Eduard Kaykov MD, Benyamine Abbou MD, Scott Friedstrom MD, Doron Hermoni MD and Nathan Roguin MD
Background: Previous work has suggested an association between Chlamydia pneumoniae infection and coronary artery disease. The infection was demonstrated by titers of antibodies - enzyme-linked immunosorbent assay or immunofluorescence, and polymerase chain reaction - and by the findings of C. pneumoniae in the atherosclerotic plaque.
Objectives: To evaluate the association between chronic infection with C. pneumoniae, as measured by a high titer of IgG antibody, and CAD. Our study was designed to explore the relationship between seropositivity to C. pneumoniae and serious coronary events, and to assess whether or not there may be an additional association between established cardiovascular factors and infection with this organism.
Methods: The serum of 130 patients with proven CAD was tested for the presence of IgG antibodies to C. pneumoniae using an ELISA test. A titer ≤1:64 using the microinfluorescence method, the recognized "gold standard," correlates with a positive result when using the ELISA method. The mean age was 57 (40-65 years). The patients, 82% male and 18% female, had either myocardial infarction (n=109) or unstable angina (n=21) 6 months before the investigation (range 3-24 months). The serum for the control group was obtained from 98 blood donors from the same area matched for age 52 (40-58 years) and sex. The donors had no known cardiac history.
Results: In the CAD group 75% of patients were positive for C. pneumoniae compared to 33% in the control group (P=0.001). No increased correlation could be demonstrated between traditional risk factors and C. pneumoniae infection, except in those patients with diabetes mellitus. We found a lower prevalence of IgG antibody to C. pneumoniae in the diabetes subgroup than in other subgroups (P<0.006), but a higher prevalence than in the control group.
Conclusions: We demonstrated a more than twofold increase in seropositivity to C. pneumoniae among patients suffering serious coronary events, and this trend was independent of gender, age or ethnic group. These findings suggest that chronic C. pneumoniae infection may be a significant risk factor for the development of CAD, but this correlation should be investigated further.
CAD= coronary artery disease
Haya Zaltzberg MSc, Yoram Kanter MD, PhD, Michael Aviram DSc and Yishai Levy MD
Background: Atherosclerosis and microvascular complications in patients with non-insulin-dependent diabetes have been linked to increased oxidative stress. The glutathione redox cycle is a major determinant of the antioxidative capacity of plasma and its constituents.
Methods: We attempted to investigate plasma oxidation and plasma and erythrocyte glutathione and glutathione enzymes in 20 patients with NIDDM, compared with euglycemic matched controls. Plasma oxidation was analyzed both basally (without) and as induced by 2,2'-azobis,2-amidopropane hydrochloride measured by the generation of thiobarbituric acid reactive substances and lipid peroxides.
Results: There was a significant increase in oxidation both basally (without) and as induced by AAPH. Plasma glutathione was lowered by 50% (P<0.01) and erythrocyte glutathione peroxidase, glutathione s-transferase and glutathione reductase activities were lower by 30%, 27% and 46%, respectively (P<0.01) in the patients with NIDDM.
Conclusions: Confronted by increased oxidation, patients with NIDDM show an abnormal plasma and erythrocyte antioxidative capacity, which may result in an accelerated rate of complications.
NIDOM= non-insulin-dependent diabetes mellitus
Zvi Fireman MD, Victor Gurevich MD, Daniel Coscas MD, Yael Kopelman MD, Arie Segal MD and Amos Sternberg MD
Background: Chronic occult blood loss from the gastrointestinal tract is widely accepted as a major cause of iron deficiency anemia.
Objectives: To evaluate the diagnostic yield of gastroscopy, colonoscopy and fecal occult blood testing of hospitalized IDA patients, plus follow-up.
Methods: IDA was defined as hemoglobin <12.5 g/dl (men) and 11 g/dl (women), and serum iron <50 g/dl. The study group comprised 90 patients (42% male) with a mean age of 65±15 years and mean Hb 8.1 g/dl.
Results: Gastroscopy and colonoscopy revealed a bleeding source in 28.8% and 14.4% respectively. Gastrointestinal symptoms were found in 23% of patients with diseases of the upper gastrointestinal tract and in 15.3% of the lower. The sensitivity of fecal occult blood tests in detecting lesions in the lower and upper GI tracts was 100% and 30.7% respectively. Forty-four patients (48.9%) were discharged from the hospital with IDA of unknown origin. Over the following year, 20 of the 44 patients required further hospitalization, and of these, 13 were found to have anemia. Of the remaining 24 patients who were not hospitalized again, 15 had anemia. Four patients (9%) had significant gastrointestinal lesions and two died during the follow-up.
Conclusions: Fecal occult blood is a sensitive examination for lower but not for upper GI tract lesions.
IDA= iron deficiency anemia
Eliezer Kitai MD, Talma Kushnir PhD, Michael Herz MD, Shmuel Melamed MD, Dorit Vigiser PhD and M. Granek MD
Background: Physicians need a professional environment that is conducive to efficient and satisfying work. Little has been published about the effect of work structure on the satisfaction that family physicians derive from their work.
Objectives: To assess the structure and the positive and negative job components of family physicians in Israel, as well as the effect of these components on their satisfaction with their work.
Methods: A questionnaire was sent to a random selection of members of the Israel Society of Family Physicians (n=225).
Results: Altogether 183 questionnaires were returned. Specialist family doctors, practice medical directors and salaried doctors were involved in more activities than non-specialist doctors, trainees and self-employed doctors. Overall satisfaction was highest for specialists and lowest for non-specialists. Work overload, insufficient resources and abundant paperwork were most frequently cited as negative work components. The opportunity to utilize medical knowledge, challenging work and work variety scored highest as positive components.
Conclusions: The more professionally active physicians were also the more satisfied. Clinical work and teaching provided the most satisfaction, while administrative work and lack of time were the main causes of dissatisfaction.
* This article is dedicated to the memory of our dear friend, Dr. michael Herz, who contributed to the writing of it.
Aya Peleg PhD, Roni Peleg MD, Avi Porath MD and Yael Horowitz BSc
Background: Hallway medicine is an integral part of physicians' medical culture, but little is known about it.
Objective: To characterize the practice of hallway medicine among hospital physicians, both as providers and consumers.
Methods: We conducted a survey of 112 randomly chosen hospital physicians at the Soroka Medical Center in Beer Sheva, Israel between November 1997 and May 1998. A self-administered 39-item questionnaire was used that included sociodemographic data, the extent to which hallway medicine is practiced, and satisfaction from and attitudes to it.
Results: Of the 112 selected physicians, 111 responded (99.1%). Of these, 91 (82%) had been asked by their colleagues to provide hallway medicine. Most of them (91%) agreed because of "willingness to help," because "it's unpleasant to refuse," or "it's the acceptable thing to do." Most of the requests (72%) were unscheduled and time consuming (41% up to 10 minutes and 21% more than 20 minutes). Records were kept in only 36% of the cases and follow-up in 62%. Physicians who provided hallway medicine were also consumers of it (P<0.001), based on personal acquaintance, time saved and easy accessibility. In general, the attitude to hallway medicine was negative (54%) or ambiguous (37%). Most requests for hallway medicine were made to Israeli-trained physicians, surgeons or gynecologists, and senior physicians.
Conclusions: Hallway medicine is practiced frequently among hospital physicians. A formal organization of health care service within medical centers might provide physicians with better medical care and reduce potential ethical, medical, legal, psychosocial and economic problems.
Sophia Zlatkin MD, Suhail Aamar MD, MSc, Galia Specter MD, David Leibowitz MD, Natalia Simanovsky MD, Dror Yeshurun MD and Samuel N Heyman MD
Background: Takayasu's arteritis is a rare, probably underdiagnosed disorder in Israel.
Objective: To evaluate the contribution of computerized tomography to the diagnosis of Takayasu's arteritis.
Methods: A retrospective analysis of the diagnostic process was recently conducted in three consecutive patients diagnosed over the last 3 years.
Results: Three females of Arab origin with Takayasu's arteritis were recently identified by CT. In two of the three patients the imaging procedure was performed for different working hypotheses, and the radiological findings (wall thickening, perivascular edema, and segmental intraluminal obliteration of the aorta and its major branches) were unexpected. In these two patients, repeated physical examination following the imaging procedure disclosed initially missed findings that could have led to an earlier consideration of Takayasu's arteritis (bruits above the epigastrium, subclavian and carotid arteries, and absent brachial pulses). Retrospective analysis of the patients' symptoms following CT revealed the true nature of the patients' misinterpreted complaints (e.g., typical abdominal angina replaced a faulty obtained history compatible with renal colic or dyspepsia). In the third patient CT was performed for the evaluation of an epigastric bruit associated with constitutional complaints. The diagnosis of aortitis, based upon the presence of diffuse aortic wall thickening and edema of the surrounding fat, without intraluminal narrowing, could have been missed by angiography, the traditional "gold standard" diagnostic procedure. All three patients complained of ill-defined epigastric abdominal pain and had epigastric tenderness during examination.
Conclusions: CT has the potential for detecting Takayasu's disease and may be superior to angiography, particularly at the early non-obliterative stage. Since the diagnosis of Takayasu's disease is rarely considered, the expanding use of CT and MRI technologies may reveal missed cases that are evaluated for other plausible diagnoses. The true incidence of Takayasu's arteritis in Israel may be much higher than reported, particularly in the Arab population. Our findings suggest that epigastric tenderness, originating from active inflammatory reaction in the abdominal aortic wall, should be considered as a diagnostic criterion of Takayasu's aortitis.
Yona Amitai MD, Daniel Katz MD, Matityahu Lifshitz MD, Rosa Gofin MD, Maya Tepferberg MSc and Shlomo Almog PhD, published in IMAJ.
Background: Prenatal lead exposure (umbilical cord blood lead concentration 10 (μg/dl) may impair cognitive development. Childhood lead poisoning is infrequent in Israel, and there are no data on lead exposure in immigrants to Israel from the former Soviet Union.
Objectives: To evaluate prenatal blood lead concentrations in Israeli newborns whose mothers were born in Israel and in those whose mothers recently immigrated from Russia, and to compare data of prenatal lead exposure in Israel with those reported from other countries.
Methods: We compared the UCBLC of 35 newborns of new immigrants from Russia with a group of 35 newborns whose mothers were born in Israel. Venous BLC was also measured in 50 mothers. Data are compared with similar reports on prenatal lead exposure internationally.
Results: The UCBLC in all 70 newborns (mean±SD) was 3.53±1.6 μg/dl, and mothers' BLC (mean±SD) was 3.90±1.39 μg/dl. UCBLC and BLC in the 50 mother-newborn pairs correlated (γ=0.36, P<0.01). All newborns except one had UCBLC<8.0 μg/dl. There was no significant difference between UCBLC in the two groups.
Conclusions: Prenatal lead exposure among the study subjects in both groups was low. In this sample the newborns of mothers born in Israel and those whose mothers recently immigrated from Russia were not found to be at risk for lead poisoning. Prenatal lead exposure in this sample was low compared to that reported from various parts of the world.
Hagith Nagar, MD
Background: Gastrointestinal duplications are rare, benign congenital lesions that may occur at any location along the alimentary tract and generally require surgical intervention. Presenting symptoms may be quite varied even among patients with the same anomaly.
Objective: To review the clinical presentation of gastrointestinal duplications and present our experience with such lesions over the past decade.
Methods: The records of all patients treated for gastrointestinal duplications at a tertiary hospital during 1987 through 1996 were collected, and relevant published literature reviewed.
Results: In the nine patients with gastrointestinal duplications, six were in the small bowel and one each in the cecum, colon and esophagus. Presenting clinical features were varied and often subtle. Perinatal ultrasonography, radioscintography and computerized tomography were useful in some cases, while in others the correct diagnosis was established only at surgery.
Conclusions: Alimentary tract duplications are uncommon, and may present as solid or cystic tumors, intussusception, perforation or gastrointestinal bleeding. A high index of suspicion is required when dealing with such cases. Appropriate investigations, including imaging techniques, should be directed toward adequate and planned surgery.