Israel Medical Association Journal

Background: In recent years, mother to child transmission of human immunodeficiency virus in the west has decreased markedly due to the advent of antiretroviral drugs given during pregnancy, cessation of lactation and careful monitoring of viral load in the perinatal period.

Objective: To assess mother to child transmission of HIV[1] among Ethiopian immigrants and non-Ethiopians in the Jerusalem area.

Methods: We conducted a prospective analysis of all deliveries of HIV-positive women in the Jerusalem district over a 10 year period.

Results: Between 1996 and 2006, 35 HIV⁺ women gave birth to 45 infants. Thirty-one (88%) of these women were of Ethiopian origin and gave birth to 39 infants. Of the 35 HIV⁺ women, 30 were aware of being HIV positive. They gave birth to 40 infants. Another 5 women (14%) were not aware of being HIV⁺ during delivery. They gave birth to five infants. Of the group of known HIV⁺ women, 26 (87%) were Ethiopian immigrants who delivered 34 infants and 4 were non-Ethiopians who delivered 6 infants. In the group of five women not aware of being HIV⁺, all were Ethiopians. Breast-feeding data were available for 32 of the 35 women. Only 2 women (6.2%) breast-fed their babies. Neither was aware of being HIV⁺. In the Ethiopian immigrant group (both known and unknown HIV status), 11 deliveries (28%) were vaginal, 18 (46%) were elective cesarean section and 10 (26%) were delivered by emergency cesarean section. Of the 26 known HIV⁺ Ethiopian women, 3 (12%) refused to take antiretroviral treatment despite repeated counseling. In the non-Ethiopian group, all deliveries were elective cesarean sections. Mother to child transmission of HIV occurred in 4 of the total 45 deliveries (8.8%). Of the 4 transmission cases, 2 occurred among 40 deliveries of known HIV⁺ women (5%), and 2 occurred among the 5 deliveries of women not aware of being HIV⁺ (40%, P = 0.05). In the group of Ethiopian women only, HIV transmission occurred in 4 of 39 deliveries (10%), of which 2 occurred among 34 deliveries (5.8%) of women know to be HIV⁺ and 2 among 5 deliveries (40%) of women not aware of being HIV⁺ (P = 0.08).

Conclusions: Pregnant Ethiopian immigrants whose HIV status was known during pregnancy were at relatively high risk of HIV transmission despite the availability of antiretroviral drugs and counseling. This is likely due to inadequate adherence to ART[2] preventive regimens and is not dissimilar to the poor adherence observed among other immigrant groups in western countries. The substantial proportion of women, all Ethiopians, unaware of being HIV⁺ at delivery, together with the significantly higher HIV transmission in that group compared to women who knew their HIV status, call for a revision of the current Ministry of Health opt-in policy for prenatal HIV screening.

Background: The co-morbidity rate of illicit substance abuse and major mental problems in Israel is far from clear.

Objectives: To investigate the extent of drug abuse in a sample of psychiatric patients hospitalized in a psychiatric hospital and in the psychiatric department of a general hospital in Israel, to compare demographic and other background factors in dual-diagnosis patients with those of abuse-free mental inpatients, and to examine the time correlation between drug abuse and the appearance of major mental problems.

Methods: Our data were derived from self-report and urine tests. The study population comprised 470 consecutively admitted patients – 250 patients in the mental health center and 220 patients in the psychiatric department of the general hospital.

Results: The lifetime prevalence of drug abuse was 24%; cannabis abuse was found in 19.7%, opiates in 5.7%, cocaine in 2.7%, amphetamines in 3.4% and methamphetamine in 1.1%. Active abuse of drugs (during the last month) was registered in 17.3%, cannabis in 11.5%, opiates in 4.9%, amphetamine in 3.8%, cocaine in 1.3% and methamphetamine in 1.1%. We also found that 28.2% of active abusers used two or more substances. In 41.6% the drug abuse appeared prior to symptoms of the mental disorder; in 37.1% the duration of the mental disorders and the drug abuse was relatively similar, and in 21.3% of cases the duration of mental problems was longer than the duration of drug abuse. Dual-diagnosis patients were younger than non-abusers, more often male, unmarried, and of western origin.

Conclusions: Substance abuse (especially cannabis) among hospitalized psychiatric patients in Israel is a growing problem.

Background: Heart rate variability is a sensitive marker of cardiac sympathetic activity.

Objectives: To determine whether long-term hyperthyroidism induced by thyroxine suppressive therapy affects HRV[1].

Methods: Nineteen patients treated with suppressive doses of thyroxin for thyroid cancer and 19 age-matched controls were enrolled. Thyroid function tests and 1 minute HRV were performed on all subjects and the results were compared between the groups. The 1 minute HRV was analyzed during deep breathing and defined as the difference in beats/minute between the shortest and the longest heart rate interval measured by eletrocardiographic recording during six cycles of deep breathing.

Results:  One minute HRV during deep breathing was significantly lower among thyroxine-treated patients compared to healthy controls (25.6 ± 10.5 vs. 34.3 ± 12.6 beats/min, P < 0.05). There were no significant differences in mean, maximal and minimal heart rate between the groups

Conclusions: Thyroxine therapy administered for epithelial thyroid cancer resulted in subclinical hyperthyroidism and significantly decreased HRV due to autonomic dysfunction rather than basic elevated heart rate.

Background: Syncope is a common clinical problem that often remains undiagnosed despite extensive and expensive diagnostic evaluation.

Objectives: To assess the diagnostic evaluation, costs and prognosis of patients hospitalized for syncope in a tertiary referral center according to discharge diagnosis.

Methods: We retrospectively reviewed the medical records of patients with a diagnosis of syncope discharged from a tertiary referral center in 1999. In addition, mortality data were obtained retrospectively a year after discharge for each patient.

Results: The study group comprised 376 patients. Discharge etiologies were as follows: vasovagal 26.6%, cardiac 17.3%, neurological 4.3%, metabolic 0.5%, unexplained 47.3%, and other 4%. A total of 345 patients were admitted to the internal medicine department, 28 to the intensive cardiac care unit, and 3 to the neurology department. Cardiac and neurological tests were performed more often than other tests, with a higher yield in patients with cardiac and neurological etiologies respectively. The mean evaluation cost was 11,210 ± 8133 shekels, and was higher in the ICCU[1] than in internal medicine wards (19,210 ± 11,855 vs. 10,443 ± 7314 shekels, respectively; P = 0.0015). Mean in-hospital stay was 4.9 ± 4.2 days, which was longer in the ICCU than in medicine wards (7.2 ± 5.6 vs. 4.6 ± 3.5 days, respectively; P = 0.024). Short-term mortality rates (30 days after discharge) and long-term mortality rates (1 year after discharge) were 1.9% and 8.8% respectively, and differed according to discharge etiology. LTM[2] rates were significantly higher in patients discharged with cardiac, neurological and unknown etiologies (not for vasovagal), compared with the general population of Israel (1 year mortality rate for the age-adjusted [65 years] general population = 2.2%). The LTM rate was higher in patients discharged with a cardiac etiology than in those with a non-cardiac etiology (15.4% vs. 7.4%, P = 0.04). Higher short and long-term mortality rates were associated with higher evaluation costs.

Conclusions: Hospitalization in a tertiary referral center for syncope is associated with increased mortality for most etiologies (except vasovagal), cardiac more than non-cardiac. Despite high costs of inpatient evaluation, associated with more diagnostic tests, longer in-hospital stay and higher mortality rates, nearly half of the patients were discharged undiagnosed. Outpatient evaluation should be considered when medically possible.

Objectives: To investigate the incidence of splenic emboli treated in a single general internal medicine department over the last 3 years.

Methods: We examined the records of a 35 bed internal medicine department in a hospital in the center of Israel.

Results: Over a period of 3 years 13 patients admitted to one internal medicine department developed acute abdominal pain and areas of hypoperfusion in the spleen on contrast computed tomography imaging. The patients were treated with anticoagulants, their course was benign and there were no long-term sequelae.

Conclusions: Embolus to the spleen is not rare in an internal medicine department. Diagnosis can be easily made by contrast CT scanning and treatment with anticoagulants results in a good prognosis.