Israel Medical Association Journal

Abstract

Background: Findings of studies addressing outcomes of war-related famine in non-Jewish populations in Europe during the Second World War (WWII) confirmed an association between prenatal/early life exposure to hunger and adult obesity, diabetes, hypertension, cardiovascular heart disease and the metabolic syndrome. Fetal programming was suggested as the explanatory mechanism.

Objectives: To study the association between being born during WWII in Europe and physical long-term outcomes in child Holocaust survivors.   

Methods: We conducted a cross-sectional study on all Jewish Clalit Health Services (CHS) North District members born in 1940–1945 in Europe ('exposed', n=653) or in Israel to Europe-born parents ('non-exposed', n=433). Data on socio-demographic variables, medical diagnoses, medication procurement, laboratory tests and health services utilization were derived from the CHS computerized database and compared between the groups.

Results: The exposed were significantly more likely than the non-exposed to present with dyslipidemia (81% vs. 72%, respectively), hypertension (67% vs. 53%), diabetes mellitus (41% vs. 28%), vascular disease (18% vs. 9%) and the metabolic syndrome (17% vs. 9%). The exposed also made lower use of health services but used anti-depressive agents more often compared to the non-exposed. In multivariate analyses, being born during WWII remained an independent risk marker for hypertension (OR = 1.52), diabetes mellitus (OR = 1.60), vascular disease (OR = 1.99) and the metabolic syndrome (OR = 2.14).

Conclusions: The results of this cross-sectional study based on highly validated data identify a high risk group for chronic morbidity. A question regarding potential trans-generational effects that may impact the ‘second generation’ is also raised.

Background: Intra-articular corticosteroid injection (IACI), a common procedure in juvenile idiopathic arthritis, is usually associated with anxiety and pain. In a previous study, we concluded that nitrous oxide (NO₂) provides effective and safe sedation for such procedures. Following the introduction of medical clowns in our hospital, we added them as an integral part of the team performing IACI.

Objectives: To prospectively evaluate the effect of a medical clown on pain perception during intra-articular corticosteroid injection for juvenile idiopathic arthritis using NO₂ conscious sedation.

Methods: Patients scheduled for IACI first met and interacted with the medical clown. During the procedure, the rheumatologist and the medical clown worked in parallel to create distraction. NO₂ was administered. The patient, parent, physician, medical clown and nurse completed a visual analog scale (0–10) for pain. Change in heart rate ≥ 15% was recorded to evaluate physiologic response to pain and stress.

Results: A total of 46 procedures were performed in 32 children: 23 girls, 9 boys, with a mean age of 10.9 ± 3.6 years. The median visual analog scale pain score for the patients, parents, physicians, medical clown and nurses was 2, 2, 1, 1 and 1, respectively. Five patients had increased heart rate and experienced increased pain.

Conclusions: Active participation of a medical clown during IACI with nitrous oxide for juvenile idiopathic arthritis further decreases pain and stress and results in a positive patient experience. 

Background: The prevalence of thyroid dysfunction in early pregnancy in Israel is not known.

Objectives: To assess the rate of abnormal thyroid-stimulating hormone (TSH) tests in low risk pregnant women attending a community clinic in Israel.

Methods: We conducted a retrospective analysis of the charts of low risk pregnant women (n=303) who had undergone a TSH screening during the first trimester of pregnancy at Clalit Health Services Women's Health Centers in Ashkelon and Tel Aviv. The TSH normal range during first trimester was considered to be 0.1–2.5 mIU/L.

Results: The TSH levels ranged from 0.04 to 13.3 mIU/L (median 1.73 mIU/L, mean 1.88 mIU/L). The rate of abnormal TSH was 25.6%, with low TSH 2.3% and high TSH 23.4%. The prevalence of abnormal TSH was not influenced by gravidity (primigravidas versus multigravidas) or place of residence (Ashkelon or Tel Aviv).

Conclusions: In view of the high prevalence of abnormal TSH (25.6%) in pregnant women in Israel during the first trimester, a universal country-wide screening should be considered.

* Israel Glaucoma Screening Group 2009-2010 (in alphabetical order):

Applebaum E, Arodi A, Avidar A, Barkana Y, Beiran I, Bracha Z, Burgansky Z, Cotlear D, Dafna O, Drori L, ElNaddaf H, Epstein E, Garzozi H, Gawi H, Geffen N, Glovinsky Y, Hadayer A, Jubran R, Kalev-Landoy M, Kaniezer B, Kratz A, Kurtz S, Matanes M, Mazover A, Mazzawi N, Naveh L, Nesher R, Neuman H, Pedut T, Pikel Y, Rachmiel R, Rath E, Robinson A, Segev E, Shemesh G, Shoham N, Silverston B, Tam G, Tessler Z, Tiosano B, Vidan A, Vishinevski I, Zalish M, Zarfati D, Zorani Y.

Background: Early detection of glaucoma enables early initiation of treatment. Screening populations at risk is likely to help achieve this goal.

Objectives: To increase public awareness regarding early detection of glaucoma, and estimate the prevalence of increased intraocular pressure (IOP) and optic disk cupping in the screened population.

Methods: A public awareness campaign was carried out in Israel during the 2009 and 2010 World Glaucoma Week, culminating each year in a one-day, free-of-charge screening of individuals in 13 outreach public locations. Screening was performed by 45 ophthalmologists and included a brief medical history, slit-lamp exam with measurement of intraocular pressure (IOP), and evaluation of cup/disk ratio.

Results: A total of 2560 individuals were screened; the mean age was 59 ± 13 years. IOP ≥ 21 mmHg was found in 4.8%, and 12.3% had cupping ≥ 0.5. IOP ≥ 21 mmHg together with cupping ≥ 0.5 were present in 1.4% and this rate increased with age: 3.7% of cases in the age group ≥ 70 years compared to 1% and 0.6% in the age groups 50–69 and < 50 years, respectively (P < 0.001). Likewise, the prevalence of cupping ≥ 0.7 and of IOP ≥ 24 mmHg increased significantly with age. The prevalence of IOP ≥ 21 mmHg increased in cases with a family history of glaucoma in first-degree relatives (10.5% compared to 3.9%, P < 0.001). The prevalence of IOP ≥ 21 mmHg was also increased in diabetic patients (8.3% vs. 4.3% in non-diabetics, P = 0.002). Further ophthalmologic evaluation was recommended to 13% of the screened individuals.

Conclusions: Outreach screening for glaucoma is a valuable tool for detecting glaucoma, pre-perimetric glaucoma, or ocular hypertension in a meaningful number of previously undiagnosed cases. Yet, cost-effectiveness issues should also be considered. The yield of such screening increases with age and seems to be most advantageous in cases with diabetes or a family history of glaucoma. 

Objectives: To determine whether exposure to the Holocaust from preconception to early infancy is a cause of chronic morbidity in adulthood.

Methods: This pilot study involved 70 European Jews born in countries under Nazi rule (exposed group) during the period 1940–1945 who were interviewed to determine the presence of chronic diseases. A control group of 230 Israeli-born individuals of the same descent, age, and gender distribution were extracted from the Israel National Health Interview Survey-2 (unexposed group). The prevalence of selected risk factors and chronic diseases was compared between the groups.

Results: The prevalence of cardiovascular risk factors and morbidity was significantly higher in the exposed group: body mass index (BMI) (29.06 ± 3.2 vs. 26.97 ± 4.42, P = 0.015), hypertension (62.9% vs. 43%, P = 0.003), dyslipidemia (72.9% vs. 46.1%, P < 0.001), diabetes (32.9% vs. 17.4%, P = 0.006), angina pectoris (18.6% vs. 4.8%, P = 0.001) and congestive heart failure (8.6% vs. 1.7%, P = 0.013). The prevalence of cancer (30.0% vs. 8.7% P < 0.001), peptic ulcer disease (21.4% vs. 7%, P = 0.001), headaches/migraines (24.3% vs. 12.6%, P < 0.001) and anxiety/depression (50.0% vs. 8.3%, P < 0.001) was also higher in the exposed group.

Conclusions: These results suggest that exposure to Holocaust conditions in early life may be associated with a higher prevalence of obesity, dyslipidemia, diabetes, hypertension, cardiovascular morbidity, malignancy and peptic diseases in adulthood. These findings set the stage for further research, which might define those exposed as a high risk group for chronic morbidity.

Methods: We developed a one-day tutor training program based on six simulated scenarios with video-based debriefing. The program's efficacy was assessed using questionnaires completed by the participating physicians and their students. Main outcome measures were self-perceived teaching skills at baseline, after participation in the program, and following completion of the tutor role. Secondary outcome measures were the students' perceptions regarding their tutor skills.

Results: Thirty-two physicians (mean age 35.5, 56% females) participated in the program. Self-assessment questionnaires indicated statistically significant improvement following the program in 13 of 20 measures of teaching skills. Additional improvement was observed upon completion of the tutor role, leading to significant improvement in 19 of the 20 measures. Questionnaires completed by their students indicated higher scores in all parameters as compared to a matched control group of tutors who did not participate in the program, though not statistically significant. Most participants stated that the program enhanced their teaching skills (88%), they implement program-acquired skills when teaching students (79%), and they would recommend it to their peers (100%). Satisfaction was similar among participants with and without previous teaching experience.

Conclusions: A novel one-day simulation-based tutor training program was developed and implemented with encouraging results regarding its potential to improve clinical teaching and mentoring skills. 

Background: Janus kinase-2 (JAK2) is mutated in a high proportion of patients with polycythemia vera and in a smaller number with essential thrombocythemia and primary myelofibrosis. Mutated JAK2 is an important diagnostic marker for myeloproliferative neoplasm (MPN) and may also play a major role in the pathogenesis of MPN.

Objectives: To evaluate the prevalence of mutated JAK2 (JAK2-V617F) among patients with major intraabdominal vein thrombosis who had normal blood counts at diagnosis of the initial event.

Methods: The medical records of patients who presented with a major intraabdominal venous thrombosis and normal peripheral blood counts were obtained. JAK2-V617F mutation status was determined by real-time polymerase chain reaction.

Results: Twenty-two patients were available for this analysis and 9 (41%) were found to have JAK2-V617F. Patients with positive JAK2-V617F were younger and had more frequent clinical splenomegaly than those with wild-type JAK2.

Conclusions: A high proportion of patients presenting with “idiopathic” major intraabdominal vein thrombosis and normal blood counts carry JAK2-V617F. We recommend searching for the mutation in this clinical setting to detect patients with occult MPN.

Objectives: To examine the files of patients hospitalized in a tertiary hospital in Israel following a serious suicide attempt. Their mental conditions were determined and their unique demographic and clinical characteristics and needs compared to the other patients examined by the psychiatric service.

Methods: The study focused on 49 consecutive patients admitted after performing a life-threatening suicide attempt. They were compared to 389 non-suicidal patients assessed by the same psychiatric service during one year.

Results: Nearly half the patients hospitalized following a serious suicide attempt had only an axis II diagnosis (personality disorder). Non-violent methods of suicide were used predominantly by females, and violent methods mainly by males. All suicide attempts by Muslims used violent methods, while less than half the attempts by Jews were violent. Compared to the non-suicidal patients, the suicide-attempters group was younger, had greater representation of Jewish females and Muslim males. Compared to the non-suicidal patients, these patients required more intense psychiatric care, earlier commencement of treatment in the course of hospitalization, more psychiatric visits and treatment hours, and more referrals for further care. Several risk factors appear to be associated with a need for more intense in-hospital care and a greater need for referral: male gender, religion, method of suicide attempt (violent vs. non-violent), and the existence of a psychiatric diagnosis.

Conclusions: Suicide-attempt patients who are in need of hospitalization for further medical treatment have unique clinical characteristics and require more intense treatment provided by the Consultation-Liaison Unit. 

Methods:  Between February 2004 and June 2012, 100 patients in our department suffering from aortic aneurysm with aortic valve regurgitation underwent elective aortic valve-sparing surgery. Of them, 30 had Marfan syndrome, were significantly younger (30 ± 13 vs. 53 ± 16 years), and had a higher percentage of root aneurysm, compared with ascending aorta aneurysm in their non-Marfan counterparts. We evaluated the safety, durability, clinical and echocardiographic mid-term results of these patients.

Results: While no early deaths were reported in either group, there were a few major early complications in both groups. At follow-up (ranging up to 8 years with a mean of 34 ± 26 months) there were no late deaths, and few major late complications in the Marfan group. Altogether, 96% and 78% of the patients were in New York Heart Association functional class I-II in the Marfan and non-Marfan groups respectively. None of the Marfan patients needed reoperation on the aortic valve. Freedom from recurrent aortic valve regurgitation > 3+ was 94% in the Marfan patients.

Conclusions: Aortic valve-sparing surgery in Marfan symdrome patients is safe and yields good mid-term clinical outcomes.