Israel Medical Association Journal

Background: Population screening for the BRCA mutations in Ashkenazi Jewish women was recently implemented in Israel and is expected to lead to a 10-fold increase in the diagnosis of asymptomatic carriers. Performing the screening follow-up within multidisciplinary dedicated clinics for carriers is recommended for early detection and risk reduction.

Objectives: To determine the availability, capacity, and practices of dedicated screening clinic for BRCA carriers in Israel.

Methods: A telephone-based survey of all public hospitals in Israel was conducted October 2020 to August 2021 to determine whether they had a dedicated clinic. Dedicated clinics were defined as multidisciplinary screening clinics offering at least breast and gynecological screening and risk reducing services on site. The clinic director or nurse navigator answered a questionnaire about screening practices followed by a semi-structured interview.

Results: Of the ten dedicated BRCA clinics found in Israel, nine participated. Approximately 4500 BRCA carriers are currently being followed. No specialized clinics are available in the southern district or in the northernmost half of the northern district of Israel, leading to a disparity between periphery and center. Screening recommendations, although asserted as adhering to international guidelines, vary among clinics including age at initiating of clinical exam, use of adjunct imaging modalities, and follow-up during lactation and after risk reducing surgery.

Conclusions: There is a suboptimal distribution of dedicated clinics for BRCA carriers in Israel. Nationally centralized attempt to create guidelines that will unify screening practices is warranted, especially considering the expected increase in demand.

Background: Obstructive sleep apnea (OSA) is a common health problem with an estimated prevalence of 4% among men, many of whom are undiagnosed and untreated. 

Objectives: To compare demographic characteristics, health profiles, risk factors, and disease severity in Arab and Jewish men with OSA syndrome.

Methods: In this cross-sectional study we retrospectively analyzed clinical data from the medical files of men ≥ 22 years old who were referred to the Rambam Medical Center sleep clinic during the period 2001–2009 with a suspected diagnosis of OSA. OSA severity was measured using the apnea-hypopnea index (AHI). Categorical variables were compared using the chi-square test. Relations between OSA severity and a set of independent risk factors were assessed by linear regression analysis.

Results: A total of 207 men were included (39 Arabs, 19%; 168 Jews, 81%). Arab participants were younger than their Jewish counterparts (45.5 ± 8.9 years vs. 49.8 ± 11.8, P = 0.04) and their body mass index (BMI) was higher (33.1 ± 5.1 vs. 30.0 ± 4.4, P = 0.001). OSA severity (AHI score) was higher among Arab men, with low, medium and high severity scores seen in 10%, 33% and 56% of Arab men vs 35%, 29% and 37% of Jewish men, respectively [T(198)=2.39, P = 0.02]. Mean blood oxygen saturation was comparable.

Conclusions: Arab men presenting for evaluation of sleep apnea harbored more severe OSA symptoms, were younger, and had higher BMI compared to Jewish men. Since OSA syndrome evolves for several years until it becomes severe, these findings suggest that Arab men seek medical assistance later than Jewish men with OSA.

 

Mortality rates have been falling at all ages, even for very old cohorts, in most western countries as well as in Israel. The question remains open as to whether morbidity rates are also decreasing, especially for Israel’s elderly. While health is improving in almost all industrialized countries, the situation in Israel is not yet resolved. While the more recent cohorts of the young-old (65–74 years) are healthier than their predecessors, Israel’s old-old (75+) may still be lagging behind other countries with regard to improvements in health status. This phenomenon is not well understood but could be explained in part by the more severe formative experiences of many of Israel’s very elderly cohort.

In 2001 the number of residents aged 65 and over in Israel was 639,000, or 10% of the population. The rate of increase of the elderly population is twice that of the general population, thus the predicted number of elderly for 2020 is around 1,025,000, representing a 60% increase. While this process is determined by a decline in both fertility and mortality, in Israel, immigration has also been a central factor in the process of aging. Life expectancy stands at 76.7 for men and 80.9 for women; at age 65 it is 16.4 years for men and 18.5 for women. The major factor influencing the increase in life expectancy during the past two decades has been the prevention of death among older people. Population aging, or “the demographic transition,” also represents an "epidemiological transition” – from high rates of infectious and communicable diseases, to high rates of chronic diseases among older people. During the past two decades, the number of disabled elderly has increased more than 2.5 times. In 2001, there were about 97,400 disabled elderly in Israel, constituting about 15% of all elderly. By the year 2010, the number of disabled elderly is expected to reach 120,100. The rate of increase of the disabled elderly population is almost double that of the total elderly population, due to changes in this population’s composition. However, recent research indicates that new cohorts of elderly are healthier than earlier cohorts but experience a decline in health at older ages. While advances in standard of living, medicine, and technology have made this possible, a greater allocation of resources is required to prevent disability and maintain the quality of life.

The Arab population of Israel is relatively young. However, a significant increase is expected in the number of elderly Arabs in the coming years. At the end of 2001 there were 38,500 Arab elderly, but their number is expected to reach 92,100 by 2020. This will represent a nearly 2.5-fold increase in absolute numbers. As the population ages, the number and percentage of people with chronic diseases and related disabilities will rise significantly. While the Arab elderly are much younger than the Jewish elderly, they are more disabled and therefore have greater medical and nursing needs. An extremely important measure of the need for formal services is an elderly person’s functional ability, especially the ability to live independently. The percentage of Arab elderly who are disabled and need help with activities of daily living is two times higher than that of the Jewish elderly population. At present, 30% of the Arab elderly (39% of the women and 20% of the men), compared to 14% of Jewish elderly (17% of the women and 11% of the men), need help in at least one ADL[1] (bathing, dressing, eating, mobility in the home, rising and sitting, getting in and out of bed). Concomitant with demographic changes are forces that affect the ability of informal support systems to provide care. For example, the rising number of Arab women in the labor force together with changes in elderly peoples' living arrangements have increased the need for formal services to share responsibility for the elderly with families. As services are developed, questions arise regarding the extent to which they have been adapted to the culture and norms of Arab society and meet that society’s unique needs. This paper elaborates on some of these issues.