Israel Medical Association Journal

Background: Vaginal symptoms are a leading reason for a patient to visit her gynecologist. Little is known about the prevalence of the different causes of vaginitis and the risk factors for this entity in Israel.

Objective: To determine the prevalence in a gynecologic practice in Israel of the main forms of vaginitis: vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis.

Methods: We evaluated 208 patients presenting with vaginal symptoms to a gynecologic clinic; 100 asymptomatic women who attended the clinic for routine check-up served as controls. Demographic, medical and gynecologic histories were obtained, and a pelvic examination was performed in all patients. Vaginal specimens were tested for pH and amine reaction, smeared for Gram-staining and cultured for yeasts and Trichomonas vaginalis. Bacterial vaginitis was diagnosed using the Nugent scoring system. candida infection was diagnosed by microscopic examination and by culture.

Results: Candida spp. was the most common pathogen, documented by microscopy and culture in 35.5% of symptomatic women and 15% of asymptomatic controls (P < 0.001). Detection by culture only (negative microscopy) was documented in 18.7% of symptomatic patients and 15% of controls (P = 0.5). Bacterial vaginosis (Nugent score ≥ 7) was diagnosed in 23.5% of patients and 13% of controls (P = 0.04). Trichomoniasis was present in 8.1% of symptomatic women and 4% of controls (P = 0.1). The main risk factors were antibiotic use for candidiasis and lack of use of oral contraception and condom use for trichomoniasis.

Conclusion: Candida was by far the most common pathogen detected in our population. A statistically significant difference between patients and controls was noted for the prevalence of microscopically diagnosed candidiasis and bacterial vaginosis.
 

Background: In southern Israel, a discrepancy between a relatively high prevalence of Group B streptococcus maternal carriage (12.3%) and a very low incidence of neonatal disease (0.1/1,000 live births) has been found despite the fact that no preventive strategy has been implemented.

Objectives: To determine the risk factors for maternal carriage in order to clarify this discrepancy and further examine the different aspects of GBS[1] in southern Israel.

Methods: Cultures for GBS were obtained from 681 healthy pregnant women and relevant demographic and obstetric data were collected. The medical records of 86 neonates born to carrier women were retrospectively examined. Statistical analysis was performed using the Pearson chi-square test.

Results: Women who were not born in Israel, particularly immigrants from the former USSR, were significantly prone to carry the pathogen compared to native Israeli women (Bedouin Arabs and Jews) (P = 0.03).

Conclusions: A high GBS transmission rate is expected among immigrants who came from areas with a high prevalence of maternal carriage to one with a low incidence of neonatal disease environment and were not subject to any preventive strategy. Clinical attention should be directed to this issue throughout Israel.

Only one case of a cow infected with bovine spongiform encephalopathy has been reported in Israel. Its publication, in 2002, caused both public and professional concern. The inevitable health policy question raised was whether or not to recommend against consuming beef and what public health measures should be taken. In this article we describe the prion diseases among animals and humans, their interaction and the precautionary procedures that were carried out by the state Veterinary Services and the Ministry of Health since 1988. The BSE[1] case (a 10 year old dairy cow) is believed to be the result of local consumption of infected food with mammalian meat and bone meal more than a decade earlier. The risk assessment took into consideration that no cases of vCJD (a new variant of Creutzfeldt-Jacob disease) have ever been diagnosed in Israel, as well as the low risk of contamination of the meat due to the religious method of slaughtering performed in the country. The policy decision was to implement a contingency plan prepared in advance. Israel was reclassified from the level II category of geographic risk where BSE is unlikely but not excluded in the herds, to level III, where BSE is likely but not confirmed, or confirmed at a lower level. No undue damage to the meat industry has occurred. By the end of 2002, despite the examination of more than 3,800 brains from slaughtered cows older than 3 years, no other cases of BSE have been detected.

Background: Despite the high incidence of pemphigus in the Jewish population, data on the epidemiology and etiology of the disease in Israel are sparse.

Objective: This study was conducted to identify clinical and epidemiologic features of pemphigus patients in Israel, while searching for risk factors that induce or exacerbate the disease.

Methods: Demographic and clinical information was recorded from the charts of 55 pemphigus patients treated over a 5 year period. A sample of 22 patients was compared to 22 age and gender-matched controls by means of a questionnaire querying details on lifestyle, including occupation, diet, sun exposure, and smoking.

Results: The findings show that the typical Israeli pemphigus patient is middle-aged, married, and of East European or Middle Eastern origin. The most common diagnosed clinical variant was pemphigus vulgaris, followed by pemphigus erythematosus. Some 70% of patients were treated with two or more immunosuppressive drugs and 62% entered long-lasting remission. Twenty-three percent of patients were exposed through their work to chemical substances, mainly pesticides, at the beginning of the disease and 18% of patients were continually exposed to ultraviolet radiation 5 years prior to onset of the disease.

Conclusions: There is a possible correlation between occupational exposure to pesticides and UV[1] radiation, and pemphigus induction.

Background: Risk factors for injurious falls among elderly people differ from those for falls in general. The characteristics of falls play an important role in determining the risk of hip fracture.

Objective: To investigate the risk factors associated with the fall characteristics known to be associated with the majority of hip fractures, e.g., a lateral fall and a subsequent impact on the greater trochanter.

Methods: In this 6 month prospective observational case-control study 101 individuals aged 65 years and over hospitalized following a hip fracture were interviewed 7–14 days after the accident. Data were also obtained from medical records, focusing on known predisposing and situational risk factors for the fall. We compared the risk factors between two groups: patients who suffered a lateral fall and subsequent impact on the greater trochanter of the femur, and patients who suffered other types of falls.

Results: Only 51.5% of the hip fracture patients reported that they had fallen directly to the side. Apart from age, there were no significant differences between the groups in other factors studied. When considering both fall direction and the area that took the main impact, we found that the majority of patients (85%) reported having fallen onto the posterolateral aspect and/or a fall with an impact on the greater trochanter.

Conclusion: Our findings did not show differences (except for age) in the factors studied between the groups. This study suggests that both fall direction and the area that takes the main impact should be considered in the characteristics of falls that might cause a hip fracture. Characteristics associated with greatest fracture risk include a fall onto the posterolateral aspect and/or a fall with an impact on the greater trochanter. More studies are needed to evaluate potential risk factors associated with this type of injury.

Background: The mainstay of therapy for acute cholecystitis is cholecystectomy, which has a mortality of 14–30% in high risk patients. An alternative approach in patients suffering from acute cholecystitis with contraindications to emergency surgery is percutaneous cholecystostomy.

Objective: To evaluate the efficacy and safety of percutaneous cholecystostomy as the initial treatment of acute cholecystitis in high risk patients.

Methods: Eighty consecutive patients (42 men, 38 women) underwent ultrasound-guided percutaneous cholecystostomy over a 5 year period. Sixty-five patients suffered from acute calculous cholecystitis, 4 patients had acalculous cholecystitis, and 11 patients had sepsis of unknown origin.

Results: Sixty-eight patients improved after the percutaneous gallbladder drainage, 10 patients died from co-morbid disease and 2 patients died from biliary peritonitis. During a 1 year follow-up, 32 of the patients underwent interval cholecystectomy, 4 additional patients died from a co-morbid disease, 18 patients did not suffer from any gallbladder symptoms, and 14 were lost to follow-up.

Conclusions: Percutaneous cholecystostomy is an effective contribution to the treatment of acute cholecystitis in high risk patients.

Background: Prematurity remains the most significant cause of neonatal morbidity and mortality. Knowing which group of women is at risk for developing preterm labor will define a target population for better prenatal care and prevention modalities.

Objective: To examine whether preterm delivery rates are associated with ethnicity, age, parity, and style of living.

Methods: We conducted a longitudinal case series examining obstetric and demographic data of 17,493 deliveries that occurred between June 1994 and May 1999. All deliveries were performed in the obstetric department of HaEmek Medical Center (Afula, Israel), which serves as a referral center. The main outcome measures were preterm delivery, as related to the women's ethnicity, age parity, and style of living ± namely, town, village, or kibbutz.

Results: The overall preterm delivery rate was 8.5%. The preterm delivery rate in non-Jewish women (10.5%) was higher than in Jewish women (7.1%) (P < 0.00001). The preterm delivery rate in women younger than 20 or older than 40 (12.5%) was much higher than in women between the ages of 21 and 40 (8.0%) (P< 0.00001). Grand-multipara women (>8) had a higher preterm delivery rate (13.8%) than less parous women (8.5%) (P < 0.012). Style of living was also associated with the preterm delivery rate (P< 0.00001): kibbutz 5.5%, Jewish towns 7.8%, non-Jewish towns 8.7%, Jewish villages 6.7%, and non-Jewish villages 11.0%.

Conclusions: Style of living, ethnicity, age and parity are statistically significant risk factors for preterm delivery in our area. These factors provide a more definable target population for better prenatal care.
 

Background: Elevated fibrinogen, considered an independent risk factor for coronary disease, stratifies an individual as high risk for coronary disease. A risk marker requires little intra-individual variability during a long period.

Objectives: To establish intra-individual variability of fibrinogen levels in patients with coronary disease.

Methods: We investigated fibrinogen levels prospectively in four blood samples drawn from 267 patients with a history of arterial disease (arterial group) and from 264 patients with cardiac valve replacements (valvular group). The samples were taken during the course of 78.7 and 78.8 days from the arterial and valvular groups respectively.

Results: Marked intra-individual dispersion with a reliability coefficient of 0.541 was found in the arterial group and 0.547 in the valvular group. The Bland-Altman test showed low probability to obtain similar results in different samples from the same individual. These results show large intra-individual variability, with similarities in the arterial as well as in the valvular group.

Conclusions: It is not possible to stratify a patient by a specific fibrinogen dosage.

Background: Genes that confer mild or moderate susceptibility to breast cancer may be involved in the pathogenesis of sporadic breast cancer, modifying the phenotypic expression of mutant BRCA1/BRCA2 alleles. An attractive candidate is the insulin-like growth factor I, a known mitogen to mammary ductal cells in vivo and in vitro, whose serum levels were reportedly elevated in breast cancer patients.

Objective: To evaluate the contribution of the IGF-1 gene polymorphism to breast cancer risk by genotyping for a polymorphic allele size in breast cancer patients and controls.

Methods: We analyzed allele size distribution of the polymorphic CA repeat upstream of the IGF-I gene in 412 Israeli Jewish women: 268 women with breast cancer (212-sporadic and 56 carriers of either a BRCA1:or BRCA2 mutation), and 144 controls. Genotyping was accomplished by radioactive polymerase chain reaction of the relevant genomic region and size fractionation on polyacrylamide gels with subsequent auloradiography,

Results: Among women with breast cancer, with or without BRCA germline mutations, 196 and 198 basepair alleles were present in 4.7% (25/536 alleles), compared with 9% (26/288) controls (P = 0.02). This difference was more pronounced and significant in the non-Ashkenazi population. Conversely, the smaller size allele (176 bp) was present in the breast cancer group only {3/536, 0.6%).

Conclusions: The IGF-I polymorphism may serve as a marker for breast cancer risk in the general Jewish population, in particular non-Ashkenazi Jews, but extension and confirmation of these preliminary data are needed.
 

Background: The implementation of treatment guidelines is lacking worldwide.

Objectives: To examine whether follow-up in a specialized lipid clinic improves the achievement rate of the treatment guidelines, as formulated by the National Cholesterol Education Program and the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Methods: The study group included patients who were referred to the lipid clinic because of hyperlipidemia. At each of five visits over a 12 month period, lipid levels, liver and creatine kinase levels, body mass index, and adherence to diet and medications were measured, and achievement of the NCEP[1] target level was assessed.

Results: A total of 1,133 patients (mean age 61.3 years, 60% males) were studied. Additional risk factors for atherosclerosis included hypertension (41%), type II diabetes mellitus (21%), smoking (17%), and a positive family history of coronary artery disease (32%). All patients had evidence of atherosclerotic vascular disease (coronary, cerebrovascular or peripheral vascular diseases). The low density lipoprotein target of <100 mg was present in only 22% of patients before enrollment, with improvement of up to 57% after the follow-up period. During follow-up, blood pressure control was improved (from 38% at the time of referral to 88% after 12 months, P < 0.001), as was glycemic control in diabetic patients (HgA₁C improved from 8.2% to 7.1% after 12 months, P < 0.001). Improved risk factor control was due to increased compliance to medication treatment (from 66% at enrollment to more than 90% after 12 months), as well as careful attention to risk factor management that translated into a change in the treatment profile during the follow-up. There was an increase in the use of the following medications: aspirin from 68% to 96%, statins from 42% to 88%, beta blockers from 20% to 40%, and angiotensin-converting enzyme inhibitors from 28% to 42%; while calcium channel blocker use decreased from 40% to 30% in patients during follow-up.

Conclusion: Follow-up of patients in a specialized clinic enhances the achievement of LDL[2]-cholesterol treatment goals as well as other risk factor treatment goals, due to increased patient compliance and increased use of medications.

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