Israel Medical Association Journal

Background: The "obesity paradox" is defined as an inverse association of good health, survival and obesity. Usually in healthy persons the more obese you are the more metabolic complications you have; however, thin patients with chronic obstructive pulmonary disease (COPD) have more cardiovascular complications and a higher mortality rate.

Objectives: To explore whether atherosclerosis and peripheral artery disease (PAD) contribute to the higher morbidity and mortality of patients with COPD.

Methods: This prospective study included 87 patients with chronic COPD who were treated in the pulmonary outpatient clinic; all signed a consent form before enrollment. We documented their lung function (FEV1%), body mass index (BMI) and ankle brachial index (ABI). The primary endpoints were to find an association between atherosclerosis and BMI in patients with COPD, and between atherosclerosis and severity of lung disease.

Results: Average ABI[1] was 1.01 ± 0.20, BMI[2] was 29.33 ± 7.48 kg/m2, and the abdominal circumference was 107.34 ± 18.87 cm. A positive correlation was found between BMI and ABI (P = 0.001) and between abdominal circumference and ABI (P = 0.000). Patients with peripheral artery disease were older (73.6 ± 11.5 vs. 68.1 ± 11.6 years old, P = 0.04), were thinner (average BMI 25.5 ± 6.2 vs. 31.06 ± 7.3, P = 0.001), and had a lower abdominal circumference (97.7 ± 18.3 vs. 111.7 ± 17.5 cm, P = 0.001). No such difference was observed for years of smoking. Male PAD patients with COPD had a lower BMI (25.2 ± 5.6 vs. 29.9 ± 7.4, P = 0.016), and their abdominal circumference was smaller (96.1 ± 18.0 vs. 110.2 ± 16.5 cm, P = 0.004). Female PAD patients with COPD had a lower BMI (26.3 ± 8.2 vs. 33.1 ± 7.0, P = 0.045), but their abdominal circumference was not different from females without PAD (102.0 ± 19.7 vs. 114.0 ± 19.4 cm, P = 0.162). Patients with PAD had a worse lung disease (FEV1% 34 ± 8% vs. 45 ± 16%, P = 0.01). During the 1 year of follow-up five patients died: two PAD patients due to acute myocardial infarction and three non-PAD patients died from pulmonary insufficiency (two patients) and pulmonary emboli (one patient).

Discussion: We found that COPD patients with PAD were older and thinner and had a lower abdominal circumference and a more progressive lung disease. Extensive atherosclerosis in patients with COPD may partly explain the “obesity paradox” observed in patients with COPD.

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: Music therapy has been recommended as an adjuvant therapy for both preterm infants and mothers during their stay in the neonatal intensive care unit (NICU), and has been shown to have beneficial effects.

Objectives: To study the usefulness of combining live harp music therapy and kangaroo care (KC) on short-term physiological and behavioral parameters of preterm infants and their mothers in the NICU setting.

Methods: Included in this study were stable infants born between 32 and 37 weeks of gestation, with normal hearing .Mother-infant dyads were randomly assigned to KC and live harp music therapy or to KC alone. Using repeated measures, neonatal and maternal heart rate, oxygen saturation and respiratory rate were recorded along with neonatal behavioral state and maternal anxiety state. Maternal age, ethnicity, education, and love of music were documented.

Results: Fifty-two mother-infant dyads were tested. Compared with KC alone, KC and live harp music therapy had a significantly beneficial effect on maternal anxiety score (46.8 ± 10 vs. 27.7 ± 7.1, respectively, P < 0.01). Infants’ physiological responses and behavior did not differ significantly. No correlation was found between mothers’ age, ethnicity, years of education and affinity for music, and anxiety scores (P = 0.2 to 0.5 for all four variables).

Conclusions: KC combined with live harp music therapy is more beneficial in reducing maternal anxiety than KC alone. This combined therapy had no apparent effect on the tested infants’ physiological responses or behavioral state.
 

Background: The majority of human brucellosis cases in Israel are caused by the ingestion of unpasteurized dairy foods produced from unlicensed family-owned flocks whose products are sold door-to-door at low prices. Exposure to infected farm animals is another major cause of infection.

Objectives: To determine, by examining recent incidence data and brucellosis control programs, whether a reduction in the incidence of human brucellosis in Israel can be sustained.

Methods: Case information is reported to the Health Ministry and national data are compiled and analyzed by the Division of Epidemiology. The current study focuses on data from 1998 through 2009 and discusses several of the major prevention and health education programs that have been implemented.

Results: An incidence decline of almost 70% during the period 1998–2002 was followed by a return to previously existing levels, although the incidence has remained consistently lower than in past decades. The disease is mostly limited to certain sectors of the rural Arab population. In 2009 the incidence rate per 100,000 population was 7.0 among Arabs compared with 0.2 among Jews. Between 1998 and 2009, 63% of cases were from the Beer Sheva and Acre health districts, which together comprise 15.5% of the Israeli population. Control programs - including efforts to combat brucellosis in animals and to discourage the sale of unpasteurized homemade dairy products - have met with partial success.

Conclusions: Without routine vaccination of all family-owned flocks, more effective restraints on the market for unpasteurized dairy foods and improved regional cooperation, human brucellosis will continue to be a contained, but persistent, health problem in Israel due to cultural behavior, socioeconomic factors, and the regional political environment.
 

Background: Concomitant human immunodeficiency virus and human papillomavirus infection increases both HPV[1] persistence and the risk of invasive cervical cancer. An estimation of HPV prevalence among HIV[2]-positive women in Israel would contribute to improving care for this population and preventing morbidity and mortality related to cervical cancer.

Objectives: To determine the prevalence of HPV infection and cervical cytology abnormalities, and to assess the possible influence of HIV infection on HPV carriage in HIV-positive women attending the Infectious Disease Clinic at Soroka University Medical Center.

Methods: The study population included 84 HIV-seropositive women. They were examined by a gynecologist and screened for HPV genotyping, and Pap smears were obtained for cervical cytology. Demographic, behavioral, and HIV infection variables were also recorded and analyzed.

Results: Forty-nine (58.3%) of the study participants were HPV-positive; 34 of them had oncogenic genotypes. Young age (< 16 years) at first sexual intercourse was the only variable significantly associated with HPV infection (P < 0.05). Abnormal cervical cytology was present in 17 women (20.3%); 21 women were referred to colposcopy, which was abnormal in 9 (10.7%).

Conclusions: The prevalence of HPV carriage among HIV-positive woman in our study was slightly higher than published elsewhere. The prevalence of pathological cervical cytology was much higher than in the general population. An extremely high prevalence of pathological colposcopies requiring further treatment was found. Screening for HPV and premalignant changes in the uterine cervix is highly recommended in the HIV-seropositive population. We suggest that colposcopy be considered part of the routine workup in HIV-seropositive woman.

Background: Simulation-based medical education has become a powerful tool in improving the quality of care provided by health professionals.

Objectives: To evaluate the effect of a simulated patient-based educational program for military recruitment center physicians on the quality of medical encounters with adolescent candidates for military service.

Methods: Twelve physicians participated in an educational intervention that included a one day SP[1]-based workshop, where simulations of eight typical candidates for military service were conducted. Assessment of the physicians' performance before and after the intervention was based on questionnaires filled by 697 and 508 military candidates respectively, upon completion of their medical examination by these physicians. The questionnaire explored health topics raised by the examining physician as well as the atmosphere during the encounter. The candidates were also asked whether they had omitted important medical information during the medical encounter.

Results: Pre- and post-intervention comparison revealed significant changes in the percentages of candidates who reported that they were asked questions related to psychosocial topics: school problems – 59.7% and 68.9% (P = 0.01), protected sex – 29.6% and 36.4% (P = 0.01), mood changes – 46.9% and 52.2% (P = 0.05) respectively. Physicians were perceived as being interested in the candidates by 68.2% of the candidates before the intervention and 77.5% after (P < 0.01). The percentage of candidates who reported omitting medical information decreased from 6.6% before the intervention to 2.4% after (P < 0.01).

Conclusions: A simulated patient-based educational program for military physicians improved the quality of physician-candidate encounters. Such programs may serve as an effective instrument for training physicians to communicate with adolescents.