Israel Medical Association Journal

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: Various studies support the concept of an inherited vulnerability to drug dependency, while emphasizing the importance of social and environmental influences and their interactions

Objectives: To compare the characteristics of heroin-dependent Jewish men in Israel with those of the general population, focusing on the nature of family history of substance abuse.

Method: This case-control study compares 64 heroin-dependent Jewish male residents of Jerusalem with a community sample of 131 randomly selected Jerusalem residents with no drug use disorder. Univariate and mulbvariate moderns were employed to appraise the independent associations between heroin dependence and exposure variables such as family history of substance misuse and exposure to legal psychoactive substances.

Results: The case group is characterized by heavy tobacco and' alcohol involvement. Nearly 70% of the cases report an alcohol and/or drug problem in at least one first-degree relative compared with 10% of controls (odds ratio 14.5, adjusted for sociodemographic and other potential confounders). Cases with a positive family history have, on average, higher alcohol consumption levels and higher heroin-use severity scores, as compared with cases with no such history.

Conclusions: Familial aggregation of drug and alcohol problems, along with smoking at a young age, is the strongest predictor of heroin dependence in this population. Better understanding of the components underlying this familial aggregation can lead to improved prevention and treatment strategies.
 

Asthma in Israel is a growing medical problem, affecting at least 7% of children and 3.7% of the total population. Mortality rates in the age group 5-34 years were on a rise between 1976 and 1990 but show a marked decrease in recent years, perhaps due to the sharp increase in sales of inhaled corticosteroids. There is also a recent indication that the relatively high crude mortality rate among women is declining (from 3.68 and 4.58 per 100,000 in 1997). In spite of better asthma education and management there is still a gap between available medical knowledge and medical therapy and its utilization for benefit of the asthmatic population in Israel.

Background: The prevalence of attention deficit-hyperactivity disorder and its pharmacologic treatment have increased dramatically in the past decade in the United States and Britain. We examined the use of methylphenidate hydrochloride for the treatment of ADHD in children in northern Israel.

Methods: We evaluated all prescriptions for methylphenidate filled in 1999 for children aged 5–18 years residing in northern Israel who were insured by Clalit Health Services, a health maintenance organization that covers approximately 70% of the population.

Results: Methylphenidate was prescribed to 1.45% of the children in northern Israel in 1999, an increase of 20% in the overall prevalence of methylphenidate use since 1992. Eighty-two percent were boys. The rate of prescription varied widely by type of settlement, from 0.2% in Arab cities and towns to 5.7% in kibbutzim. Primary care physicians wrote 78% of all the prescriptions.

Conclusions: The increase in methylphenidate use was much smaller in northern Israel than in most other developed regions and countries. More efforts at diagnosis and treatment of attention deficit disorders may need to be directed at Arab populations and those with inadequate medical services.

Background: Spinal dural arteriovenous fistulae comprise the majority of spinal vascular malformations. The most common clinical presentation is that of progressive myelor­adicuiopathy, probably related to venous hypertension, which may lead to permanent disability and even death.

Objective: To report our clinical experience with spinal dural arteriovenous fistulae.

Methods: Nine patients with spinal dural AVF were managed at our center during a one year period (1998-1999). The patients, eight men and one woman ranging in age from 46 to 75 years, presented with initially fluctuating and eventually permanent and progressive paraparesis, sensory disturbances and sphincter dysfunction. The neurological signs generally began symmetrically and progressed from the distal to proximal limb regions. The duration of symptoms before diagnosis ranged from 6 to 36 months during which the patients underwent an extensive but fruitless work-up and even unnecessary operations due to misdiagnosis. All patients finally underwent magnetic resonance imaging and spinal angiography, which demonstrated the pathological vascular fistula. Interruption of the AVF was achieved by embolization or by surgical resection.

Results: Following treatment, six patients experienced improvement of gait and sphincter control, and the severe neurological deficits stabilized in the other three patients with long duration of illness. There was no further deterioration in any of the treated patients.

Conclusions: The history, neurological findings and radiological changes on MRI scan should alert clinicians to the possibility of spinal dural AVF, leading to diagnostic spinal angiography. Early diagnosis and treatment may significantly improve outcome and prevent permanent disability and even mortality.

Background: Knowledge of the prevalence of chronic disease in the population is essential for health planners and providers.

Objectives:To present the results of a concentrated effort by the largest health maintenance organization in Israel (Clalit Health Services) in order to develop a comprehensive register of chronic diseases.

Methods: In 1998, all 2,704 primary care physicians in Israel’s largest health provider were requested to report on all patients with selected chronic diseases. In addition, all the filled prescriptions for medications relevant to the investigated diseases and all relevant hospitalization events were added to the database. Prevalence rates were calculated based on the reporting practices only (1,653 physicians responsible for a total of 1,409,725 adults).

Results: Hypertension (10.2/100), diabetes (6.1/100), hyperlipidemia (5.7/100), peptic ulcer (4.7/100) and ischemic heart disease (4.3/100) were the most prevalent. Females had significantly higher rates of hypothyroidism, psychoses, neu­roses and malignancies, and lower rates of ischemic heart disease, chronic obstructive pulmonary disease, heart failure and asthma. Arabs had higher rates of diabetes mellitus and lower rates of ischemic heart disease, hypertension and hyperlipidemia than Jews. About 20% of the adult population had one or more of the selected chronic diseases.

Conclusions: Differences in rates noted between physi­cians, not explainable by population characteristics, may reflect differences in the quality and delivery of health services. Rate differences between demographic subgroups call for further studies on the etiology, susceptibility and natural history of these diseases.
 

Background: Hepatitis B is a major problem worldwide. Israel has intermediate endemicity for hepatitis B virus, and an annual carrier rate of 1-3%.

Objective: To evaluate both the prevalence of HBV infection among family members of HBV carriers and the competence of family practitioners in performing a compre­hensive assessment.

Methods: A total of 152 HB surface antigen-positive blood donors were discovered in our subdistrict during the years 1993-97. Their family physicians were questioned regarding the patients' family members. Specific information on 85 spouses and 200 children was also obtained.

Results: Among the 85 married carriers, 5 of the spouses (5.9%) were found to be HBsAg positive. None of the 200 children was HB5Ag positive. We found that in a third (n=52) of the patients, the sexual partner had never been tested by a primary care physician. Patients were not routinely tested for HB e antigen or anti-HBe antibodies. Neither the parents nor the siblings had undergone any serological evaluation. How­ever, most family members of the carriers had received an HBV vaccine from their family physicians.

Conclusions: Our findings show that horizontal transmis­sion of HBV among spouses of HBV carriers still exists. We did not find any vertical transmission, probably due to male predominance and previous vaccination. Family physicians should be trained to perform an extensive serological evalua­tion of family members of patients with chronic HBV infection, including parents and siblings, and should vaccinate sero­negative family members.

Background: Between 1970 and 1979, there was an increase in the incidence of viral hepatitis in Israel with a shift of peak incidence to an older age in the Jewish population, followed by a declining trend during the early 1980s. In July 1999 universal immunization of infants against hepatitis A was introduced.

Objective: To evaluate the chan-ges in the epidemiology of viral hepatitis A in Israel during the past decade.

Methods: Viral hepatitis is a notifiable disease in Israel and cases are reported to the regional health offices, which in turn provide summary reports to the Ministry of Health's Department of Epidemiology. The data in this study were derived from the summary reports and from results of seroprevalence studies.

Results: Following the increase in the incidence of reported viral hepatitis (mainly due to type A) between 1970 and 1979, the rates then stabilized and around 1984 began to decline until 1992. Since then there has been a slight increase. Whereas until 1987 the rates were consistently higher in the Jewish population. since then they are higher in the Arab population. The shift in the peak age-specific incidence from the 1-4 to the 5-9 year age group observed in the Jewish population around 1970 occurred 20 years later in the Arab population. The previously described seasonality is no longer evident. Recent seroprevalence studies indicate that by age 18 years only about 30-40% of the Jewish population have anti-hepatitis A antibodies.

Conclusions: The decline in the incidence of hepatitis probably reflects the changing socioeconomic condition occurring at different times in the two major population groups. Since hepatitis A accounts for almost all the acute viral hepatitis in Israel, the universal vaccination of infants introduced in 1999 should substantially lower the morbidity within the next few years.

Background: Autism is a pervasive developmental dis­order. The incidence rate and other related epidemiological characteristics of the Israeli population are not available.

Objectives: To assess the incidence rate of autism in the Haifa area and to compare family characteristics with previous reports from other countries.

Methods: We approached facilities in the Haifa area that are involved with the diagnosis and treatment of autism. The study group comprised children born between 1989 and 1993. Records of the children were scrutinized and 69% of the mothers were interviewed. Live-birth cohorts of the same years were employed for incidence computation.

Results: An incidence rate of 1/1000 was derived. Male to female ratio was 4.2:1. Pregnancy and perinatal periods were mostly uneventful. A low prevalence of developmental and emotional morbidity was reported for family members.

Conclusions: The epidemiological characteristics found in the Haifa area are similar to those reported from non-Israeli communities. This finding supports an underlying biological mechanism for this disorder. These data can be used for future trend analyses in Israel.
 

Cancer is a multi-step disease involving a series of genetic alterations that result in the loss of control of cell proliferation and differentiation. Such genetic alterations could emerge from the activation of oncogenes and the loss or malfunctioning of tumor suppressor gene activity. Our understanding of cancer has greatly increased through the use of DNA tumor viruses and their transforming proteins as a biological tool to decipher a cascade of events that lead to deregulation of cell proliferation and subsequent tumor formation. For the past ten years our laboratory has focused on the molecular biology of the human neurotropic papovavirus, JCV. This virus causes progressive multifocal Ieukoencephalopathy, a fatal neuro­degenerative disease of the central nervous system in immunocompromised patients. JCV is a common human virus that infects more than 80% of humans but does not induce any obvious clinical symptoms. The increased incidence of acquired immune deficiency syndrome and the use of immunosuppressive chemotherapy have dramatically raised the incidence of PML. The coincidental occurrence of malignant astrocytes and oligodendrocytes in PML patients, coupled with the induction of glioblastoma in JCV-intected non­human primates, provides intriguing speculation on the association between JCV and CNS malignancies. In this report we discuss clinical data and laboratory observations pointing to the direct involvement of JCV in cancer.

Objective: To describe the epidemiology of ceftazidime-resistant K. pneumoniae in our medical center, as representing the situation in tertiary care hospitals in Israel.

Methods: We vigorously restricted the use of ceftazidime in the ICU and enforced barrier precautions. The susceptibility rate of K. pneumoniae was surveyed in the ICU and throughout the hospital before and after the intervention in the ICU.

Results: Following the intervention, the susceptibility rate of K. pneumoniae increased from 11% (3/28) to 47% (14/30) (P0.01) among ICU isolates, from 55% (154/280) to 62% (175/281) (P=0.08) among total hospital isolates, and from 61% (50/82) to 74% (84/113) (P0.05) among total hospital blood isolates, although no additional control measures were employed outside the ICU.

Conclusions: The epidemiology of ceftazidime-resistant K. pneumoniae in our medical center is similar to that reported from other centers around the world. Early awareness to the emergence of this resistance, identification of the source of the epidemic, and prompt action at the putative source site may reduce the rate of acquisition and spread of such resistance inside and outside of the source unit.