Daniel Chemtob, MD, MPH, DEA, Leon Epstein, MD, MPH, Paul E. Slater, MD, MPH and Daniel Weiler-Ravell, MD
Background: Sensing an inadequacy of tuberculosis control due to an influx of TB associated with immigration, we analyzed TB treatment outcome in Israel by population groups.
Objectives: To provide an epidemiological basis necessary for any new national TB control policy, and to bring it to the attention of the medical profession in Israel and abroad since its results led to a change in Israel’s TB control policy.
Methods: We reviewed all TB cases notified during the period 1990 to September 1992. New cases” (820 cases, 93.5%) and “re-treatment cases” (57 cases, 6.5%) were analyzed according to three mutually exclusive groups: “successful outcome,” “death” and “potentially unsatisfactory outcome” (according to WHO/IUATLD definitions).
Results: Of 820 “new cases,” 26.6% had a satisfactory outcome,” 68.5% had a “potentially unsatisfactory outcome” and 4.9% died compared to 47.4%, 45.6% and 7% among 57 “re-treatment cases,” respectively. Using logistic regression analysis, outcome was associated with the district health office (P<0.0001), the TB experience” of the notifying clinic (P<0.0001), and the form of TB (P=0.02). No significant relationships were obtained for population groups, gender and age, interval between arrival in Israel and TB notification, and bacteriological results.
Daniel Chemtob, MD, MPH, DEA, Leon Epstein, MD, MPH, Paul E. Slater, MD, MPH and Daniel Weiler-Ravell, MD
Background: Spinal dural arteriovenous fistulae comprise the majority of spinal vascular malformations. The most common clinical presentation is that of progressive myeloradicuiopathy, probably related to venous hypertension, which may lead to permanent disability and even death.
Objective: To report our clinical experience with spinal dural arteriovenous fistulae.
Methods: Nine patients with spinal dural AVF were managed at our center during a one year period (1998-1999). The patients, eight men and one woman ranging in age from 46 to 75 years, presented with initially fluctuating and eventually permanent and progressive paraparesis, sensory disturbances and sphincter dysfunction. The neurological signs generally began symmetrically and progressed from the distal to proximal limb regions. The duration of symptoms before diagnosis ranged from 6 to 36 months during which the patients underwent an extensive but fruitless work-up and even unnecessary operations due to misdiagnosis. All patients finally underwent magnetic resonance imaging and spinal angiography, which demonstrated the pathological vascular fistula. Interruption of the AVF was achieved by embolization or by surgical resection.
Results: Following treatment, six patients experienced improvement of gait and sphincter control, and the severe neurological deficits stabilized in the other three patients with long duration of illness. There was no further deterioration in any of the treated patients.
Conclusions: The history, neurological findings and radiological changes on MRI scan should alert clinicians to the possibility of spinal dural AVF, leading to diagnostic spinal angiography. Early diagnosis and treatment may significantly improve outcome and prevent permanent disability and even mortality.
Manuel Katz, MD, Sheila S. Warshawsky, MSc, Avi Porat, MD and Joseph Press, MD
Background: Appropriateness of hospital admission has both clinical and economic relevance, especially in light of the growing pressure for increased efficiency of health services utilization. In Israel, the number of referrals and use of the emergency room continue to rise along with an increase in hospital admissions and the number of inappropriate admissions. Using evaluation protocols, such as the Pediatric Appropriateness Evaluation Protocol, international studies have shown that 10-30% of hospital admissions are medically unnecessary. Inappropriate hospitalizations have an economic impact as well as medical and psychological effects on the child and the family.
Objectives: To assess the extent and characteristics of inappropriate pediatric admissions to a tertiary care facility in Israel.
Methods: We conducted a prospective study using chart review of pediatric admissions to Soroka University Medical Center on 18 randomly selected days in 1993, and evaluated the appropriateness of admissions using the PAEP.
Results: Of the 221 pediatric admissions 18% were evaluated as inappropriate. The main reason for such an evaluation was that the problem could have been managed on an ambulatory basis. Inappropriate admissions were associated with hospital stays of 2 or less days, children older than 1 year of age, Jewish children, and self-referrals to the pediatric emergency room.
Conclusions: The assessment and identification of characteristics of inappropriate hospital admissions can serve as indicators of problems in healthcare management and as a basis for improving quality of care and developing appropriate medical decision-making processes.
Michael D. Lockshin, MD
Autoimmune diseases are said to have high female/male (F/M) ratios, but these ratios are imprecise. Published definitions and classifications of autoimmune diseases differ substantially, as do the F/M ratios themselves. Imputed causality of auto-immune diseases requires better precision. Some thyroid, rheumatic and hepatic diseases consistently have high F/M ratios, but marked differences exist in the reported quantity of the ratios. Other autoimmune diseases have low F/M ratios. Because F/M ratios reflect incidence and not severity of disease, gonadal hormones, if they play a role, must do so through a threshold or permissive mechanism. Sex differences related to environmental exposure, X-inactivation, imprinting, X or Y chromosome genetic modulators, and intrauterine influences remain as alternate, theoretical, explanations for sex differences of incidence. The epidemiology of the sexdiscrepant autoimmune diseases - young, female - suggests that an explanation for sex discrepancy lies in differential exposure, vulnerable periods, or thresholds, rather than in quantitative aspects of immunomodulation.
Howard Carp, MB, BS, FRCDG
Leonid Feldman, MD, Anna Basok, MD, Leonid Kachko, MD and David Tovbin, MD
Mehrdad Herbert, MD, Michael Segal, MD, Gratiana Hermann, MD and Judith Sandbank, MD