Limited value of physical examinations in upper respiratory illness: account of personal experience and survey of doctors' views

Medical tradition considers a physical examination (PE) an essential part of the clinical encounter. In real medical practice, however, a full PE may not be necessary when the diagnosis is clear after anamnesis and general impression. We assessed the value of PEs in 500 diagnoses of upper respiratory infection (URI) and the attitudes of 123 doctors regarding the utility of PEs in virtual cases.

METHODS

Computerized files of consecutive cases with a diagnosis of URI over 8 months in two practices were reviewed and correlation studies between the extent of PE and clinical outcomes were performed. In addition, doctors' attitudes and declarations about PEs were compared.

RESULTS

Five hundred paediatric and adult patients were included. Less than one-fifth underwent a full PE. More patients who underwent a full PE returned because they still felt unwell or their parents felt they were unwell. Fewer doctors declared actually having performed PEs than supported giving one in two virtual cases of URI. Specialized doctors were less inclined to perform PEs than doctors without a specialization.

CONCLUSIONS

Our study suggests that in many cases presenting as URI, doctors may conduct limited PEs or even omit them entirely.

Mercury in traditional Tibetan medicine - panacea or problem?

Symptoms of mercury toxicity, biochemical changes, and blood/urine mercury levels were evaluated in a small group of patients. Six patients attending Delek Hospital, Dharamsala, India, taking mercury-containing traditional Tibetan medicine (TTM) (Group I), were compared with three patients taking non-mercury containing TTM (Group II) and healthy volunteers(Group II). Quantitative estimation of mercury ingestion based on chemical analysis was compared with US regulatory standards.

RESULTS

Group I were significantly older (mean 55 years+/-SE 6.4) range 26-69 years, than Group II (26.7 years+/-SE 5) range 17-34 years and Group III (32.5 years +/-SE 0.5) range 33-34 years (P =0.05). Group I took TTM on average for 51 months and had a mean of 2.5 non-specific, mercury-related symptoms. Group I had higher mean diastolic pressures (85 mmHg) than Group II (73 mmHg) (P=0.06) and more loose teeth. Mean daily mercury intake for Group I was 674 microg, estimated as 10 microg/kg per day. (Established reference dose for chronic oral exposure: 0.3 microg/kg per day.) Blood mercury levels were non-detectable, but mean urinary mercury levels for Group I were 67 microg/L (EPA levels <20 microg/L). Renal and liver function tests were not significantly different between groups and within normal clinical range.

CONCLUSIONS

Prolonged ingestion of mercury containing TTM is associated with absent blood levels, but relatively high urinary levels. Further studies are needed to evaluate toxicity and therapeutic potential.

Changes in psychological distress of women in long-term remission from breast cancer in two different geographical settings: a randomized study

GOALS OF WORK

Psychological distress and coping styles in women diagnosed with stages I and II breast cancer have attracted substantial clinical and research attention over the last several decades. The contradictory and, at times, controversial findings stimulated the present randomized research whose purpose was to explore the possibility and probability of predicting which variables affect the psychological distress level of women with breast cancer 1 to 5 years after diagnosis (time period 1) and 6 to 8 months after period 1 (time period 2).

PATIENTS AND METHODS

The study was conducted in two large oncology centers in Graz, Austria, and Jerusalem, Israel, with a sample population comprising 424 patients.

MAIN RESULTS

The only variables that significantly predicted change in the psychological distress levels (Grand Severity Index, GSI; except for the GSI level during period 1) were Fighting Spirit (Mental Adjustment to Cancer, MAC) in the Graz sample and Perceived Family Support (PFS) in the Jerusalem sample. These results are discussed in relation to other findings.

CONCLUSIONS

In light of these findings, it is highly important to preliminarily identify women with less adaptive psychological coping mechanisms and to provide them with efficacy tools for behavioral and cognitive changes within their own network of social and health resources.

Resin-bonded fixed partial denture retention: a retrospective 13-year follow-up

A total of 51 resin-bonded fixed partial dentures (RBFPDs) were inserted under controlled clinical conditions and evaluated over a period of 13 years. Three levels of survival were defined: complete survival (no debonding); functional survival (loss of retention on one occasion with rebonding of the original RBFPD); and multiple survival (loss of retention on several occasions with rebonding of the original RBFPD). The effect of the aetiology, location (anterior/posterior or maxillary/mandibulary) and number of units of the missing tooth on RBFPD survival rates were investigated. The mean survival times and confidence levels were determined for each survival category, using the Kaplan-Meier procedure. The relative risks were calculated by the Cox regression procedure. The overall complete survival level of the study population at the end of the follow-up period was 85 months +/- 13%. Rebonding the RBFPDs once increased the overall functional survival rate to 112 months +/- 10% and multiple rebonding led to a further increase to 131 months +/- 8%. The RBFPD placement under conditions of good periodontal support in which orthodontic treatment was not required, such as trauma among other factors, showed significantly higher survival rates than those placed after periodontal or orthodontic treatment. This indicates that, under both these conditions, RBFPDs may serve as long-term or semi-permanent restorations.

Do different cultural settings affect the psychological distress of women with breast cancer? A randomized study

Breast cancer is the most common malignant disease among women in developed countries. In Austria and Israel, it accounts for 15% and 18%, respectively, of all cancers and 30% of all cancers in women. The purpose of this study, conducted in Graz, Austria, and Jerusalem, Israel, was to determine whether different geographical and cultural settings differentially affect the psychological distress of women who have survived breast cancer and why. The dependence of psychological distress on psychosocial variables such as quality of life, body image, impact of cancer and coping styles was examined at time 1 in a randomized sample of 424 breast cancer women who were disease-free at the time of the study and were surveyed 1-5 years after diagnosis. The most contributing variables to the level of psychological distress in both populations were: the number of stressful life events during last year, financial problems and feeling uncomfortable with the body. Regarding coping styles, mental adjustment to cancer was the principal contributor to psychological distress level [determined by the Grand Severity Index (GSI) scores] in the Graz group, while intrusion was the principal contributor to the GSI level in the Jerusalem group.

Effects of age on coping and psychological distress in women diagnosed with breast cancer: review of literature and analysis of two different geographical settings

Age-related differences in emotional distress were examined by studying two random samples (N=424) of women diagnosed with early stages of breast cancer in Graz, Austria and Jerusalem, Israel. We found that psychological distress, coping abilities, and different perceptions of illness are attributable to socialization differences of age experience according to young (49 or younger), intermediate (50-64) and old (65 and older) age groups. Patients were interviewed at home to obtain sociodemographic and medical background data. They also completed five standardized instruments (Brief Symptom Inventory, Psychological Adjustment to Illness Scale, Impact of Events Scale, Mental Adjustment to Cancer, and Perceived Family Support). A two-way MANOVA for all the demographic variables yielded significant main group (Graz vs. Jerusalem) effect (P<0.0001), significant main age effect (P<0.0001) and significant interaction (group by age) effect (P<0.001). Examination of the contribution of the age category to the level of the coping variables showed a different pattern in each group. The psychological distress variables revealed that, in the Jerusalem sample, there is a tendency toward decreasing distress levels with age and, in the Graz sample, elevated scores for the intermediate-age group. Age was found to be related to the level of Global Severity Index (GSI) and to the variables correlated to the GSI level. Psychological intervention should be guided to the different age groups.

Traumatic wound dehiscence after cataract extraction

PURPOSE

To study the visual outcome and factors associated with it in patients with traumatic dehiscence of a cataract surgery wound.

SETTING

Department of Ophthalmology and the Brown School of Public Health and Community Medicine, The Hebrew University-Hadassah Medical School, Jerusalem, Israel.

METHODS

A retrospective observational study of 37 eyes of 37 consecutive patients with traumatic wound dehiscence of a cataract surgery wound was conducted. A complete ophthalmic evaluation was performed in all patients. Statistical analysis was done to identify factors associated with the best corrected visual acuity at the end of follow-up.

RESULTS

Patients had extracapsular cataract extraction (n = 29), intracapsular cataract extraction (n = 4), or lensectomy (n = 4). No patient had phacoemulsification via a small incision. A univariate analysis showed that factors associated with a worse visual outcome included the presence at presentation of hyphema (P = .05), intraocular lens dislocation or loss (P = .006), vitreous hemorrhage (P = .0002), scleral rupture (P = .001), a long interval from surgery to trauma (P < .0001), and fall as the cause of trauma (P < .0001). In a multivariate model, only a surgery-to-trauma interval longer than 8 weeks was associated with a worse visual outcome (P < .0001). Visual acuity immediately after trauma was a poor predictor of final visual acuity.

CONCLUSIONS

Visual outcome after traumatic wound dehiscence of a cataract surgery wound was strongly associated with the interval from surgery to trauma. Other factors were less reliable predictors of visual outcome. Traumatic wound dehiscence only moderately affected visual outcome after cataract surgery in most cases.

Children with baby bottle tooth decay treated under general anesthesia or sedation: behavior in a follow-up visit

The purpose of the present study was to compare the behaviors of a group of children, who were treated for baby bottle tooth decay (BBTD) under general anesthesia (GA) or under sedation in a dental school environment in a routine follow-up examination, and to assess the dental anxiety levels of the parents. Sixty-five children, who were treated for BBTD in the Pediatric Dentistry clinic of the Hebrew University-Hadassah School of Dental Medicine between 1995-1997 under GA (34 children) or sedation (31 children). The parents of these children agreed to attend our clinic for recall examination 13 months post treatment following a telephone conversation. Frankl's behavioral scale and the sitting pattern were recorded for each child. In the sedation group, Frankl's scores of the present visits were then compared to the scores recorded at the initial examination visit that were obtained from the dental records. The accompanying parents were asked to note the number of visits to the dentist in the past two years, and to complete Corah's dental anxiety scale (DAS). No difference was observed between the children in both groups. Most of the children in the GA and in the sedation groups sat alone on the dental chair, without the assistance of the parents. Parents of the sedation group showed higher scores than the GA group in the total DAS (9.35 and 8.90 respectively), however these differences were not statistically significant. It is concluded that children treated for BBTD under GA or under sedation at a very young age behave similarly in a follow-up examination nearly 13 months postoperatively.

Overcoming the language barrier in visual field testing

PURPOSE

To evaluate the effect of using recorded instructions in patients' native language compared with interpreter-assisted instructions on the reliability and duration of the visual field test.

PATIENTS AND METHODS

Sixty patients referred for visual field testing were included in the study. Thirty-five had limited or no knowledge of the Hebrew language, and 25 control patients were fluent in Hebrew, the native language. None had previous experience with automated perimetry. Patients were randomized to receive recorded instructions on the visual field test in their native language or translator-assisted instructions by the technician before performing the test. For each patient, the time required for instructions and test performance and the reliability indices were documented.

RESULTS

The method of instruction (recorded or interpreter-assisted) did not affect the time required for patient instructions (66 +/- 24 seconds and 57 +/- 30 seconds, respectively), the time for test performance (7.2 +/- 1.5 minutes and 7.8 +/- 1.8 minutes, respectively), and test reliability as measured by the rate of fixation losses. Regardless of the method of explanation, the time required for instructions and for performing the test were significantly shorter for Hebrew speakers than for non-Hebrew speakers.

CONCLUSION

The use of a recorded explanation in the patient's native language before visual field testing is an applicable method for patient instruction. Clinics in areas with multilingual populations may use this method to save technicians time, without adversely affecting the time required for performing the test and its reliability.

Psychological distress in healthy women with familial breast cancer: like mother, like daughter?

OBJECTIVE

In 1977, the Israel Cancer Association held a one-day conference, on the subject of familial breast cancer, for healthy women with at least one first-degree relative diagnosed with breast cancer. The objective of this study was to assess the psychological distress of a sample of the women who attended.

METHOD

Of the 333 healthy women present at the conference, 230 completed three questionnaires: one on sociodemographic data and the medical history of the first-degree relative(s) (mother and/or sister), and two that measure psychological distress: the Brief Symptom Inventory and the Impact of Events Scale.

SAMPLE

The subjects were divided into three categorical groups: those whose mother had breast cancer (group A, N = 176), those whose sister had breast cancer (group B, N = 34), and those whose mother and sister both had the disease (group C, N = 20). In addition, subjects were divided into two groups according to the psychological distress level.

RESULTS

Analysis of results (using ANOVA and a Chi square test for categorical variables and both univariate and multivariate procedures for psychological distress assessment) showed elevated levels of distress and persistent intrusive thoughts in all groups, and particularly in group C.

CONCLUSION

There is a need to promote genetic diagnostic and appropriate counseling, notwithstanding the potential risks that genetic counseling poses for such women.

Dental health behavior of children with BBTD treated using general anesthesia or sedation, and of their parents in a recall examination

The aim of the study was to assess the dental status and dental health behavior of children with Baby Bottle tooth Decay treated using general anesthesia or sedation, and the dental health behavior of their parents in a recall examination. The study population consisted of sixty-five children, among whom thirty-four were treated using general anesthesia and thirty-one using sedation. The recall examination included a full dental examination from which the children's dif index could be drawn. Loe's plaque index was used to assess the amount of plaque on the teeth. Sociodemographic information and the dental health behavior of the parents and children were obtained. Plaque index was similar in the general anesthesia and sedation groups. The parents of the general anesthesia group were younger than the parents of the sedation group (35.0 +/- 6.7 and 38.8 +/- 6.2 for the fathers, and 32.4 +/- 5.9 and 34.9 +/- 5.3 for the mother, respectively). More firstborn children were treated using general anesthesia than using sedation. Significantly more siblings were treated in the sedation group. Children treated using sedation had significantly more siblings treated in the same mode. Parents of the children in the general anesthesia group were significantly more involved in brushing their children's teeth than the other group. In the sedation group, more children brush their teeth without parental help. Significantly more children in the general anesthesia group reduced their sweet consumption than in the sedation group. We conclude that preventive behaviors were more frequently adopted among the families of children treated using general anesthesia.

The distribution of gentamicin in the rabbit cornea following iontophoresis to the central cornea

The purpose of this study was to evaluate the penetration of gentamicin into the central, midperipheral and peripheral cornea of rabbits following iontophoresis to the central 3 mm of the cornea. Four groups (groups 1-4) of five rabbits (one eye per rabbit) underwent corneal iontophoresis using gentamicin dissolved in agar. Low (1 mg/ml) and high (10 mg/ml) concentrations of gentamicin in agar were used for one or ten minutes. Two control groups (groups 5 and 6) of five eyes each underwent mock iontophoresis with low and high concentrations of agar-gentamicin mixture. Following sacrifice of the rabbits, the central, midperipheral and peripheral parts of each cornea were excised. Gentamicin concentration was determined in each part of every cornea. High concentrations of gentamicin (951.6 +/- 369.4 microg/ml to 26.6 +/- 41.34 microg/ml) were obtained in the central parts of all the iontophoresis-treated corneas. In each group, except group 6, central corneas had higher concentrations of gentamicin compared to midperipheral corneas (p = 0.038 to p = 0.021), and midperipheral corneas had higher levels than peripheral corneas (p = 0.038 to p = 0.021). Following iontophoresis, gentamicin is found in all portions of the corneas; however, the highest concentration of the drug remains in the central cornea.

Accumulation of Streptococcus mutans on light-cured composites and amalgam: an in vitro study

The aim of the in vitro study was to examine the accumulation of Streptococcus mutans on light-cured composite materials and amalgam. Bacteria cultures were grown in a brain heart infusion medium, and their growth rate was determined through turbidity measurements. The data, so obtained, were evaluated statistically by analysis of variance (ANOVA) followed by Scheffe test. Experiments on amalgam showed better results compared to those on composite materials. There were no statistically significant differences in plaque accumulation on different composite materials after finishing and polishing procedures, compared to plaque accumulation on composite materials against a Mylar strip.

Antibodies to cytomegalo and Epstein-Barr viruses in human saliva and gingival fluid

The prevalence of antibodies to EBV and CMV was studied in 34 samples of whole saliva and gingival crevicular fluids (GCF) obtained from clinically healthy volunteers and compared to the corresponding antibodies present in the serum of each individual. Higher prevalence of serum antibodies was found to EBV (85.2%) than to CMV (64.7%) (P < 0.04). The percentage of saliva samples containing IgG and/or IgA antibodies was not significantly different for the two viruses (79.4% for EBV and 58.8% for CMV). However, in the GCF the percentage to EBV was lower-32.3% as compared to 70.5% for CMV (P < 0.002). The prevalence of CMV in serum saliva and GCF was similar. However, while in the saliva similar levels of IgG and IgA were found, in the GCF IgA prevails. The picture for EBV is different: a similar percentage of antibodies was noticed in serum and saliva, but it was significantly lower in the GCF. However, antibodies to EBV were mostly IgA both in the saliva and the GCF. Although a similar number of samples were positive to both viruses in the saliva, the IgA response to EBV was higher than to CMV (P < 0.05), while in GCF IgA response was higher to CMV (P < 0.05). Passive transudation rather than active transport of plasma-derived Ig is probably responsible for the presence of IgG, while the IgA found in saliva and GCF is derived from local synthesis by plasma cells rather than from selective transport from blood.

Topical use of zinc desferrioxamine for corneal alkali injury in a rabbit model

PURPOSE

To evaluate the efficacy of topical zinc desferrioxamine in acute corneal alkali injury in rabbits.

METHODS

Twenty rabbits were anesthetized and a standardized alkali burn (1N NaOH) was performed in the center of the cornea (7.5-mm diameter). The animals were randomly divided into two groups and treated (double-masked) with topical zinc desferrioxamine, 220 microM, (group 1) or its vehicle (group 2). Drops were applied 7 times/day for 28 days. Topical gentamicin, 0.3%, was instilled twice a day. Animals were evaluated twice a week. At each examination (using the slit-lamp), the depth of corneal ulcer was graded as follows: 0, no ulcer; 1, tissue loss less than one third of corneal thickness; 2, one third to two thirds tissue loss; 3, more than two thirds tissue loss; 4, descemetocele; or 5, perforation. Ulceration area, vascularization, and epithelial defects also were measured.

RESULTS

During the study period, the grading of mean corneal ulcerations in group 1 ranged from 0.2 to 1.00, whereas in group 2, it ranged from 1.4 to 2.7. The mean grade and area of ulceration in group 2 were greater than those in group 1 (p < 0.05).

CONCLUSION

Topical zinc desferrioxamine may be an adjunctive treatment in protecting the cornea against induced alkali injury.

Efficacy of iontophoresis in the rat cornea

BACKGROUND

Iontophoresis can enhance penetration of drugs into tissues. We examined the extent of penetration of gentamicin into the cornea of rats during iontophoresis and the effect of varying the concentrations of gentamicin, the duration of iontophoresis and the current densities during iontophoresis.

METHODS

Eight groups of rats underwent corneal iontophoresis using gentamicin dissolved in agar. Low and high concentrations of gentamicin were used, as well as low and high current densities and long and short durations of iontophoresis. Control groups received topical or subconjunctival gentamicin, topical saline solution and mock iontophoresis with the agar-gentamicin mixture. The Mann-Whitney test was used for statistical evaluation.

RESULTS

Highly bactericidal concentrations of gentamicin were obtained in all the iontophoresis-treated corneas. The high concentration compared to the low concentration of gentamicin in agar significantly increased the concentration of gentamicin in the corneas, as did the longer duration of iontophoresis. However, higher current intensity did not significantly enhance the drug concentration in the cornea.

CONCLUSION

Iontophoresis with a concentrated gentamicin-agar mixture may provide a rapid increase of gentamicin levels in the cornea.

Fluoride and hard cheese exposure on etched enamel in neck-irradiated patients in situ

OBJECTIVES

The effect of a fluoride mouth rinse with hard cheese exposure was investigated on rehardening of an etched tooth enamel surface in subjects with radiation-induced hyposalivation in situ.

METHODS

Ten patients, six males and four females of mean age 48 years, irradiated with 30 Gy per week for neck and head cancer, volunteered for the present intraoral study. The unstimulated saliva flow rate varied between 0.01 and 0.15 ml min-1. Enamel slabs, approximately 2 mm x 2 mm in size, cut from human molar teeth were embedded in self-curing acrylic resin to fit a microhardness tester. Hardness measurements were carried out on the polished and subsequently etched enamel surface, rinsed for 1 min in the mouth with 10 ml Meridol (GABA INT), containing 0.025% F as amine fluoride and stannous fluoride, and exposed alternatively to mastication of 20 g cheddar cheese for 5 min.

RESULTS

Surface erosion of the enamel slabs decreased the mean hardness to a similar degree in all samples. The difference between the mean increased degrees of enamel microhardness following fluoride, fluoride and hard cheese, or repeated fluoride-cheese exposures was significant compared to the etched enamel values. The rate of rehardening derived from a second fluoride-cheese treatment was found to be improved significantly. It seems that the reduced saliva flow in xerostomic patients is sufficient to release bound calcium and phosphate from cheese products.

CONCLUSIONS

It is suggested that for xerostomic patients frequent exposures to low-fluoride solutions combined with hard cheese consumption may prevent and remineralize initial demineralization.

Coping with additional stresses: comparative study of healthy and cancer patient new immigrants

The adjustment and psychological distress of 166 cancer patients, who are new immigrants from the former Soviet Union, was assessed and compared to that of 288 healthy new immigrants from the the former Soviet Union. The healthy new immigrants had many adjustment problems and their psychological distress was fairly high. The cancer patients reported extremely severe psychological distress. In the healthy immigrants, age contributed to distress while family support had significant protective effects especially in the male immigrants. In the patients, these differences were even more extreme with family support being protective in the male group but not in the female group. Intrusiveness (IES) seems to be maladaptive adding to distress. The results clearly indicate that additional stresses, such as immigration, make cancer patients more vulnerable. The results also suggest possible interventions, especially those that will help to decrease intrusiveness.

Crossing new bridges: the process of adaptation and psychological distress of Russian immigrants in Israel

Between the end of 1989 and June 1992, 380,152 Russian Jews left the former Soviet Union for Israel, swelling Israel's Jewish population by nearly 10%. Absorbing great waves of immigrants was not new to Israel. Since its establishment in 1948 and the enactment of its Law of Return, large population groups from dozens of different ethnic and cultural backgrounds had immigrated into the country. In 1992 Israel's Jewish population totaled 4,242,500. Of that number, 360,949 had been born in Asian countries, 458,009 in Africa, 1,252,131 in Europe, and 184,317 in America and Oceana.

The impact of culture on perceptions of patient-physician satisfaction

One of the focal points of the present study was to gain further understanding about whether cultural differences among cancer patients influence the satisfaction of patients with their physicians. The study population comprised randomly selected ambulatory cancer patients at the Sharett Institute of Oncology. Of the 450 patients in the study, 200 were veteran Israelis and most of the other 250 patients were immigrants from the former Soviet Union who arrived in Israel during the past 4 years. Patients were asked to describe their physicians using an eight-item questionnaire, and then to describe their ideal physician using the same questionnaire. The discrepancy between the two descriptions--actual and ideal--represents patient satisfaction. Our findings show that satisfaction among the Russian patients was very high, with scarcely any discrepancy between actual and ideal physician. In the Israeli group, however, a substantial discrepancy was noted in all items. It can be concluded that the Israeli patients were far less satisfied with their physicians than were the Russian patients.

Umbilical cord fluoride serum levels may not reflect fetal fluoride status

OBJECTIVE

To evaluate the reliability of fluoride levels in the umbilical cord as reflecting neonate fluoride status.

DESIGN

Prospective study of fluoride levels of pregnant women at term and their neonates.

SETTING

Delivery room and maternity unite of Hadassah Hospital Mount Scopus.

PATIENTS

Fluoride serum levels were determined in the sera of 20 women with normal pregnancies at term, during delivery, in the corresponding mixed cord sera and neonatal sera at 24 hours after delivery.

RESULTS

The mean maternal fluoride serum level was 0.0303 microgram/ml (SD 9.015), mean cord fluoride serum level 0.0183 microgram/ml (SD 0.012), and mean neonatal fluoride serum 0.0380 microgram/ml (SD 0.016).

CONCLUSION

The significantly (p < 0.001) low mixed cord serum levels of fluoride as compared with neonatal and maternal serum levels may be explained by placental sequestration of fluoride. It is suggested that cord serum fluoride levels to not reflect fetal fluoride status.

Psychological distress in female cancer patients with Holocaust experience

This study examined whether severe emotional and physical trauma in the past affects the psychological condition of female patients currently afflicted with cancer. Using the Brief Symptom Inventory (BSI), 41 women with cancer, who had sustained extreme trauma during the Nazi Holocaust of the midcentury, were compared with three different groups: a matched group of cancer patients without Holocaust experience, a physically healthy group of female Holocaust survivors, and healthy women without a Holocaust past. Although psychological distress was comparable in the two healthy groups, it was far higher in Holocaust cancer patients than in either their non-Holocaust counterparts or in the group of healthy Holocaust survivors. These results may suggest that the severe trauma of the Holocaust could be responsible for markedly diminished psychological response when such patients are confronted with new stress.

Breast feeding in Israel: maternal factors associated with choice and duration

STUDY OBJECTIVES

To determine the influence of maternal characteristics on the incidence and duration of breast feeding.

DESIGN

All the women who delivered in three obstetric wards within a two year period were surveyed. These three wards cover 93% of all births in the Jerusalem district. Women were interviewed on breast feeding of the previous child on the first or second day post partum by a research nurse.

PARTICIPANTS

Altogether 8486 women whose previous pregnancy had resulted in a live born singleton who survived for at least one year.

MEASUREMENTS AND MAIN RESULTS

Breast feeding information was linked to demographic and health information from hospital records. Using logistic regression analysis, failure to start breast feeding was best predicted (p < 0.001) by caesarean delivery, infant's birth weight, maternal smoking habits, and mother being non-immigrant. Maternal age (< 24 or > 40 years) and father being an ultraorthodox Jew were also positively (p < 0.05) associated with the decision to breast feed. Long term breast feeding (three months or more) was strongly affected (p < 0.001) by maternal education level, with both women with the fewest and the greatest number of years of schooling more likely to breast feed. A similar association was observed in all ethnic groups. Primipara and grandmultipara (parity > 4), new immigrants, ultraorthodox Jews, and non-smokers breast fed their babies for longer.

CONCLUSIONS

The importance of maternal characteristics in relation to breast feeding was shown. Caesarean delivery and the infant's birth weight were strongly related to the decision to breast feed as were the demographic characteristics of mother's age and her country of birth. Education was not related to this decision but was strongly associated with the duration of breast feeding, as was parity. The behavioural characteristics of smoking and being ultraorthodox were related to both the decision to start and the duration of breast feeding. Efforts to encourage breast feeding ought to be targeted during the hospital stay and post partum period towards women identified as being at increased risk.

High concentration of soluble interleukin-2 receptors in ejaculate with low sperm motility

The various cytokines are involved in infection and immunological reactions and thus may be involved in impairment of sperm function. The present study determined the concentrations of interleukin-1, interleukin-6 and soluble interleukin-2 receptors in ejaculates of normal donors and patients suffering from pure asthenozoospermia and patients suffering from oligoteratoasthenozoospermia. Ejaculates of patients attending the fertility clinic in Hadassah Mount Scopus Hospital, Israel, were evaluated. The patients were divided into three groups: (i) controls (n = 20), (ii) pure asthenozoospermia (n = 30), (iii) oligoteratoasthenozoospermia (n = 36). Significantly higher concentrations of soluble interleukin-2 receptors were found in the ejaculates of patients with pure asthenozoospermia 2243.1 +/- 473.6 mu/ml (mean +/- SE) as compared with controls 673.5 +/- 281.3 mu/ml (P < 0.05) and oligoteratoasthenozoospermic patients 1012.3 +/- 206.9 mu/ml (P < 0.05). Interleukin-1 and interleukin-6 concentrations were comparable in all groups studied. Our results show that human ejaculates contain interleukin-1, interleukin-6 and soluble interleukin-2 receptors. High concentrations of soluble interleukin-2 receptors in the ejaculates of asthenozoospermic patients may be related to either infectious or immunological processes.

Prevalence of viral antibodies in gingival crevicular fluid

The prevalence of antibodies to CMV, Mumps and Coxsackie virus strains 1, 3 and 4 was studied in 39 samples of gingival crevicular fluids (GCF) obtained from clinical healthy patients and compared to the corresponding antibodies present in the serum of each individual. In spite of the high prevalence of humoral antibodies to CMV (75%), only 24% of the gingival crevicular fluid samples exhibited IgG or IgA antibodies to this virus. The differences in the prevalence of antibodies against Mumps virus in the sera and GCF were even greater: whereas 87% of the patients exhibited serum antibodies, not even a single gingival fluid sample was found to be positive. Antibodies to Coxsackie B strains 1, 3 and 4 were found in 72%, 63% and 52% of the sera and in 25%, 19% and 33% of the gingival fluid samples (IgG only). The presence of the antibodies and their profile in GCF and serum is different. The mechanism of possible permeation is not clear but it seems that viral antibodies in this milieu are not derived from the serum solely by passive transudation, and that the antibodies are produced locally at least in some of the GCF specimens.

Ultrasound transmission gel in the vagina can impair sperm motility

The effect of ultrasound transmission gel on sperm motility was assessed because of a few unsatisfactory post-coital tests, encountered after vaginal ultrasonography in otherwise normal couples. Swim-up samples of spermatozoa from donors and patients with asthenozoospermia were incubated in ultrasonic transmission gel at various concentrations. Sperm progressive motility and viability were checked. Donor sperm progressive motility declined from 90.9 +/- 2.5% (mean +/- SD) to 30.6 +/- 2.7% (P < or = 0.001) within 18 h at a gel concentration of only 10% (by volume). There were no progressive motile spermatozoa after incubation in 80% gel. In the swim-up fraction from asthenozoospermic patients, motility declined from 92.2 +/- 2.5% to 11.6 +/- 2.1% (P < or = 0.001) within 130 min at a gel concentration of 10% (by volume). Eosin staining for viability demonstrated that the loss of motility was mostly due to loss of viability. The use of ultrasound transmission gel should be avoided during follicular follow-up close to the date of expected ovulation in couples who practise dated natural intercourse or cervical insemination. Normal saline is an adequate substitute in this period with relatively large follicles.

The pattern of serum melatonin levels during ovarian stimulation for in vitro fertilization

OBJECTIVE

To characterize the relationship between the pineal gland hormone, melatonin, and gonadal hormones.

METHODS

We studied the pattern of serum melatonin at the time of ovarian stimulation for in vitro fertilization. Blood samples were obtained every morning, from 20 healthy women during the in vitro fertilization cycle.

RESULTS

A progressive rise in serum estradiol and prolactin was noted in all IVF cycles, while serum melatonin levels remained unchanged throughout the cycles. In two of the subjects the circadian rhythm of serum melatonin was assessed at 4-hour intervals for 24 hours. In both subjects the melatonin rhythm was remarkably consistent in terms of phase, amplitude, and total melatonin secreted during the treatment cycles.

CONCLUSIONS

These results indicate that endogenous estradiol, progesterone, and prolactin do not affect the levels or circadian phase of melatonin secretion in humans.

[Epidemiology of Hansen's disease in Israel]

There are currently 200 patients with Hansen's disease in Israel who are being followed by the Hansen's Disease Government Hospital and the Ministry of Health (prevalence 4.4/100,000). Most of them immigrated from countries where the disease is endemic. Dermatological findings dominated the initial clinical picture, although 5% of patients are asymptomatic contacts of known cases. Age at onset of disease was less than 20 years in 1/4 of the cases. The incidence in Israel is falling: 0.4/100,000 in 1985-89 compared to 3.6/100,000 in 1950-54. Neurologic and dermatologic findings in an immigrant of any age originating from countries where Hansen's disease is endemic, should prompt appropriate diagnostic evaluation, even years after immigration to Israel. Contacts of known cases of Hansen's disease should be aggressively screened, even if asymptomatic.

Efficacy of doxycycline and tetracycline in ocular rosacea

We compared the effects of doxycycline and tetracycline hydrochloride on the subjective symptoms in ocular rosacea. Twenty-four patients with symptomatic ocular rosacea were randomly assigned to two groups and treated with doxycycline 100 mg/day (group 1, 16 patients) or tetracycline hydrochloride 1 g/day (group 2, eight patients). The dosages of each drug were gradually tapered and discontinued according to symptomatic response. At each examination all the manifesting symptoms were scored by the patients. Patients were followed up from six weeks to three years. After six weeks of drug treatment, all patients except one had symptomatic improvement. Although most of the scores of the symptoms were significantly decreased in both groups, greater symptomatic relief occurred in the tetracycline hydrochloride-treated patients (P = .041). However, after three months of treatment there was no significant difference in symptoms between the two groups. Gastrointestinal tract complications occurred in two of the 16 patients (12.5%) in group 1 and in three of the eight patients (37.5%) in group 2. Both tetracycline hydrochloride and doxycycline can control the symptoms of ocular rosacea.

Effect of eye patching on ocular surface

We studied the effect of pressure patching in 27 medical students. Fourteen students had pressure patching in one eye (group 1) and 13 (group 2) had light patching. The fellow eye of each volunteer remained unpatched (group 3). Clinical signs and symptoms were scored and evaluated at the first and the following (after overnight) examinations. Before patching no subject had any of the clinical signs or symptoms. After the patch was removed in groups 1 and 2, all except one volunteer in each group had clinical signs or symptoms, or both, whereas in group 3, none had clinical signs or symptoms. Group 1 had greater scores for clinical signs (P = .019) and for symptoms (P = .038) as compared to group 2. In group 1, two participants did not complete the study period (by removal of the patch) because of severe discomfort and three had temporary irregularities in corneal surface with temporary decrease of vision. We suggest that pressure patching may cause discomfort and changes in visual acuity that are usually attributed to other reasons.

Prevention strategy of hepatitis B virus infection among the Ethiopian community in Israel

Between 1980 and 1985, over 16,000 immigrants from Ethiopia, a population at high risk for hepatitis B virus (HBV) infection, arrived in Israel. The present study was designed to provide epidemiological information necessary for developing prevention strategies against HBV infection. Among the 144 subjects studied in an absorption center in Israel, only 32% had no detectable HBV markers and were therefore susceptible to infection. The prevalence rate of HBsAg was 19% compared with 42% for anti-HBs and 7.6% for anti-HBc alone. The percentage of subjects with no HBV marker decreased sharply with age, and there was similarly an age-linked increase in anti-HBs, indicating the importance of horizontal transmission in HBV infection. The distribution of HBV markers was similar in both sexes. Evidence of mild liver disease was found in only three subjects. All newborns and new arrivals less than 2 years of age in the Ethiopian community are vaccinated against HBV infection to prevent vertical and early horizontal transmission. The data obtained in our study suggest that this means of prevention of HBV infection is insufficient. We suggest that the vaccination of all children aged 2-7 without prevaccination screening, and the vaccination of children aged 8-18 found to be susceptible on anti-HBc screening, would substantially lower HBV transmission in this community.

Effect of maternal smoking and age on congenital anomalies

The incidence of congenital anomalies was examined by the level of maternal and paternal smoking during pregnancy for 17,152 infants. A multiple regression analysis was used to control for the possible confounding effects of maternal age, formal education, ethnic origin, religion, marital status, parity, social class, and work outside the home. Neither maternal nor paternal smoking habits were significantly associated with the occurrence of congenital malformations. Maternal age was significantly (P less than .005) related to the incidence of major anomalies. Mothers aged 35 years and older who smoked were found to have a significantly (P less than .002) higher risk for minor malformations and a nonsignificantly increased rate of major malformations. Maternal cigarette smoking may be an important preventable risk factor for congenital anomalies among mothers aged 35 years or older.

Breast cancer screening in Tel Aviv

Optimal breast cancer screening includes both physical examination and mammography. In anticipation of the addition of routine mammographic screening to Israel's 25-year-old early breast cancer detection program, we examined the demographic characteristics of almost one thousand women attending a breast cancer screening examination in Tel Aviv for the first time. The specific objective of the survey was to see whether women attending screening were those who stood a good chance of benefiting from it. Only half the women were aged 40 or older, and there was a preponderance of women of Western origin. Almost half had a breast-related complaint at the time of the visit. Targeted public education and appropriate administrative measures are necessary to ensure that women who can benefit from screening attend screening clinics and that clinics are not filled to capacity by women needing diagnostic evaluation and followup rather than routine screening. Tel Aviv general practitioners appeared to be aware of the advantages of breast cancer screening.

The effect of abortion on the incidence of pre-eclampsia

The incidence of pre-eclampsia was studied in 9771 women that were pregnant for the first or second time. The protection offered by a previous pregnancy which ended in abortion was compared to that provided by a first pregnancy that proceeded to term. The rate of pre-eclampsia was 2.9% for primigravid women and was significantly lower (1.5%, p less than 0.001) for women giving birth for the second time. Adjusting by multiple regression for confounding factors (e.g., maternal age, social class, ethnic origin and smoking), the incidence of pre-eclampsia was also significantly lower (p = 0.038) following an induced abortion, but not following a spontaneous abortion.

The effect of maternal weight gain in pregnancy on birth weight

The association between maternal weight gain during pregnancy and the infant's birth weight was studied in 14,121 term singleton births. The parturients were stratified into four body-mass categories, three age groups, four parity groups, and three levels of educational attainment. A separate multiple regression analysis was performed for each category to control for the confounding effect of gestational age, maternal social class, ethnicity, cigarette consumption, marital status, age, parity, education, and weight for height. A significant positive influence of prenatal weight gain on birth weight was found for all subgroups. The effect varied depending on maternal pre-pregnancy body mass, age, parity, and the level of formal education.

Child-bearing after induced abortion: reassessment of risk

We reviewed 1791 singleton pregnancies of women with a history of previous induced abortion and compared them with 14,857 pregnancies in mothers with no previous induced abortions. Therapeutic termination of pregnancy was associated with a statistically significant increase in the incidence of low birth weight infants and bleeding in the first trimester of pregnancy. When other variables were examined, no significant differences were found between the two groups, except for a significantly higher rate of stillbirths among women who had not had a prior induced abortion. There were no increases in major or minor congenital malformations.

Birth order and birth weight reexamined

We studied the longitudinal association of birth order and birth weight in two series of very large sibships, each consisting of at least seven children, and compared the findings with those based on analysis of cross-sectional data from a large population-based survey, the Jerusalem Perinatal Study. The birth weights of the cross-sectional sample were adjusted by multiple linear regression for a number of factors known to confound cross-sectional studies, including maternal age, education, marital status, religion, smoking, height and prepregnant weight, gestational age, and sex of the newborn. Birth weight increased with increasing birth order in both adjusted cross-sectional and socioeconomically homogeneous longitudinal data.

Crown size asymmetry in males with fra (X) or Martin-Bell syndrome

We measured the mesio-distal and bucco-lingual crown diameters of 13 males with the fra(X) or Martin-Bell syndrome. Fluctuating crown-size asymmetry was calculated and compared with values obtained in normal Caucasian children and also with a sample of 19 males with Down syndrome. A statistically significant increased asymmetry was found in the fra(X) males when compared to normal control individuals. In the maxilla, Down syndrome males showed a significantly higher tooth crown asymmetry than fra(X) males. (less than 0.02); in the mandible, no significant differences were found between the 2 groups. It is suggested that crown size asymmetry be included in the evaluation of fra(X) males.

Maternal and fetal serum levels of organochlorine compounds in cases of premature rupture of membranes

Blood residue levels of some organochlorine pesticides (DDT and its analogues, lindane, dieldrin, heptachlor epoxide) and polychlorinated biphenyls were measured in maternal and cord blood in 20 cases of premature rupture of fetal membranes at term and in 15 matched controls. No evidence of a possible organochlorine compounds role in the pathogenesis of premature rupture of the membrane was found.

Accuracy of mothers' recall of birthweight and gestational age

Information on the birthweight and gestational age of previous siblings is usually dependent upon maternal recall. This information is of importance in assessing the current risk of perinatal morbidity and mortality. The validity of maternal recall of birthweight and gestational age of 880 children born to 97 multiparas was examined by comparison with hospital records. About 75% of all reported birthweights were accurate to within 100 g and a similar proportion of reported gestational ages was correct to within 1 week. Recall was most accurate for most recent births as well as for earliest births and was not related to maternal age or education. There was a tendency for the smallness of low birthweight infants to be exaggerated by mothers. We conclude that within defined limitations, maternal recall of birthweight and gestational age of previous children is sufficiently accurate for clinical and even for epidemiological use.

Does grand multiparity affect fetal outcome?

Low birthweight and stillbirth rates of 16,647 Jerusalem deliveries were examined by birth-order comparing longitudinal to cross-sectional data. Six hundred fifty-seven complete sibships of 7 or more were assessed, including 95 sibships from the socio-economically homogeneous ultraorthodox Jewish community of Mea Shearim. In both cross-sectional and longitudinal studies grandmultiparas were not at increased risk for low birthweight, but did have a higher frequency of stillbirths.

Need for urgent medical care in a Jerusalem neighborhood: a population-based study

We conducted a population-based survey of an urban community in Jerusalem to estimate the incidence of urgent and emergency medical events and to characterize the response of the populace to various medical episodes. We found deficiencies in the ability of the population to identify an urgent event, resulting in long delays in seeking professional care, as well as inappropriate choice of source of care, in a substantial proportion of subjects. These deficiencies can and should be corrected by inexpensive educational programs.

Risk factors for coronary artery disease in 124 Jerusalem medical students

As part of an epidemiologic teaching exercise, we studied coronary risk factors in two consecutive classes of Jerusalem medical students (n = 124) and calculated a summary coronary risk score for each student. Men were at higher risk than women because of greater body mass, higher blood pressure and more cigarette smoking. Married males were at lower risk than single males because they had lower cholesterol levels and smoked less. Married and single females were at equal risk. Jerusalem students smoked more than most groups of American medical students and less than their European counterparts. There is reason to believe that an exercise of this kind may result in risk-reducing behavior on the part of high-risk students.

Recruitment of subjects for fecal occult blood screening: a comparison of two methods in Jerusalem

Two approaches to the recruitment of subjects for screening for fecal occult blood were tested in two middle-class neighborhoods in Jerusalem. After invitations were mailed to 2,909 persons aged 40 and older, 855 (29%) requested the special "Colo-Screen" packet of slides; and 496, one-sixth of those contacted originally, ultimately returned stool specimens for examination. In a parallel campaign by family doctors, invitations were distributed personally to 324 patients visiting a Sick Fund Clinic; 225 (69%) requested Colo-Screen slides and 137 (42% of the persons invited) sent in stool specimens. Males and females responded equally. Of the 633 specimens received, 29 (4.6%) were positive for occult blood; two cancers and seven adenomatous polyps were found and resected. Screening programs for colorectal cancer should encourage greater personal participation of family doctors in the recruitment process.

Emergency department utilization during a doctors' strike

Emergency department (ED) patient volume at Jerusalem's Shaare Zedek Hospital was 33% higher during the 1983 doctors' strike as compared with the same period in 1982. Excess visits were recorded for both sexes (P less than 0.0001), but there were many more excess visits by females than males. The largest increase in visits by adults (60-70%) was in persons aged 40-64 years (P less than 0.02), and there was also a large and unexplained increase in ED visits by girls under age 6 (P less than 0.0003). In contrast to excess ED visits, which were higher during the strike for both sexes, excess hospital admissions via the ED were recorded only among females (P = 0.007). The number of ED visits during the strike was increased on all three hospital work shifts (P less than 0.0001), with the greatest number of excess visits occurring between 7 AM and 3 PM.

Health expenditure under multiple-priority pressures. A case study of Israel

Since Israel's inception, it has faced many problems that have a high priority in the national consciousness. Problems of defense and national security are outstanding among these, and problems such as absorption of immigrants, education, land reclamation and water supply are next. This creates heavy pressure on scarce resources, and is reflected in the share of specific items in Government and national expenditures. An analysis of developments since the early 1950s shows how health expenditure has been given a high priority in the evaluation of the nation's needs on one hand, and has been influenced by defense needs and other pressing requests on the other hand. It may be concluded that health receives a fair share of the nation's resources, but, in view of the strained economic situation in the country, careful planning for future health services in coordination, cooperation and integration with other welfare services is essential.