Expert Recommendations on Use of Topical Therapeutics for Vitiligo in Pediatric, Adolescent, and Young Adult Patients

Importance

Evidence-based recommendations for the treatment of vitiligo in pediatric, adolescent, and young adult patients in the US are needed.

Objective

To develop evidence- and consensus-based expert recommendations on the diagnosis and treatment of vitiligo in young patients.

Evidence Review

A process was developed to produce consensus recommendations addressing questions regarding pediatric vitiligo. A librarian-conducted literature review was performed using articles that met the inclusion criteria: published in English, containing primary data (including meta-analysis) and pediatric-specific data, and analysis of 6 or more patients. Included articles were graded by the Strength of Recommendation Taxonomy criteria and Oxford Centre for Evidence-based Medicine's Levels of Evidence and Grades of Recommendation. Research questions were reviewed on May 9, 2022, through a video conference. One month after the conference, participants participated in an online survey documenting their level of agreement with the generated statements, using a 5-point Likert scale.

Findings

Articles on topical corticosteroids and/or topical calcineurin inhibitors (n = 50), topical Janus kinase inhibitors (n = 5), pseudocatalase (n = 2), and microdermabrasion (n = 2) met inclusion criteria. Forty-two recommendations were made on the diagnosis of vitiligo and optimal topical therapeutics, with 33 recommendations obtaining a 70% or greater composite agreement and strong agreement. Topical calcineurin inhibitors twice daily, topical corticosteroids with time limitation due to atrophy risk, and topical ruxolitinib, 1.5%, cream-used off-label for patients younger than 12 years and limited to nonsegmental vitiligo-were identified as evidence-based first-line therapies in the management of pediatric and adolescent patients, with specific guidance on age-based data, minimum therapeutic trial of 6 months or greater, prolonged therapy to prevent recurrence, and the positive benefit of coordinated use of UV therapeutic sources.

Conclusions and Relevance

Evidence supports the use of topical calcineurin inhibitors, topical corticosteroids, and topical Janus kinase inhibitors as effective therapeutics for vitiligo in pediatric, adolescent, and young adult patients, with specific decisions on choice of agent based on factors such as site location, body surface area, and age.

Gut microbiota predicts severity and reveals novel metabolic signatures in acute pancreatitis

OBJECTIVE

Early disease prediction is challenging in acute pancreatitis (AP). Here, we prospectively investigate whether the microbiome predicts severity of AP (Pancreatitis-Microbiome As Predictor of Severity; P-MAPS) early at hospital admission.

DESIGN

Buccal and rectal microbial swabs were collected from 424 patients with AP within 72 hours of hospital admission in 15 European centres. All samples were sequenced by full-length 16S rRNA and metagenomic sequencing using Oxford Nanopore Technologies. Primary endpoint was the association of the orointestinal microbiome with the revised Atlanta classification (RAC). Secondary endpoints were mortality, length of hospital stay and severity (organ failure >48 hours and/or occurrence of pancreatic collections requiring intervention) as post hoc analysis. Multivariate analysis was conducted from normalised microbial and corresponding clinical data to build classifiers for predicting severity. For functional profiling, gene set enrichment analysis (GSEA) was performed and normalised enrichment scores calculated.

RESULTS

After data processing, 411 buccal and 391 rectal samples were analysed. The intestinal microbiome significantly differed for the RAC (Bray-Curtis, p value=0.009), mortality (Bray-Curtis, p value 0.006), length of hospital stay (Bray-Curtis, p=0.009) and severity (Bray-Curtis, p value=0.008). A classifier for severity with 16 different species and systemic inflammatory response syndrome achieved an area under the receiving operating characteristic (AUROC) of 85%, a positive predictive value of 67% and a negative predictive value of 94% outperforming established severity scores. GSEA revealed functional pathway units suggesting elevated short-chain fatty acid (SCFA) production in severe AP.

CONCLUSIONS

The orointestinal microbiome predicts clinical hallmark features of AP, and SCFAs may be used for future diagnostic and therapeutic concepts.

TRIAL REGISTRATION NUMBER

NCT04777812.

The Pediatric Dermatologist's View of Pediatric Vitiligo

BACKGROUND

No guidelines exist for pediatric vitiligo.

OBJECTIVE

To identify practice patterns of pediatric dermatologists treating vitiligo.

METHODS

A PeDRA survey was completed online by 56 pediatric dermatologists.

RESULTS

Practitioners reported feeling most comfortable treating 13- to 17-year-olds and least comfortable treating infants. Quality of life was assessed by interview in 89.3%. Topical calcineurin inhibitors (TCIs), topical corticosteroids (TCSs), narrowband UVB, coverup makeup, topical JAK inhibitors (tJAKis), and 308-nm laser were the leading vitiligo therapeutics chosen. 94.5% of practitioners reported experiencing frustration due to difficulties procuring therapies.

CONCLUSION

Pediatric vitiligo has notable effects on quality of life. Some therapeutic options exist which are preferred by pediatric dermatologists. There is a need for more data on therapeutics in infants and young children, J Drugs Dermatol. 2024;23(2): doi:10.36849/JDD.7572e.

A review of the vitiligo literature to standardize the expression of disease severity

The literature on vitiligo is extremely heterogeneous with limited standardization in vitiligo disease severity reporting. The IDEOM Vitiligo Workgroup initiated a project to develop an improved understanding of clinical reporting of vitiligo severity and extent. A medical librarian-developed literature review identified 51 English-language clinical trials treating vitiligo topically using topical corticosteroids or topical tacrolimus that included adult and paediatric patients, with 10 or more patients. Grading of studies was performed using SORT criteria. The grading systems used included three studies reporting overall improvement: one as absolute Improvement vs. did not improve (B2), one as marked improvement (C3) and one as improvement, no change or worse (A2). Severity was reported as straight body surface area scoring (BSA) in five trials with grades of (A1, A1, B1, C2 and C3), and two via photography and mapping (A1, A2). Many studies report success as meeting the metric of 50% improvement or clearance (C3). Kanwar et al. further subdivides this into 50% to <75% or >75% (C3). Three studies add the complete clearance metric (A1, A1, B1), with some adding worsening categories. Most studies create a grading system including G0- no change (A1, A1, A2, A2< B2, B2, B3, B3), G1- 1–25%, G2- 26–50%, G3- 51–75%, G4- 75–99% (one study by Lepe et al. reports this as >75%) and G5- 100% re-pigmentation [Bae et al. (C2) report these numbers as 0, 1–24%, 25–49%, 50–74%, 75–99%, 100%]. Variations in response include the meta-analysis by Lee et al. reporting >25%, >50% and >75% re-pigmentation and the combination of G0 and G1 as < or = 25% re-pigmentation, considered a failure (A1, A1, A2. B2, C3, C3, C3). Koopmans-VanDorp (B2) and Kandil (B2) break down re-pigmentation as none, beginning (<25%), good (25–90%) or complete or almost complete (90–100%) or spontaneous re-pigmentation. Success can be defined as G3–G5 or G4–G5. Kathuria classifies <50% as failure (A1). Hu and Farajzadeh (A2) classify >50% as success, Bae (C2) classifies >75% and Kumari (B2) as >90% improvement. Majid further subdivides the score into six subdivisions (A1). Abd-Elazim (A2) reports VASI and Baldo reports DLQI. Sach (C1) and Batchelor (A1) use the vitiligo noticeability scale Baldo, with target patches reported as ‘a lot less noticeable’ or ‘no longer noticeable’ being successful. Ibrahim (A2) uses Patient-Expressed Satisfaction, reporting ‘not satisfied’, ‘slightly satisfied’, ‘satisfied’ or ‘very satisfied’. Batchelor (A1) report percentage re-pigmentation, onset and maintenance of response, treatment burden, QoL, side effects and cost-effectiveness. Body surface area total and quartiles of improvement are the most commonly reported metrics in studies with high-level evidence. The addition of categories of no improvement, complete clearance, spontaneous improvement and worsening appears to enhance information collection. Collection of data using photographs or computer-assisted BSA monitoring enhances data reproducibility. Using 50%, 75% and 90% as thresholds for success appears to be standardized, with a rarer inclusion of 100%. Validated scores like VASI represent a validated alternative collection method, which can be modified to address the 50%, 75% and 90% thresholds. Quality of life has not per se been correlated to clinical response to topical therapeutics, and current scores including patient expression of satisfaction, vitiligo noticeability and satisfaction are not known to reflect topical response at this time.

Diverse approaches to the diagnosis and treatment of paediatric vitiligo: a survey of paediatric dermatologists

There is a paucity of research concerning the diagnosis and treatment of paediatric vitiligo. This reality parallels published patient reports of profound dissatisfaction with the state of knowledge and available treatments. This study was meant to assess the attitudes of paediatric dermatologists towards the therapeutics of paediatric vitiligo. A survey was designed and approved by the survey committee of the Pediatric Dermatology Research Alliance to be distributed to the members. The study was exempted by the IRB of the Mount Sinai Hospital and posted to an online survey system. A total of 56 dermatologists completed the survey, a majority of whom practiced in the US (n = 44, 78·6%), followed by Mexico (n = 6, 10·7%). Most were board-certified (n = 48, 85·7%). Practitioners reported seeing an average of eight paediatric and adolescent vitiligo patients per month. Providers surveyed reported feeling most comfortable treating older patients 13–17 (n = 48, 85·7%), 9–12 (n = 47, 84%), 5–8 (n = 40, 71·4%), 2–4 years (n = 18, 32·1%), 13–23 months (n = 12, 21·4%), 7–12 months (n = 4, 7·1%), and 0–6 months (n = 1, 1·7%). Among the 8 (14·3%) respondents who used an oral JAK inhibitor, the age of the patients ranged from 4 months to 16 years. Most providers surveyed (n = 50, 89·3%) used an interview with the patient and parents to assess for quality-of-life impairments in children and adolescents. Bloodwork was performed always or usually (n = 25, 44·6%), sometimes (n = 11, 19·6%), and rarely (n = 9, 16·1%). Full thyroid panels (n = 38, 67·8%) and 25-OH vitamin D levels (n = 27, 48·2%) led tests ordered. For children under 8 years with <25% +/− eyelid localization TCI (n = 52, 92·9%; n = 46, 82%), TCS (n = 17, 30·3%; n = 29, 51·7%), Narrow band UVB (NB-UVB, n = 11, 19·6%; n = 5, 8·9%), topical JAK inhibitors (tJAK-i) (n = 6, 10·2%, n = 5, 8·9%), cover-up makeup (n = 7, 11·9%; n = 6, 10·7%), and excimer laser (n = 5, 8·5%; n = 9, 16·1%) were prescribed. For <8 with >25% vitiligo +/− eyelid involvement TCI (n = 48, 85·7%; n = 45, 80·3%), TCS (n = 21, 37·5%; n = 30, 53·6%), excimer laser (n = 8, 85·7%; n = 11, 19·6%), NB-UVB (n = 6, 10·7%; n = 7, 12·5%), and cover-up makeup (n = 7, 11·9%; n = 8, 14·3%) were used. For 8+ with body depigmentation <25% or 25%+, TCI (n = 29, 51·8%, n = 22, 39·3%), TCS Class 1 (n = 24, 42·8%), and NB-UVB (n = 17, 30·4%; n = 31, 55·4%), oral steroids (n = 10, 17·9%; n = 12, 21·4%), tJAK-i (n = 5, 8·9%; n = 16, 28·6%); TCS (n = 13, 23·2%), NB-UVB/home phototherapy units (n = 8, 14·3%; n = 22, 39·2%), oral methotrexate (25%+ only; n = 10, 17·9%), TCS (n = 9, 16·1%), and Class 3 TCS (n = 5, 8·9%). Paediatric segmental vitiligo localized to the face was predominantly treated by TCI (n = 46, 82·1%), excimer laser (n = 14, 25%), and occasional tJAKi (n = 8, 14·3%). Treatments identified for segmental vitiligo of the body included TCS (n = 48, 85·7%), TCI (n = 24, 42·9%), NB-UVB (n = 15, 26·8%), and tJAKi (n = 5, 8·9%). Methodologies for assessing vitiligo improvement were clinical photographs, measurement of lesion size (n = 48 each, 85·7%), subjective patient-reported satisfaction (n = 41, 73·2%) and percent re-pigmentation (n = 34, 60·7%). A total of 94·6% reported occasional to constant frustration due to a lack of treatment options and insurance barriers and always or often experiencing challenges in procuring appropriate therapies for patients, including tJAKi and TCI. Parental phobia of topical corticosteroid in paediatric patients was noted at least occasionally (n = 29, 51·8%) to regularly (n = 10, 17·8%). Topical calcineurin inhibitors are favoured for the youngest patients as well as for segmental vitiligo. Topical steroids and UVB light sources are used for older children with more extensive and body disease. The diverse treatment modalities represented underscore the need for a systemized approach to this disease. Even paediatric dermatologists are uncomfortable with infants and small children with vitiligo and more data are needed for guidance in all children, especially infants and toddlers.

Vitiligo evidence-based expert consensus recommendations for paediatric and adolescent patients: part I—topical therapeutics

No United States paradigm for the treatment of paediatric, adolescent and young adult vitiligo has been developed. To develop evidence and consensus-based expert opinion to promote therapeutic consistency for the diagnosis and treatment of vitiligo. An IRB-exempted process was developed to produce consensus recommendations based on literature review and SORT criteria. Research questions were reviewed on 9 May 2022 in a video-based conference. Forty-two recommendations were made on the diagnosis of vitiligo (5) and optimal topical therapeutics (37). Topical calcineurin inhibitors, topical corticosteroids and topical ruxolitinib 1·5% cream were all identified as potential first-line therapies in the management of paediatric and adolescent patients with specific guidance on age-based data, frequency of application, minimum length of the therapeutic trial and coordinated usage of ultraviolet light therapy. The literature on paediatric and adolescent vitiligo has a heterogeneous methodology and lack of patient-reported outcomes. Children with vitiligo may be effectively managed with a variety of topical agents as first- and second-line therapy. Evidence supports the utility of topical calcineurin inhibitors, topical corticosteroids and topical JAK inhibitors, with limitations based on factors such as location, body surface area and age.

Treatment of Reactive Keratoacanthomas with Acitretin Following Multiple Excisions and Mohs Surgery for Recurrent Squamous Cell Carcinoma

Surgical intervention is seen as the gold standard in the treatment of Squamous cell carcinoma. Yet, in cases of recurrence, repeated surgical procedures may unwittingly foment the rise of reactive keratoacanthomas at the surgical margins or edge of a newly placed skin graft.

Leukocytoclastic Vasculitic Rash Following Second Dose of Moderna COVID-19 Vaccine

The immunization against coronavirus disease (COVID-19) via vaccination serves as a significant milestone in the fight against the pandemic. Rapid introduction of various COVID-19 vaccines to stem the spread of virus has researchers scrambling to document the adverse effects left in its wake. Thus far, there have been singular examples of cutaneous vasculitis associated with COVID-19. A history of vasculitis leaves little error to miss its inclusion in diagnostic differentials. It also invokes the physiologic possibility that afflicted patients possess a more susceptible landscape for recurrence that was then triggered by the vaccine when compared with those who lack similar history. In our case report, we build on those findings with one of the first documented examples of vaccination-induced vasculitic rash in a previously asymptomatic patient.

Teaching internal medicine in the community

BACKGROUND

Teaching Internal Medicine is mainly hospital-based. Chronic diseases are treated mostly in community-based ambulatory care. This study describes our experience during the first year of teaching Internal Medicine in the community, with a focus on chronic disease management.

METHODS

This was an observational study describing the content of clinical exposure and the feedback from students after a two-week clerkship in community health centers.

RESULTS

Over a period of three months, 54 students spent two weeks in health centers singly or in pairs. The disciplines covered were: Endocrinology, Gastroenterology, Pulmonology, Rheumatology and Geriatrics. In their feedback, the students most frequently noted knowledge acquired in the management of diabetes, infectious diseases and cardiology. The teaching content was determined by the case-mix of patients. The spectrum of conditions was wide. Students who were used to more structured hospital-based study found it difficult to cope with this mode of learning by discovery.

DISCUSSION

Future research should concentrate on the transition between the different modes of learning as students move from the hospital to the community setting.

INDUCED SEISMICITY. High-rate injection is associated with the increase in U.S. mid-continent seismicity

An unprecedented increase in earthquakes in the U.S. mid-continent began in 2009. Many of these earthquakes have been documented as induced by wastewater injection. We examine the relationship between wastewater injection and U.S. mid-continent seismicity using a newly assembled injection well database for the central and eastern United States. We find that the entire increase in earthquake rate is associated with fluid injection wells. High-rate injection wells (>300,000 barrels per month) are much more likely to be associated with earthquakes than lower-rate wells. At the scale of our study, a well's cumulative injected volume, monthly wellhead pressure, depth, and proximity to crystalline basement do not strongly correlate with earthquake association. Managing injection rates may be a useful tool to minimize the likelihood of induced earthquakes.

Low-Temperature Processed Hybrid Organic/Silicon Solar Cells with Power Conversion Efficiency up to 6.5%

Hybrid organic/silicon heterostructures have become of great interest for photovoltaic application due to their promising features (e.g. easy fabrication in a low-temperature process) for cost-effective photovoltaics. This work is focused on solar cells with a hybrid heterojunction between the polymer poly(3-hexylthiophene-2,5-diyl) (P3HT) and n-doped monocrystalline silicon. As semi-transparent top contact, a thin (15 nm) Au layer was employed. Devices with different P3HT thicknesses were processed by spin-casting and compared with a reference Au/n-Si Schottky diode solar cell.

The current density-voltage (J-V) measurements of the hybrid devices show a significant increase in open-circuit voltage (VOC) from 0.29 V up to 0.50 V for the best performing hybrid devices compared to the Schottky diode reference, while the short-circuit current density (JSC) does not change significantly. The increased VOC indicates that P3HT effectively reduces the reverse electron current into the gold contact. The wavelength-dependent JSC measurements show a decreased JSC in the wavelength range of P3HT absorption. This is related to the reduced JSC generation in silicon not being compensated by JSC generation in P3HT. It is concluded that the charge generation in P3HT is less efficient than in silicon.

After a thermal annealing of the hybrid P3HT/silicon solar cells, we achieved power conversion efficiencies (PCE) (AM1.5 illumination) up to 6.5% with VOC of 0.52 V, JSC of 18.6 mA/cm² and a fill factor (FF) of 67%. This is more than twice the efficiency of the reference Schottky diode.

Very late antigen-5 facilitates stromal progenitor cell differentiation into myofibroblast

Fibrotic disease is associated with abrogated stromal cell proliferation and activity. The precise identity of the cells that drive fibrosis remains obscure, in part because of a lack of information on their lineage development. To investigate the role of an early stromal progenitor cell (SPC) on the fibrotic process, we selected for, and monitored the stages of, fibroblast development from a previously reported free-floating anchorage-independent cell (AIC) progenitor population. Our findings demonstrate that organotypic pulmonary, cardiac, and renal fibroblast commitment follows a two-step process of attachment and remodeling in culture. Cell differentiation was confirmed by the inability of SPCs to revert to the free-floating state and functional mesenchymal stem/stromal cell (MSC) differentiation into osteoblast, adipocyte, chondrocyte, and fibroblastic lineages. The myofibroblastic phenotype was reflected by actin stress-fiber formation, α-smooth muscle production, and a greater than threefold increase in proliferative activity compared with that of the progenitors. SPC-derived pulmonary myofibroblasts demonstrated a more than 300-fold increase in fibronectin-1 (Fn1), collagen, type 1, α1, integrin α-5 (Itga5), and integrin β-1 (Itgb1) transcript levels. Very late antigen-5 (ITGA5/ITGB1) protein cluster formations were also prevalent on the differentiated cells. Normalized SPC-derived myofibroblast expression patterns reflected those of primary cultured lung myofibroblasts. Intratracheal implantation of pulmonary AICs into recipient mouse lungs resulted in donor cell FN1 production and evidence of epithelial derivation. SPC derivation into stromal tissue in vitro and in vivo and the observation that MSC and fibroblast lineages share a common ancestor could potentially lead to personalized antifibrotic therapies.

Induced earthquakes. Sharp increase in central Oklahoma seismicity since 2008 induced by massive wastewater injection

Unconventional oil and gas production provides a rapidly growing energy source; however, high-production states in the United States, such as Oklahoma, face sharply rising numbers of earthquakes. Subsurface pressure data required to unequivocally link earthquakes to wastewater injection are rarely accessible. Here we use seismicity and hydrogeological models to show that fluid migration from high-rate disposal wells in Oklahoma is potentially responsible for the largest swarm. Earthquake hypocenters occur within disposal formations and upper basement, between 2- and 5-kilometer depth. The modeled fluid pressure perturbation propagates throughout the same depth range and tracks earthquakes to distances of 35 kilometers, with a triggering threshold of ~0.07 megapascals. Although thousands of disposal wells operate aseismically, four of the highest-rate wells are capable of inducing 20% of 2008 to 2013 central U.S. seismicity.

Influenza surveillance during winter 1997-1998 in Israel

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.

Folk, traditional and conventional medicine among elderly Yemenite immigrants in Israel

BACKGROUND

Migration leads to changes in almost all areas of life including health. But how far are health beliefs also preserved, and how far are they affected by the process of acculturation to the host society?

OBJECTIVES

To examine the difference between behavior and attitudes towards conventional and traditional medicine among elderly Yemenite immigrants.

METHODS

A community-based study was conducted in the Yemenite neighborhoods in the city of Rehovot. All inhabitants of Yemenite origin over the age of 70 were identified from the population register, excluding those who were institutionalized or demented. Social work students interviewed them at home. The questionnaire inquired after health problems in the preceding month. For each of these problems, the respondent was asked whether any mode of treatment had been employed--Yemenite folk remedies, conventional medical care, or other. Their attitudes towards Yemenite folk medicine and conventional medicine were recorded. Socioeconomic data included their current age, age at immigration, year of immigration, marital status, gender, religiosity, and education.

RESULTS

A total of 326 elderly people were identified who fulfilled the selection criteria, of whom 304 (93%) agreed to be interviewed. Of these, 276 (91%) reported at least one health problem in the preceding month, providing 515 problems of which 349 (68%) were reported to a conventional medical doctor while 144 (28%) were treated by popular folk remedies. Fifty-nine problems (11.5%) were treated by specifically Yemenite traditional remedies, mostly by the respondents themselves (38/59) rather than by a traditional healer. Immigrants who arrived in Israel over the age of 30 years, as compared to respondents who immigrated at an earlier age and grew up in Israel, were more likely to use traditional Yemenite remedies (24.4% vs. 8.2%, P < 0.005).

CONCLUSION

Aged Yemenite Jews in Israel prefer modern medicine. The earlier the immigrant arrived in Israel, the more positive the attitude towards modern medicine and the less use made of traditional Yemenite healing.

Job satisfaction among certified and non-certified general practitioners

BACKGROUND

The aim of family medicine is to provide patients with comprehensive care within the biopsychosocial model. High job satisfaction is necessary to attract physicians to this specialty.

OBJECTIVE

To compare job satisfaction levels between primary physicians with training in family medicine and physicians without specialty training.

METHODS

A self-report questionnaire, the "Task Profiles of General Practitioners in Europe," was mailed to a stratified random sample of 664 primary care physicians in Israel. The response rate was 77.6%. Bivariate and logistic regression procedures were used to analyze the data.

RESULTS

Physicians with training in family medicine were less satisfied with the rewards for their work than general practitioners with no formal specialization in family medicine. Satisfaction with the intrinsic aspects of the work was found to be equal. Women and rural physicians were more satisfied than men and urban physicians.

CONCLUSION

Measures should be taken by health maintenance organizations to increase the level of job satisfaction of specialist-certified family physicians to avoid a crisis in the profession.

Increased galectin-3 expression in gastric cancer: correlations with histopathological subtypes, galactosylated antigens and tumor cell proliferation

Galectin-3 represents an endogenous galactoside-binding lectin which may be involved in tumor cell adhesion and proliferation. In order to evaluate its biological significance in human gastric cancer, we investigated its expression in the stomach of a large series of patients (n = 193) by immunohistochemical staining with the monoclonal antibody Mac-2. Compared to normal tissues, primary gastric adenocarcinomas showed a slight increase in galectin-3 expression. However, there was no correlation of membrane-bound and cytoplasmic galectin-3 with histopathological differentiation parameters (according to the WHO and Laurén classifications) or tumor progression (as documented by pTNM staging). Nuclear galectin-3 reactivity was significantly stronger in diffuse-type cancer compared to the intestinal-type tumors. Galectin-3 binds to terminal GalNAcalpha(1-3) bound to polylactosamine chains and related glycotopes. Therefore, the strong coexpression of membrane/cytoplasmic galectin-3 with Griffonia simplicifolia agglutinin I (GSA I) binding sites (Galalpha1-3Gal-, GalNAcalpha-) on carcinoma cells seems to be interesting. On the other hand, nuclear galectin-3 immunoreactivity did not correlate with the incidence of Ki-67-positive tumor cells. A prognostic value of galectin-3 regarding patient survival could not be established.

Comparison of sexual activity of women and men after a first acute myocardial infarction

Studies of gender differences in the sexual activity of men and women after a first acute myocardial infarction (AMI) have produced conflicting results. The present study was performed to determine whether there are gender differences (1) in the quantity and quality of sexual activity after a first AMI, and (2) in the relations between selected demographic and medical variables and sexual activity after AMI. Four hundred sixty-two men and 51 women with a first AMI were interviewed once before discharge and again 3 to 6 months after AMI. Patients' demographic and medical background and their frequency of and satisfaction with sexual behavior were obtained from the interviews and from medical charts. Analyses of variance showed that women reported significantly less frequency of and satisfaction with sexual activity than men before and after AMI. Both women and men reported significantly less sexual activity and less satisfaction with sexual activity after AMI than before AMI. The decrease in frequency of and satisfaction with sexual activity after AMI was similar for women and men. The relations between selected demographic and medical variables such as age, education, and perceived health before the first AMI and the frequency of and satisfaction with sexual activity of the women and men did not appear to be affected differently by the AMI. A first AMI appears to reduce the frequency of and satisfaction with sexual activity of women and men similarly 3 to 6 months after AMI.

[The new family physician in the clinic]

The content of all consultations of a family physician during the first 2 months in a new practice and again in the same 2 months, 2 years later were analyzed. The workload did not change between the 2 periods, but in the first period there were relatively more men over the age of 60 years, and a more marked predominance of women in the 45-59 year age-group. There were more follow-ups of pre-existing conditions during the first period, but in both periods the main reason for visits was an acute condition; a quarter of visits required only simple counseling without further investigation or prescribing of medication. During the first period 9% of visits were for the explicit purpose of getting to know the new physician, usually by women. Thus the initial period in a new practice is not excessively burdensome, but involves seeing a number of patients who come either simply to get to know the new doctor, or to present non-chronic problems without expectation of further investigation.

[Use of sentinel reporting clinics for influenza surveillance in the winter of 1996-1997]

In a joint effort of the Israel Center for Disease Control, the National Center for Influenza in the Central Virology Laboratory, together with a group of collaborating pediatricians and family physicians, a network for influenza surveillance was established in the winter of 1996-97. Nose and throat swabs were obtained from 571 patients with flu-like illness. 133 (23%) were positive for influenza virus. Both influenza A(H3N2) and B were isolated, predominantly influenza B during the beginning of the season. Both circulating strains were antigenically similar to those included in the vaccine for 1996-1997. Patients from whom influenza virus was isolated were significantly more likely to suffer from cough and myalgia in comparison with patients whose cultures were negative (p = 0.02 and 0.003, respectively). Results of the first year of surveillance indicate that sentinel reporting clinics are useful for timely detection and identification of the viral strains circulating in the community, thus allowing prompt intervention in preventing the spread of influenza. Conclusions from the first year of the study were drawn and applied in the winter of 1997-1998.

Sexual activity after first acute myocardial infarction in middle-aged men: demographic, psychological and medical predictors

The study examined important diverse sociodemographic, medical and psychological variables as potential predictors of sexual activity frequency/satisfaction in male patients following a first acute myocardial infarction (AMI). The sample comprised 276 Israeli male patients, age range 30-65 years, with a documented first AMI who were admitted to any of eight medical centers in Israel. All patients were sexually active prior to AMI. Data were elicited from interviews and medical charts on two occasions: before discharge and 3-6 months after AMI. The research variables explained a greater extent of the variance in sexual activity frequency than in satisfaction 3-6 months after AMI (32 and 23%, respectively). Sexual activity frequency/satisfaction prior to AMI were the major contributors to frequency/satisfaction after AMI. Of the other variables, age and education were the major contributors to sexual activity frequency; of these two variables, age was the sole contributor to sexual satisfaction. Medical and psychological variables (diabetes and depression) were minor contributors.

Psychiatric liaison with a primary care clinic--14 years' experience

An analysis is presented of the experience of a psychiatric liaison team that visited one primary care community health center on a monthly basis for 14 years. The content of the liaison changed character over time, starting as a teaching relationship and developing successively into case discussions, tripartite consultations with joint interviews, a satellite psychiatric clinic, a Balint group, observation of routine general practice consultations and, finally joint assessments of video-tapes of routine consultations. The primary care team of nurses and doctors developed insight into the complexities of their relationships with each other and with their patients. The psychiatric team developed a more holistic view of psychological distress in the community and of the therapeutic potential of routine primary care. The patient population benefited from the improved accessibility of psychiatric care and from the increased psychological sensitivity of their doctors and nurses.

[Correlation between success in specialty examinations and learning methods of family medicine residents]

Learning methods chosen by residents in family medicine during their residency and the correlation between them and achievement in the written specialty exams (Stage 1) were investigated. The learning patterns studied were: structured learning (certification course, study with a tutor, staff meetings, conferences) and self-learning (textbooks, journals, the Hebrew publication "Update," and audio tapes). Of 184 residents who took the examination in 1994-5. 104 responded to a questionnaire as to preferences for the various learning aids and satisfaction with their use. There was no correlation between use of a given learning method and success in the examination. Significantly more candidates preferred self-learning, especially among those who were successful, but also among some who failed the examination. There was no direct connection between the examination and the high level requirements of the residency program, for which up-to-date, integrated knowledge based on self-learning is needed.

The third party in general practice consultations

OBJECTIVE

To describe the impact of outside agents in doctor-patient consultations.

DESIGN

In-depth group discussions with psychoanalytically oriented leadership.

SETTING

A Balint group which met weekly for two years.

SUBJECTS

15 senior general practitioners with an interest in teaching.

FINDINGS

Outside agents are almost invariably present in general practice consultations. The "third party" in the consultation fitted four separate categories according to its helpful or disturbing, real or projected characteristics.

CONCLUSION

The dyadic nature of general practice consultations is illusory. The third party is an inherent component of the consultation and may be used consciously to gain extra insight into the needs of patients and their doctors.

Listening to patients' stories. Storytelling approach in family medicine

This paper discusses the relevance of a storytelling approach for understanding psychological problems in family practice and assesses the value of such an approach.

Personal Primary Care: Understanding why therapy sometimes fails

A new scheme of organizing the family physician's approach to office patients is presented. This scheme is designed to help physicians understand the unpredictability of the course of disease. Its use might help avoid some of the failures of therapy that frequently occur despite quality clinical medicine. Six questions are directed at defining the characteristics of the host as well as the details of the disease.

Identification of sorbitol 3-phosphate and fructose 3-phosphate in normal and diabetic human erythrocytes

Using 31P NMR spectroscopy, we have identified sorbitol 3-phosphate and fructose 3-phosphate in normal human erythrocytes wherein their concentrations are estimated to be 13 mumol/liter cells. Incubation of hemolysates with sorbitol, fructose and ATP suggest that both sorbitol and fructose are phosphorylated separately and directly at the 3-hydroxyl position suggesting the presence in these cells of a novel and specific kinase(s). In addition to sorbitol 3-phosphate and fructose 3-phosphate which were previously identified in the mammalian lens and sciatic nerve, erythrocytes have two extra metabolites resonating at 6.7 and 6.8 ppm in the 31P NMR spectrum. Although not identified in this study, the unusual chemical shifts of these compounds, their low pKa values and the fact that they appear as doublet in proton-coupled 31P NMR spectra, suggest that these phosphomonoesters belong to the same class of metabolites as sorbitol 3-phosphate and fructose 3-phosphate. Preliminary studies of erythrocytes from an unselected group of diabetic subjects showed an overall increase in the concentration of all four metabolites, although an overlap with normal values was noted.

Respiratory monitoring of carbon dioxide and oxygen: a ten-year perspective

During the past 10 years, instrumentation has been developed that can continuously and noninvasively measure changes in carbon dioxide and oxygen. The information generated, which cannot be obtained through the human senses, provides vital clinical data regarding the effectiveness of intubation, ventilation, circulation, oxygenation, and the circuit. This instrumentation plays a major role in decision making both in the safe conduct of anesthesia and mechanical ventilation as well as in the detection and prevention of potentially catastrophic mishaps. For these reasons, a review of what has been learned regarding the instrumentation, collection, and interpretation of the clinical data, and the clinical value of the information is timely. The clinical significance of the carbon dioxide and oxygen waveforms, inspired to expired carbon dioxide and oxygen differences, alveolar-arterial gradients, and global supply-to-demand oxygen relationships measured by capnography, oxygraphy, and pulse oximetry are addressed in this essay.

[Blood pressure of Yemenites in Israel similar to that of other Israelis]

Studies of Yemenite immigrants shortly after their arrival in Israel reported markedly low blood pressures. A community survey was conducted in the town with the most Yemenite immigrants, 40 years after their immigration. Blood pressures were measured by family practice physicians in the course of their routine clinical work. The averages of 3432 measurements recorded in 4955 adults were the same as those reported in studies of other Israeli populations for all age groups, except in women over the age of 60, in whom it was low. Pressures rose with age from 20 to 65 years, falling off slightly in the oldest age groups. The distribution curve was positively skewed, with a tail of higher values. Hypertension was diagnosed in 153, and elevated blood pressure, not confirmed as hypertension, was recorded in an additional 226. Except in older women, the clinical epidemiology of blood pressure in Yemenites in Israel is indistinguishable today from that of the general population.

The epidemiology of methicillin-resistant Staphylococcus aureus in a burn center

The emergence of methicillin-resistant Staphylococcus aureus (MRSA) in a critical care facility creates a multifaceted epidemiological problem in uncovering the source of infection. This study was undertaken to determine the true etiology of MRSA burn wound infections. Patients with a 30% or greater TBSA burn had both burned and unburned skin surface cultured upon admission, using RODAC plates. All other body fluids were cultured when sepsis was suspected. Admission cultures of 14 patients who developed MRSA wound infections were examined for methicillin-resistant organisms. Both admission isolates and infection isolates were compared by antibiogram analysis. Of the 14 patients admitted who developed MRSA infections, 57.1% of these had methicillin-resistant staphylococci present on admission. However, the remaining 42.9% of the patients had methicillin-sensitive, B-lactamase positive staphylococci present on admission. Isolates of group D streptococci resistant to methicillin were isolated in 35.7% of the patients. This data suggests that burn wound infections caused by MRSA very likely arise from the endogenous flora present at the time of injury through conferring the resistant plasmid by conjugational transfer.