counseling.

Conclusion: The study suggests that promotional efforts should be concentrated on new immigrants and on less educated and unmarried women.

Background: Abdominal tuberculosis usually presents with general symptoms and obscure abdominal complaints for which computerized tomography is often the first imaging study.

Objective: To evaluate the CT findings of abdominal tuberculosis.

Methods: The CT scans of 19 patients (10 men and 9 women aged 20-85 years) with proven abdominal tuberculosis were retrospectively reviewed to define the location and extent of the disease. The patients were referred for the study mainly with general systemic symptoms. Additional abdominal com­plaints were present in four, including acute abdomen in one. Two had symptoms deriving from the urinary tract. Nine patients had recently arrived from high prevalence countries five of them and two others were positive for human immunodeficiency virus. Three patients had a family history of tuberculosis one had previously been treated for tubercu­losis and four others had an underlying chronic disease. The diagnosis of tuberculosis was established by standard micro­biological and histological techniques.

Results: We divided the disease manifestations into intraperitoneal (n-13) and genitourinary involvement (n- 6). Peritoneal tuberculosis was fairly common, characterized by ascites, omental and mesenteric infiltration, and smooth thickening of the parietal peritoneum. One oncology patient had a false positive Tc-99m CEA isotope scanning, suggesting tumor recurrence. Genitourinary disease manifested mainly as hydronephrosis and calcifications. Three patients had pulmon­ary tuberculosis as well.

Conclusion: The CT findings of abdominal tuberculosis may mimic various diseases, mainly diffuse peritoneal malig­nancy. We emphasize the need to consider tuberculosis in the differential diagnosis in patients with obscure abdominal symptoms, especially with multi-organ involvement. A high degree of clinical suspicion and familiarity with the abdominal CT manifestations allow early diagnosis of this treatable disease.

Background: The modest clothing that Orthodox Jewish women wear exposes very little of their skin to sunlight. Under these conditions they may develop vitamin D deficiency, even in sunny Israel.

Objectives: To determine and compare the vitamin D nutritional status in Jewish orthodox mothers to that of non-orthodox mothers who live in the same metropolitan area in Israel.

Methods: 25-Hydroxyvitamin D was measured by compe­titive protein-binding radioassay in the sera of 341 Jewish Israeli mothers (156 orthodox and 185 non-orthodox). The sera were obtained 48-72 hours after childbirth during the late summer of 1998 and the spring of 1999.

Results: The mean (SD) serum concentration of 25-OHD was significantly (P<0.002) lower (13.5 ± 7.5 ng/ml) in the orthodox than in the non-orthodox mothers (18.6 + 9.6 ng/ml). Vitamin D deficiency (<5 ng/ml) and insufficiency (<10 ng/ml) were more common in the orthodox mothers (5.1% and 32.7% respectively) than in the non-orthodox mothers (2.7% and 13%, respectively). In subgroups of mothers supplemented with 400 units of vitamin D daily during pregnancy, vitamin D deficiency and insufficiency were less common (2.2% and 13%, respectively) in orthodox and non-orthodox mothers (0% and 8.1%, respectively). Vitamin D insufficiency was more common in the winter than in the summer only among non­orthodox mothers.

Conclusions: The high prevalence of vitamin D deficiency and insufficiency in Israeli mothers raises the question whether vitamin D supplements should be given to pregnant women in Israel, at least to orthodox mothers.
 

Background: On 1 January 1995 a new mandatory National Health Insurance Law was enacted in Israel, The new law fostered competition among the four major Israeli healthcare providers (HMO5 or sick funds) already operating in the market due to the possibility that an unlimited number of patients and the relative budget share would shift among the HMOs. This led them to launch advertising campaigns to attract new members.

Objectives: To examine newspaper advertising activities during the early stages of healthcare market reform in Israel.

Methods: Advertising efforts were reviewed during a study period of 24 months (July 1994 to June 1996). Advertisements were analyzed in terms of marketing strategy, costs and quality of information.

Results: During the study period 412 newspaper adver­tisements were collected. The total advertising costs by all HMOs was approximately US$4 million in 1996 prices. Differences were found in marketing strategy, relative adver­tising costs, contents and priorities among the HMOs.

Conclusions: The content of HMO5 newspaper advertis­ing was consistent with their marketing strategy. The mes­sages met the criteria of persuasive advertising in that they cultivated interest in the HMOs but did not provide meaningful information about them. Future developments in this area should include consensus guidelines for advertising activities of HMOs in Israel, instruction concerning the content of messages, and standardization of criteria to report on HMO performance.

In diagnosing sepsis the rapid identification of bacteremia at an early stage of the disease is critical for a favorable outcome. Furthermore, it is important that exact information on the stage of the disease be obtained rapidly in order to choose and initiate the appropriate therapy. In recent years many new techniques have been added to the diagnostic tools. In this review we will focus on three new methods for the early diagnosis of sepsis. These are: polymerase chain reaction, which offers the possibility to attain detailed information about the involved bacterial (or viral) species, and the laboratory markers procalcitonin and hypophosphatemia, which are indicators of the presence of infection with gram-negative bacteria. The approaches reviewed here were developed to expedite the diagnosis of especially early sepsis and might be a further step towards the improvement of therapy for sepsis.

Background: Patients who feel involved in their treatment have better outcomes than those who do not.

Objective: To identify determinants of perceived patient involvement in obstetric care.

Methods: A retrospective study was undertaken in 1,452 (83%) of 1,750 women sampled in November 1995 from maternity wards of 14 general hospitals in Israel. A postal and telephone survey using a self-administered questionnaire included the following variables: hospital (identity number), patients' age, self-reported complications, previous deliveries, education, ethnicity, and number of obstetric interventions performed and/or considered. The main outcome measured was the reported involvement in decisions for obstetric interventions.

Results: Reported full involvement varied from 72% for epidural analgesia to 13% for forceps/vacuum extraction. Factor analysis identified two dimensions of perceived involvement: one for routine” interventions (enema, monitor­ing, IV line and episiotomy), which are performed in Israel mostly by midwives, and another for "special" interventions (forceps/vacuum extraction, epidural or other analgesia, and cesarian section) performed by physicians. Logistic regression identified hospitals, younger age, number of interventions, and Arab ethnicity as correlates of a perceived non-involvement in decisions for "special" interventions.

Conclusions: Clinical setting, age and ethnicity affected patient perception of involvement in decisions for obstetric interventions.

Background: Routine prenatal ultrasound has increased the frequency of prenatal diagnosis of congenital cystic lung malformation, such as cystic adenomatoid malformation, pulmonary sequestration, congenital lobar emphysema, and bronchogenic cyst.

Objectives: To evaluate the methods of postnatal diag­nosis, the optimal age for operation since surgery is always required, and the optimal extent of lung resection.

Methods: The clinical courses of 11 patients with congenital lung cysts who underwent surgical lung resection (8 lobectomies and 3 segmentectomies) were reviewed.

Results: The diagnosis was confirmed by computed tomography scan in all. In nine patients the diagnosis was made prenatally. Chest X-ray was normal postnatally in all patients except for two who had recurrent pneumonia. Post­operative follow-up showed excellent recovery in all operated children. One patient who underwent surgery for CCAM following episodes of severe pneumonia died from another cause 5 months later. Postoperative chest CT scan showed no residual disease in eight patients. In two who had undergone limited resection, tomography showed a small segment of residual disease in one and a suspected residual lesion in the other.

Conclusion: With prenatal ultrasound the true frequency of congenital cystic lung anomaly appears to be higher than previously reported. Postnatal CT is mandatory to confirm or to rule out the diagnosis. The mere presence of cystic lung malformation is an indication for surgery. Complete removal of the affected lung lobe is recommended. Segmental resection may be inadequate. Early operation is tolerated well by infants and small children and we recommend that surgery be performed in children between 6 and 12 months of age.