Israel Medical Association Journal

Background: During the last decade, Israel, a country with low tuberculosis rates, absorbed some 900,000 new immigrants from TB[1]-endemic countries.

Objectives: To analyze the specific impact of our screening procedures on active TB among children in Israel.

Methods: We conducted a retrospective analysis of epidemiologic and clinical data of all children (aged 0–17) with TB notified to the Ministry of Health between 1990 and 1999.

Results: There were 479 children with TB (male/female ratio 1.36). Most cases (81.8%) were foreign born, predominantly (88.2%) immigrants from Ethiopia and, therefore, huge differences existed in TB incidence rates according to countries of origin. Some 80% were diagnosed within 3 years of arrival, mainly due to active case-finding. Pulmonary TB, with infiltrates on chest X-ray, was found in 49.5%. Extra-pulmonary TB sites were: intra-thoracic lymphadenitis (31.1%), extra-thoracic lymphadenitis (12.5%), bones (3.6%), pleura (1.3%), meninges (1%), and others (1%). Seventy percent had a tuberculin skin test reaction ≥10 mm in size. Two (non-immigrant) children died of TB meningitis.

Conclusions: Most of the pediatric TB cases occurred in recent immigrants and were diagnosed within 3 years of immigration. These data support our policy of active case-finding among new immigrants from Ethiopia and extensive contact evaluation for all TB cases.

Objectives: To evaluate the sensitivity, specificity, accuracy, and positive and negative predictive values of FNAB[1] in cases of a solitary thyroid nodule.

Methods: The preoperative FNAB results of 170 patients who underwent thyroidectomy due to a solitary thyroid nodule were compared retrospectively with the final postoperative pathologic diagnoses.

Results: In cases of a solitary thyroid nodule, FNAB had a sensitivity of 79%, specificity of 98.5%, accuracy of 87%, and positive and negative predictive values of 98.75% and 76.6% respectively. All cases of papillary carcinoma diagnosed by FNAB proved to be malignant on final histology, while 8 of 27 cases of follicular adenoma detected by preoperative FNAB were shown to be malignant on final evaluation of the surgical specimen.

Conclusions: FNAB cytology reduces the incidence of thyroidectomy since this method has excellent specificity and sensitivity and a low rate of false-negative results. It proved to be cost-effective and is recommended as the first tool in the diagnostic workup in patients with thyroid nodules.

Objectives: To test the in vitro activity of linezolid (oxazolidinone) and other antimicrobial agents against MRSA[1] isolates recovered from hospitalized patients.

Methods: We tested 150 MRSA isolates recovered from hospitalized patients. The minimal inhibitory concentration of vancomycin, teicoplanin, pristinamycin (quinupristin-dalforistin), and linezolid was determined by the Etest method. Susceptibility to other antibiotics was tested by the disk diffusion method.

Results: All isolates were sensitive to vancomycin, teicoplanin, pristinamycin, and linezolid. The MIC₉₀ was 2.0 mg/ml for vancomycin and teicoplanin (range 0.5–2.0 mg/ml and 0.125–2.0 mg/ml, respectively), and 0.5 mg/ml for pristinamycin and linezolid (range 0.125–0.75 mg/ml and 0.125–0.5 mg/m, respectively). Of the other antibiotics, fusidic acid showed the best in vitro activity, with 96.7% susceptibility, associated with trimethoprim/sulfamethoxazole (85.8%) and minocycline (84%). Penicillin was associated with the lowest susceptibility (1.3%), associated with ofloxacin (3%) and erythromycin (14%). An increase in the minimal inhibitory concentration value of vancomycin was associated with a significant decrease in resistance to TMP-SMZ[2] (P < 0.01) and an apparent increase in resistance to other antibiotics.

Conclusion: The excellent in vitro activity of linezolid and its reported in vivo effectiveness renders it an important therapeutic alternative to vancomycin in the treatment of MRSA infection.

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[1] MRSA = methicillin-resistant Staphylococcus aureus

[2] TMP-SMX = trimethoprim/sulfamethoxazole

Objective: To present our algorithm of urgent and elective donor selection.

Methods: Urgent selection is expeditious and protocol‑based. Elective selection permits a comprehensive process. Both include medical, psychosocial and surgical-anatomic evaluations. Liver volumes and vascular anatomy are evaluated with computerized tomographic angiography. Informed consent is obtained after painstaking explanations. Independent institutional committees review and approve all cases.

Results: Between July 2003 and June 2004 we evaluated 43 potential live donors for 12 potential recipients (fulminant hepatic failure, n=5; chronic end-stage liver disease, n=6); primary graft non-function, n=1). Thirty-three candidates (76%) were excluded due to blood type incompatibility (n=14, 42%), incompatible anatomy (n=8, 24%) – including problematic volume distribution (n=2) or vascular anatomy (n=6) – psychosocial issues (n=4, 12%), or medical co-morbidity (n=7, 22%). Five recipients (FHF[1], n=4; chronic ESLD[2], n=1) were successfully transplanted from living donors. In the acute setting, two patients (FHF, PGNF[3]) died in the absence of an appropriate donor (cadaveric or living donor). In the elective group, one patient died of unexpected variceal bleeding and one received a cadaveric graft just before the planned living donor transplantation was performed. One candidate was transplanted overseas and two cases are scheduled. The ratio of compatibility for donation was 34% (10/29) for blood type-compatible candidates.

Conclusions: Donor selection for living donor liver transplantation is a complex, labor-intensive multidisciplinary process. Most exclusions are due to blood type incompatibility or anatomic details. Psychosocial aspects of these donations warrant special attention.

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[1] FHF = fulminant hepatic failure

[2] ESLD = chronic end-stage liver disease

[3] PGNF = primary graft non-function

Background: Continuous positive airway pressure is the treatment of choice for patients with obstructive sleep apnea syndrome.

Objective: To determine the factors influencing treatment initiation with a CPAP[1] device in a healthcare system in which co-payment is required.

Methods: A total of 400 adult patients with OSAS[2] who required CPAP therapy completed questionnaires at three different stages of the diagnostic and therapeutic process: CPAP titration study (stage 1), patient adaptation trial (stage 2), and purchase of a CPAP device (stage 3). Logistic regression was used to analyze the variables influencing CPAP use at the different stages of the diagnostic and therapeutic processes.

Results: Only 32% of the patients who underwent CPAP titration study purchased a CPAP device. The number of subjects who purchased a CPAP device increased gradually as monthly income increased, 28% vs. 62% in the “very low” and “very high” income levels respectively. Reporting for the titration increased in patients with excessive daytime sleepiness and an Epworth Sleepiness Scale score above 9 (odds ratio = 1.9, P = 0.015). Higher socioeconomic status increased reporting to stage 2 (OR[3] = 1.23, P = 0.03) and CPAP purchase (stage 3, OR = 1.35, P = 0.002). Excessive daytime sleepiness increased reporting to stage 2 (OR = 2.28, P = 0.006). Respiratory disturbance index above 35 increased CPAP purchasing (OR = 2.01, P = 0.022). Support from the bed partner, referring physician and sleep laboratory team increased CPAP purchasing.

Conclusions: A supportive environment for a patient with OSAS requiring CPAP is crucial to increase initiation of CPAP treatment. Minimizing cost sharing for the CPAP device will reduce inequality and may increase CPAP treatment initiation.

Background: The relationship between the amount of rehabilitation therapy and functional outcome in stroke patients has not been established.

Objectives: To evaluate the effectiveness of inpatient rehabilitation for post-acute stroke, and examine the relationship between intensity of therapies and functional status at discharge.

Methods: We evaluated 50 first-stroke patients, average age 63 years, in a prospective, descriptive study. The impairment and Functional Independence Measurement were assessed both at admission to rehabilitation and at discharge. Patients were monitored weekly during their stay by means of discipline-specific measures of activity level. Predictor variables included intensity of physical, occupational and speech therapies; demographic characteristics; length of stay; and time since the stroke.

Results: A significant reduction in impairment was observed at discharge. The predictors of gains and activity level at discharge as well as motor vs. cognitive components of the FIM[1] were neither consistent nor did they occur in the same trend of functional improvement. Greater FIM motor level at discharge was associated with younger age, higher admission motor and cognitive level, and receipt of any speech therapy, while greater FIM cognitive level was associated with higher cognitive level at admission, shorter interval from onset to admission, and more intense occupational therapy. More intense OT[2] was associated with greater and more cognitive improvement during the hospitalization.   

Conclusion: Since the sample was relatively small and heterogeneous in terms of the patients’ functional abilities, the findings cannot be generalized to the whole population of stroke patients. Further efforts to identify the best timing, modalities, intensity and frequency of the various treatments are needed to improve the cost-benefit equation of rehabilitation in stroke patients.

Obstructive sleep apnea syndrome is a major public health hazard affecting 2–4% of the adult population; only 10% of these patients are recognized by healthcare providers. In the last decade the number of referrals for polysomnography increased threefold in Israel, compared to 12-fold worldwide, and is expected to increase even more in the coming years. This constant demand for PSG[1] studies is beyond the current capacity of sleep laboratories, thus preventing diagnosis for most patients with suspected OSAS[2]. In the current review, we examine problems facing decision-makers on how to treat the increasing flood of patients presenting with symptoms suggestive of sleep-disordered breathing. We evaluate the cost-effectiveness of current technologies for OSA diagnosis, i.e., laboratory versus at-home technologies. We conclude that no current alternative exists to the use of PSG for OSA diagnosis. When at-home technologies are suggested for OSAS diagnosis, data should be provided on factors influencing its cost-effectiveness, e.g., accuracy rates of diagnosis, relative cost of human resources, and case-mix of patients tested. Since PSG remains the gold standard for diagnosis of OSAS, in Israel resources should be allocated to increasing the volume of beds for PSG studies in order to increase access to diagnosis and treatment, which in turn provides better quality of life, saves scarce resources of the healthcare system, prevents unnecessary accidents and increases workers’ productivity.

Background: Follow-up examinations in a rehabilitation center clinic after stroke are essential for coordinating post-acute services and monitoring patient progress. Of first-stroke patients discharged from our rehabilitation ward to the community 92% are invited for ambulatory check-up once every 6 months.

Objectives: To review patient complaints at follow-up and the recommendations issued by the attending physical medicine and rehabilitation specialist at the outpatient clinic.

Methods: We extracted relevant data from the records, and assessed the relationship between functional status on admission and discharge (measured by FIM[1]), length of stay, and number of complaints. Patients were divided according to the side of neurologic damage, etiology, whether the stroke was a first or recurrent event, and main clinical syndrome (neglect or aphasia).

Results: Patients' complaints included: decreased hand function (40%), general functional deterioration (20%), difficulty walking (11%), speech dysfunction (10%), various pains (especially in plegic shoulder) (8%), urine control (2%), sexual dysfunction (3%), swallowing difficulties (2%), and cognitive disturbances (2%). Patients received the following recommendations: physiotherapy (52.5%), occupational therapy (37.5%), speech therapy (12.5%), different bracing techniques (22.5%), pain clinic treatment (12.5%), changing medication prescriptions (7.5%), psychological treatment (10%), sexual rehabilitation (5%), vocational counseling (2.5%), counseling by social workers (2.5%), and recurrent neuropsychological diagnosis (2.5%). A reverse correlation was found between the number of complaints and FIM at admission (P = 0.0001) and discharge (P = 0.0003), and between LOS[2] and FIM at admission (P = 0.0001) and discharge (P = 0.004). A direct correlation was found between the number of complaints and LOS (P = 0.029). No relation was found between age, type of stroke, first and recurrent event, and clinical syndromes and patient complaints in the outpatient rehabilitation. Community rehabilitation services met 58% of all recommendations in 62% of patients, mainly physiotherapy and occupational therapy, with 34% of patients waiting for implementation of the recommendations and 4% not available for follow-up.

Conclusions: Follow-up examinations should be an integral part of post-stroke rehabilitation. Rehabilitation treatment in the community must be strengthened.

Background: Prone sleeping has been recognized as a risk factor for sudden infant death syndrome. Ten years ago, non-prone sleeping was recommended in many countries around the world including Israel. The rate of infants sleeping prone and the rate of parents' adherence with the recommendations have not been studied.

Objectives: To study infants' sleep position and parents’ adherence to recommendations, and to identify risk factors for prone sleeping following the campaign to prevent prone sleeping in the Israeli population.

Methods: We conducted a longitudinal telephone survey with the parents of 608 randomly selected 2 month old infants, repeated at 4 and 6 months.

Results: Non-prone sleeping decreased from 75% to 67% and 63% at 2, 4 and 6 months respectively. There was a significant relationship between prone positioning and the use of a home apnea monitor at 2 months (P = 0.038, odds ratio 1.37, 95% confidence interval 0.94–2.15). Other risk factors for prone sleeping were the level of religious practice, with ultra-Orthodox Jews having the highest prevalence (2 months: OR[1] 2.78, 95% CI[2] 1.75–4.55) and higher parity – especially in families with more than five children (P = 0.041).

Conclusions: The prone sleeping position is relatively high in Israel. Groups at high risk were closely associated with the level of religiousness and parity. Efforts to promote supine sleeping should be directed towards identifiable groups.

Background: Gallium scintigraphy is frequently used in the evaluation of fever of unknown origin, although its utility has been addressed in only a few studies.

Objectives: To evaluate the utility of gallium scintigraphy in the evaluation of patients with FUO[1] in our department.

Methods: We reviewed the charts of all patients from our department who had undergone gallium scintigraphy during the years 1995–2002 for the evaluation of FUO and who met the criteria for the definition of FUO. Demographic, clinical and laboratory data in addition to the results of gallium scintigraphy were documented. The patients were divided into two groups: those with a normal gallium study (group 1) and those with an abnormal gallium study (group 2). The second group was further divided into two groups: those whose gallium study results contributed to the diagnosis of the cause of FUO (group 2A) and those whose gallium study results did not (group 2B).

Results: A total of 102 patients met the study criteria. The male: female ratio was 54:48 and the mean age ± SD was 62.4 ± 20 years. A final diagnosis had been reached in 63 patients (62%), among whom the etiology was infectious in 54%, neoplastic in 19% and immunologic/rheumatic in 16%. Forty-one patients (40% of all the patients) (Group 2) had an abnormal gallium scintigraphy, and in only 21 patients (21% of all the patients) (Group 2A) did the gallium study results contribute to the diagnosis of the cause of FUO. However, in only two patients from Group 2A (2% of all the patients in our study) was the contribution of gallium study considered significant or crucial to the diagnosis of the cause of FUO.

Conclusions: The utility of gallium scintigraphy in the evaluation of FUO is very limited.

Background: The prognosis of patients with fulminant hepatic failure without timely liver transplantation is dismal. Given the limited availability of cadaveric organs for urgent transplantation in Israel, adult-to-adult living-donor segmental liver transplantation may be the only alternative.

Objectives: To report our initial experience with urgent lifesaving LDLT[1] in this unique scenario.

Methods: Three adult patients with FHF[2] (two of unknown etiology, one with paracetamol intoxication) were transferred from other institutions and admitted to our intensive care unit. Initial treatment and monitoring included intracranial pressure monitoring and hepatic dialysis using the Molecular Adsorbent Recirculating System. Expeditious potential donor selection included medical, psychosocial and surgical evaluation. Liver volume and vascular anatomic compatibility were assessed with computed tomography angiography.

Results: Between July and October 2003 we performed three procedures of urgent adult-to-adult LDLT. The donors (two uncles, one sister) underwent hepatic resection (two right lobes, one left lateral segment) and recovered well. The recipients underwent total hepatectomy with caval preservation, followed by lobar grafting. All recipients recovered and are alive with good liver function and without any neurologic complications.

Conclusions: Urgent adult-to-adult living-donor segmental liver transplantation can be performed safely and timely as a lifesaving procedure in the setting of comatose patients with FHF.

Background: An organ sharing system should achieve fairness and optimal graft longevity. Balancing between social and utilitarian considerations is a sensitive ethical, public and medical issue that requires a means to examine the consequences of any allocation policy or planned changes thereof.

Objective: To evaluate the performance and applicability of a computerized simulation model by examining the impact of two opposing organ allocation policies (social or utilitarian) on predicted organ distribution regarding age, waiting time, recipient sensitization measured by panel reactive antibody level and overall donor-recipient tissue matching (measured by the number of HLA antigen mismatches).

Methods: Using a computerized simulation model, virtual donors and recipients were emulated and organs were allocated according to either social algorithms or utilitarian policies. The resulting number of HLA mismatches, PRA[1], age, and waiting time distributions were compared between allocation strategies.

Results: Simulating allocation of 7,000 organs to 17,000 candidate recipients and implementing social policies yielded donor-recipient compatibility comparable to utilitarian policies (0–1 mm: 19.4% vs. 28%) while allocating 66.7% of organs to long waiters (>48 months).

Conclusion: This computerized simulation model is a valuable tool for decision-makers establishing or modifying organ allocation policies.