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עמוד בית
Thu, 18.07.24

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September 2008
J. F. Swart and N. M. Wulffraat

Raynaud's phenomenon, fatigue and pain (myalgia and arthralgia) are important presenting symptoms of pediatric-onset mixed connective tissue disease. The difficulty is that many adolescent girls complain of pain along with fatigue without evidence for serious disease. However, in patients with Raynaud's phenomenon one should search for evidence of connective tissue diseases. Capillaroscopy could be helpful since capillary changes of the SD-type significantly correlate with future development of scleroderma spectrum disorders. Symptoms of MCTD[1] change in most patients during the disease course: in general the inflammatory features that are also seen in systemic lupus erythematosus and juvenile dermatomyositis have the tendency to disappear over years, but Raynaud's phenomenon is persistent and scleroderma symptoms become progressively prominent. Long-lasting remission occurs only in a minority of patients, while the majority has mild disease activity. Mortality in children with MCTD is lower than in adults. Since a change of symptoms is in the nature of the disease a thorough and frequent evaluation of children with (probable) MCTD is important to detect organ involvement which, if present, should be treated at an early (pre-symptomatic) stage. We present a diagnostic workup scheme for children and adolescents with propable MCTD.

[1] MCTD = mixed connective tissue disease

October 2007
Y. Paran, O. Halutz, M. Swartzon, Y. Schein, D. Yeshurun and D. Justo
August 2006
D. Tekes-Manova, E. Israeli, T. Shochat, M. Swartzon, S. Gordon, R. Heruti, I. Ashkenazi and D. Justo
 Background: Coronary heart disease is a major cause of morbidity and mortality worldwide. Early detection of cardiovascular risk factors and intervention may reduce consequential morbidity and mortality.

Objectives: To assess the prevalence of reversible and treatable cardiovascular risk factors among 26’477 healthy Israeli adults: 23’339 men and 3138 women aged 25-55 years.

Methods: We collected data during routine examinations performed as part of a screening program for Israel Defense Force personnel.

Results: The three most prevalent cardiovascular risk factors were a sedentary lifestyle (64%), dyslipidemia (55.1%) and smoking (26.8%). Overall, 52.9% of the men and 48.4% of the women had two or more cardiovascular risk factors. Moreover, 52.4% of young adult men and 43.3% of young adult women, age 25-34 years, had two or more reversible cardiovascular risk factors.

Conclusions: In this expectedly healthy population there was a high prevalence of reversible and treatable cardiovascular risk factors in both genders and in young age. These observations stress the need for routine health examinations and lifestyle modification programs even in the young healthy Israeli population.

May 2006
L.M. Shulman, Y. Manor, D. Sofer, T. Swartz and E. Mendelson

Background: Poliovirus rapidly evolves by nucleic acid substitutions and genetic recombination with other polioviruses and non-polio enteroviruses. Evolving oral poliovirus (Sabin strains) can rapidly revert to neurovirulence and undergo antigenic alterations.

Objectives: To evaluate the threat of vaccine-derived poliovirus (1–15% divergence from the respective Sabin strain) for a poliomyelitis-free population in a country with a long-standing routine vaccination program.

Methods: We characterized genetic and antigenic changes in OPV[1] strains isolated from sewage in Israel and evaluated intestinal immunity by measuring fecal excretion after OPV challenge of vaccinated children.

Results: Characterization of poliovirus from sewage revealed eight type 2 and three type 3 vaccine polioviruses that had replicated and started to evolve (vaccine that replicated and diverged by 0.5 to ≤ 1.0%) and nine highly diverged type 2 vaccine-derived polioviruses (1–15% divergence from the respective Sabin strain) with 8–14% divergence between the years 1998 and 2005. Six of the eleven VRPV[2] uniquely recombined with OPV and/or NPEV[3]. The nine VDPV[4] were epidemically related, genotypically neurovirulent, and had 10–15 amino acid substitutions in antigenic sites altering their antigenicity, but shared a single recombination. Type 2 OPV was excreted by 23% and 17% of infants challenged with OPV 3 months after partial immunization (two doses each of OPV and enhanced inactivated poliovirus) or full immunization (three doses of each) respectively, despite high humoral antibody titers.

Conclusions: Our findings, which show that OPV is excreted for a significant period by children with high humoral immunity, emphasize the long-term potential threat from VDPV in highly vaccinated populations. An adequate immunization program, combined with environmental surveillance, is necessary to prevent poliomyelitis and community transmission of poliovirus. 


[1] OPV = oral poliovirus

[2] VRPV = vaccine poliovirus that has replicated and started to evolve but is < 1 % but at least 0.5% diverged from the respective Sabin strain

[3] NPEV = non-polio enterovirus

[4] VDPV = vaccine-derived poliovirus 1–15% divergence from the respective Sabin strain

September 2003
M. Birger, M. Swartz, D. Cohen, Y. Alesh, C. Grishpan and M. Kotelr

The relevance of central neurotransmission to aggressive and impulsive behavior has become more evident due to extensive research in humans and in animals. Among other findings, there are abundant data relating low serotonergic activity – as measured by low cerebrospinal fluid 5-hydroxyindolacetic acid, and a blunted response of prolactin to fenfluramine – to impulsive behavior. Many studies on testosterone activity show a relation between high plasma levels and a tendency towards aggression. It is hypothesized that the interaction between low serotonin and high testosterone levels in the central nervous system has a significant effect on the neural mechanisms involved in the expression of aggressive behavior. It seems that testosterone modulates serotonergic receptors activity in a way that directly affects aggression, fear and anxiety. Our survey reviews the main findings on serotonin, testosterone and the possible interaction between them with regard to these behavioral phenomena.

May 2003
E. Aizen, N. Dranker, R. Swartzman and R. Michalak

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.

January 2002
Manfred S. Green MD PhD, Tiberio Swartz MD MPH, Elana Mayshar JD, Boaz Lev MD, Alex Leventhal MD MPH, Paul E. Slater MD MPH and Joshua Shemer MD

Background: The large number of cases of West Nile fever diagnosed in Israel in 2000 once again brought into focus the confusion that frequently accompanies the use of the term “epidemic”.

Objective: To examine the different definitions of the term “epidemic” and to propose ways in which it can be used to both improve communication among professionals and provide the public with a better sense of the associated risks.

Methods: The literature wes reviewed for the various definitions of the terms “epidemic” and “outbreak”. Sources included popular and medical dictionaries, ancient documents, epidemiology texts, legal texts, and the medical literature.

Result: The term epidemic is variously defined. The broad definition given by epidemiologists - namely, more disease the is anticipated by previous experience - is less meaningful to the general public. In some ways it conflicts with the definitions found in the popular literature, which generally imply danger to the public and a very large number of victims.

Conclusions: The interpretation of the term epidemic may vary according to the context in which it is used. For risk communication, we suggest that every effort be made to add descriptive terms that characterize the epidemic.

December 2001
Tamar Peled MSc, Michael Weingarten BM BCh, Noemi Varsano MSc, Andre Matalon MD, Adi Fuchs MD, Robert D. Hoffman MD, Charna Zeltcer MD, Ernesto Kahan MD MPH, Ella Mendelson PhD and Tiberio A. Swartz MD MPH

Background: Each winter influenza activity is a major cause of morbidity and mortality both in Israel and worldwide.

Objectives: To identify the influenza viruses active in Israel during the winter season and to assess the extent of influenza morbidity.

Methods: Information was collected on a population of 18,684 individuals enrolled in two community clinics in central Israel. It included the total number of visits for acute respiratory infection – including influenza and influenza-like illness (ARI/flu-like) – during a 20 week surveillance period (23 November 1997 to 27 March 1998) and the percent of influenza virus isolates in nasopharyngeal specimens from a sample of patients with ARI/flu-like collected on a weekly basis during the same period.

Results: A total of 5,947 visits for ARI/flu-like were recorded among 18,684 enrolled patients in two community clinics (18.1%). The progressive increase in the number of visits for ARI/flu-like reached a peak on week 2/98 with 597 visits and a rate of 31.95 visits per 1,000 population. After this, a decrease to the initial values was evident by week 12/98. Most affected patients were in the age groups 5–14 and 65 years and over, with a rate of 733.5 and 605.3 visits per 1,000 population, respectively. Influenza virus was isolated from 92 of the 426 nasopharyngeal specimens (21.6%). The most commonly detected strain was A/Sydney/5/97(H3N2) like (77.2%). The peak rate of isolates was recorded at the beginning of January (01/98).

Conclusions: A/Sydney/5/97(H3N2) like-strain was the dominant influenza virus. Its presence did not prevent the simultaneous activity of influenza A/H1N1 virus. The dynamic of the clinical disease as expressed by the weekly visit rate for ARI/flu-like was similar to the temporal pattern of the virological findings. The extent of morbidity suggests moderate epidemic activity.

October 2001
Efraim Aizen, MD, Rachel Swartzman, MD and A. Mark Clarfield, MD, FRCPC

Background: Transfer to an emergency room and hospitalization of nursing home residents is a growing problem that is poorly defined and reported.

Objectives: To assess the clinical effectiveness of a pilot project involving hospitalization of nursing home residents directly to an acute-care geriatric department.

Methods: We retrospectively compared the hospitalization in an acute-care geriatric unit of 126 nursing home residents admitted directly to the unit and 80 residents admitted through the emergency room. The variables measured included length of stay, discharge disposition, mortality, cause of hospitalization, chronic medical condition, cognitive state, functional status at admission, and change of functional status during the hospital stay. Follow-up data were obtained from medical records during the 2 year study.

Results: No significant differences between the groups were found for length of stay, mortality, discharge disposition and most characteristics of the hospital stay. The only significant difference was in patients’ mean age, as emergency room patients were significantly older (86 vs. 82.9 years). The most common condition among nursing home patients admitted via the emergency room was febrile disease (36.9%) ,while functional decline was the most common in those coming directly from the nursing home (32.5%). The prevalence of functional dependence and dementia were similar in both groups. Functional status did not change throughout the hospital stay in most patients.

Conclusions: Treatment of selected nursing home residents admitted directly from the nursing home to an acute- care geriatric unit is feasible, medically effective, results in the safe discharge of almost all such patients and provides an alternative to transfer to an emergency room. This study suggests that quality gains and cost-effective measures may be achieved by such a project, although a randomized controlled trial is necessary to support this hypothesis.

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