Israel Medical Association Journal

Background: Pseudomonas aeruginosa (PSA) is an infectious pathogen associated with acute appendicitis; however, it is not consistently addressed by empirical antibiotic therapy, despite potential complications.

Objectives: To investigate the incidence, predictors, and outcomes of PSA-associated acute appendicitis in children.

Methods: We conducted a retrospective analysis involving pediatric patients who underwent acute appendicitis surgery and had positive peritoneal cultures. Clinical, microbiological, and intraoperative data were extracted from medical records.

Results: Among 2523 children with acute appendicitis, 798 (31.6%) underwent peritoneal cultures, revealing 338 positive cases (42.3%), with PSA detected in 77 cases (22.8%). Children with PSA were three times more likely to exhibit high intraoperative grading ≥ 3 (93.4% vs. 76.8%, 95% confidence interval [95%CI] 1.2–8.3, P = 0.023) and nearly four times more likely to have polymicrobial cultures (88.3% vs. 62.1%, 95%CI 1.8–8.0, P < 0.001) than those without PSA in peritoneal cultures. Duration of symptoms did not predict PSA isolation (P = 0.827). Patients with PSA had longer median hospital stays (8 days, interquartile range [IQR] 7–10) than those with other pathogens (7 days, IQR 5–9) (P = 0.004). Antibiotic treatment duration, intensive care unit admission rates, readmission, and mortality were similar between the two groups (P = 0.893, 0.197, 0.760, and 0.761, respectively).

Conclusions: PSA is a common pathogen in children diagnosed with acute appendicitis and positive peritoneal cultures. The likelihood of isolating PSA increases with high-grade intraoperative assessment and in the presence of multiple pathogens in peritoneal cultures, suggests antipseudomonal treatment.

Background: The incidence of congenital cytomegalovirus (CMV) infection in Israel is 0.7%. Only 10–15% are symptomatic. Valganciclovir has been shown to improve hearing and neurodevelopmental outcomes in neonates with symptomatic congenital CMV infection. Targeted examination of infants who fail routine neonatal hearing screening or have clinical or laboratory findings suggestive of symptomatic congenital CMV infection may be a cost-effective approach.

Objectives: To assess the possibility of targeted examination for the detection of newborns with symptomatic congenital CMV infection.

Methods: A prospective observational study was conducted in 2014–2015 at two medical centers in northern Israel. Included were all newborns who were tested in the first 3 days of life by polymerase chain reaction (PCR) for urine CMV DNA (n=692), either for failure the hearing screening (n=539, 78%), clinical or laboratory findings suggestive of symptomatic congenital CMV infection, or primary CMV infection during pregnancy (n=153, 22%).

Results: During the study period 15,433 newborns were born. The predicted rate of infection was 10–15% (symptomatic) of 0.7% of newborns, namely 0.07–0.105% or 10–15 infants. In fact, 15 infants (0.11%, 95% confidence interval 0.066–0.175) were diagnosed with symptomatic congenital CMV infection, 2/539 (0.37%) in the failed hearing group and 13/153 (8%) in the clinical/laboratory findings group. The incidence of symptomatic congenital CMV infection was within the predicted range.

Conclusions: Targeted examination of only 4.5% (n=692) of newborns detected the predicted number of infants with symptomatic congenital CMV infection in whom valganciclovir therapy is recommended

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.

Background: Human parvovirus B19 is a global and common infectious pathogen in humans, primarily in children.

Objectives: To assess the immunoglobulin G seroprevalence of B19 in children in Israel.

Methods: Overall, 128 previously healthy children (1.5–17 years old) hospitalized for various diseases other than acute human parvovirus B19 infection were assessed for IgG[1] to the virus by enzyme-linked immunosorbent assay. 

Results: The IgG seroprevalence increased from 22% in children aged 1.5–9 years to 52% in older children (P = 0.001).

Conclusions: Our data suggest that most acute parvovirus B19 infections in Israel occur in the early school years, and that by 18 years of age 50% of Israeli children have been infected by the virus.

[1] IgG = immunoglobulin G

Objectives: To define the incidence of congenital CMV infection in two different subpopulations, as a model for the entire population of Israel.

Methods: Urine specimens were randomly collected from 2,000 newborns in Shaare Zedek Medical Center, Jerusalem, and HaEmek Medical Center, Afula (1,000 specimens each). These hospitals have many characteristic differences, presumably representing the diverse population of Israel. Urine specimens were subjected to a CMV PCR[2] reaction and positive specimens were validated by urine viral culture. Maternal seroprevalence was determined in a representative sample of the mothers in each hospital. Epidemiologic characteristics of the mothers were extracted from hospital records and compared.

Results: The population in Shaare Zedek Medical Center was mostly Jewish (95.8%) and urban (87.0%), as compared to that of HaEmek Medical Center (49.2% and 61.0%, respectively, P < 0.01). Nevertheless, CMV seroprevalence was similar: 81.5% and 85%, respectively. Ten (1.0%) and 4 (0.4%) newborns, respectively, were found to have congenital CMV infection (not significant).

Conclusions: The combined incidence of congenital CMV infection in the study population was 0.7% (95% confidence interval 0.3–1.0%). If this rate is extrapolated to the entire population of Israel, then a total of 945 cases of congenital CMV can be expected among the 135,000 annual deliveries. A nationwide screening program for congenital CMV should be considered.

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[1] CMV = cytomegalovirus

[2] PCR = polymerase chain reaction

Background: The emergency department is one of the hospital’s busiest facilities and is frequently described as a bottleneck. Management by constraint is a managerial methodology that helps to focus on the most critical issues by identifying such bottlenecks. Based on this theory, the benefit of adding medical staff may depend on whether or not physician availability is the bottleneck in the system.

Objective: To formulate a dynamic statistical model to forecast the need for allocating additional medical staff to improve the efficacy of work in the emergency department, taking into account patient volume.

Methods: The daily number of non-trauma admissions to the general ED[1] was assessed for the period 1 January 1992 to 1 December 1995 using the hospital computerized database. The marginal benefit to shortening patient length of stay in the ED by adding a physician during the evening shift was examined for different patient volumes. Data were analyzed with the SAS software package using a Gross Linear Model.

Results: The addition of a physician to the ED staff from noon to midnight significantly shortened patient LOS[2]: an average decrease of 6.61 minutes for 80–119 admissions (P<0.001). However, for less than 80 or more than 120 admissions, adding a physician did not have a significant effect on LOS in the ED.

Conclusions: The dynamic model formulated in this study shows that patient volume determines the effectiveness of investing manpower in the ED. Identifying bottleneck critical factors, as suggested by the theory of constraints, may be useful for planning and coordinating emergency services that operate under stressful and unpredictable conditions. Consideration of patient volume may also provide ED managers with a logical basis for staffing and resource allocation.

Objectives: To assess mortality causes and trends over time and identify target groups with excessive mortality rates among Israeli youth aged 10-24, in order to formulate an intervention policy for prevention of adolescent mortality.

Methods: Mortality data for Israeli residents aged 10-24 were extracted from the Central Bureau of Statistics compu­terized death certificate file for the period 1984-95. Trends were evaluated by cause of death and demographic char­acteristics.

Results: The crude mortality rate among Israeli youth aged 10-24, during 1993-1995, was 39.6 per 100000. Rates were 2.7 times higher among males, increased with age, and reached a peak among 18-21 year olds. Rates were 1.4 times higher among Arabs than among Jews. The sharp increase in mortality among Jewish males of military service age (18-21 years) was due mainly to motor vehicle crashes and suicide. Although overall mortality decreased by 9.4% from 1984-86 to 1993-95, the gap between the subgroups increased. MVC­related mortality increased over time by 100% among Arab males. The rate of completed suicide among Jewish males increased by 110%. Although injury-related mortality is lower in Israel compared with the U.S., similar demographic differen­tials and trends were found in both countries.

Conclusions: Suicide among Jewish males of military service age, as well as MVC fatalities among Arab males, present a growing public health issue. Intervention strategies should therefore be targeted towards these subgroups in order to minimize the rates of preventable death.

Background: Two recent studies found that the prevalence of cryptosporidiosis among children in Israel was 3.4-7.4%.

Objectives: To assess the cumulative infection rate by testing immunoglobulin A and G seroprevalence for Cryptosporidium in children and adults in Israel.

Patients and Methods: The seroprevalence of IgA and IgG anti-Cryptosporidium antibodies was determined by an enzyme-linked immunosorbent assay procedure in a group of 163 healthy children and adults.

Results: The overall seroprevalence rates for IgG, IgA, both IgA and IgG, and any immunoglobulin were 12.6%, 23%, 30% and 65.6% respectively. Half the children under the age of 12 years were already infected, with seroprevalence increasing to 95.6% in those over age 13 (P<0.05). Seropositivity for IgG or IgA did not significantly increase with age.

Conclusions: These results indicate that a large percentage of healthy children and adults in northern Israel have been infected with Cryptosporidium, and at early ages.