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BACKGROUND There are no published large-scale epidemiologic studies regarding the prevalence of skin diseases in patients with selective immunoglobulin A (IgA) deficiency (sIgAD). The purpose of this study was to investigate the prevalence of dermatological diseases in patients with sIgAD. METHODS This retrospective matched case-control study was based on data from the Leumit Healthcare Services data base (approximately 725,000 residents of Israel), which was searched for all subjects aged ≥12 years who had undergone serum total IgA measurements during 2004-14 for any reason. The case group included subjects with sIgAD. The control A group was randomly sampled from those subjects in whom an IgA was drawn (n ≈ 725,000), with a ratio of 10 controls for every case (1:10). The control A group was randomly sampled from those subjects in whom an IgA was drawn (n = 104,729) and the control B group was randomly sampled from the full study population (n ≈ 725,000), with a ratio of 10 controls for every case (1:10). Comorbidity was compared between the study groups. RESULTS The sIgAD group was characterized: 1) By a higher prevalence of atopic dermatitis (AD) (16 [4.6 %]) than the control A group (76 [2.1 %]; p = 0.004 and the control B group (64 [1.9 %]; p = 0.002). 2) By higher prevalence of acne (69 [19.9 %]) than the control A group (516 [13.8 %]; p = 0.013) and control B group (494 [14.2 %]; p < 0.001). 3) By higher rate of chronic spontaneous urticaria (CSU) (17 [4.9 %)] than in the control A group (31 [0.9 %], with odds ratio 5.54 [3.04-10.13]; p < 0.001) and the control B group (28 [0.8 %]; p < 0.001). CONCLUSIONS sIgAD is characterized by a higher prevalence of AD, CSU and acne.

The human body interacts with the environment mainly through three major tissues: the lungs, skin, and gastrointestinal (GI) tract. In each one, an intensive nervous network is present, conjugated with abundant mast cells (MC). While MC-mediated disorders in airways and the skin are extensively discussed, MC-mediated disorders of the GI tract remain relatively uncommon. Since the GI tract is one of the three main environment-interacting tissues, it is reasonable that MC-mediated disorders of the GI may have the same weight and impact as asthma or chronic urticaria (CU). This article is protected by copyright. All rights reserved.

Background Emerging evidence suggests that chronic urticaria (CU) is associated with chronic, low grade, inflammatory process. Objective To evaluate the association between CU and metabolic syndrome and its components in a large community-based medical database. Methods A cross-sectional study of CU patients and matched controls was performed. CU was defined as eight urticaria diagnoses (with each two diagnoses registered within a period of six weeks) from 2002 to 2012. Data regarding the prevalence of metabolic syndrome, its components, and possible complications were collected. Results The study included 11,261 patients with CU and 67,216 controls. In a univariate analysis, CU was significantly associated with higher body mass index (BMI) and a higher prevalence of obesity, diabetes, hyperlipidemia, hypertension, metabolic syndrome, chronic renal failure, and gout. Multivariate analysis demonstrated a significant association between CU and metabolic syndrome (OR = 1.12, 95% CI 1.1-1.2, p < 0.001) and its components- obesity (OR = 1.2, 95% CI 1.1-1.3, p < 0.001), diabetes (OR = 1.08, 95% CI 1.01-1.15, p = 0.001), hyperlipidemia (OR = 1.2, 95% CI 1.1-1.2, p < 0.001), and hypertension (OR = 1.1, 95% CI 1.1-1.2, p < 0.001). Conclusions CU patients may have one or more undiagnosed components of metabolic syndrome despite their young age. Thus, appropriate targeted screening is advised. This article is protected by copyright. All rights reserved.

Background Data on the health care utilization of patients with hidradenitis suppurativa (HS) in primary care settings are scarce. Objective To investigate the health care service utilization of patients with HS. Methods In a cross-sectional study, patients with HS were compared with 2 age- and sex-matched control groups—general population enrollees of Clalit Health Services and a group of patients with psoriasis. Health care services data included inpatient and outpatient community clinic visits and pharmacy claims for topical and systemic treatments. Multivariate analysis of the data for patients with HS and controls was performed. Results The study included 4417 patients with HS, 22,085 general population enrollees, and 4417 patients with psoriasis. On the basis of multivariate analyses, patients with HS had more annual dermatology clinic visits compared with the general population enrollees (odds ratio [OR], 6.49; 95% confidence interval [CI], 7.06-5.97) and patients with psoriasis (OR, 1.32; 95% CI, 1.44-1.21), more annual surgical clinic visits (OR, 3.78; 95% CI 3.28-4.36 and OR, 1.65; 95% CI, 1.42-1.91, respectively), and more hospitalizations (OR, 2.21; 95% CI, 1.89-2.56 and OR, 1.51; 95% CI, 1.28-1.78, respectively). Limitations Underestimation of HS frequency was possible. Conclusions The burden on health care systems due to patients with HS is greater than that due to patients with psoriasis and the general population.

Selective IgE deficiency (IgED) is currently defined as a significant decrease in serum levels of IgE (

Rituximab has recently been reported in retrospective studies to be effective in pemphigus at the dosing schedule used for treating rheumatoid arthritis (RA) of two 1,000 mg infusions 2 weeks apart. While the effect of rituximab on B cells has been well described, its effect on global T cell function has not been assessed. Ten patients who received RA dosage rituximab were prospectively assessed for clinical response. Immunological response including autoantibody titers, CD20+ B cell, and CD4+ T cell counts was assessed pre- and post-treatment. The CD4+ T cell function was determined by a novel assay measuring intracellular ATP levels in response to mitogenic stimulus. At 6 months, 90 % of patients achieved remission. Disease control and remission were achieved at median times of 1 and 3.7 months, respectively. There was a 67 % relapse rate during an average follow-up of 22 months. Global CD4+ T cell numbers and function were preserved 3 months after rituximab. A single cycle of RA dosage rituximab with concomitant immunosuppression is effective in pemphigus. We did not find an effect on total CD4+ T cell numbers or function 3 months after treatment.

Chronic urticaria (CU) and atopic disorders such as atopic dermatitis (AD), allergic rhinoconjunctivitis (AR), and asthma are related to aberrant immune function. The relationship between atopic disorders and CU is controversial, mostly since epidemiological data are lacking. The aim of our study was to investigate the association between CU and asthma, AD, and AR using a database of Clalit Health Services (CHS) - the largest healthcare provider organization in Israel. This article is protected by copyright. All rights reserved.

Non-attendance for scheduled appointments is common in many medical specialties. However, there are no published reports on non-attendance in pediatric allergy clinics. We investigated the factors for non-attendance in pediatric allergy patients. We assessed the effects of age, gender, ethnic origin, waiting time for an appointment and the timing of the appointment on non-attendance proportions. Chi-square tests were used to analyze statistically significant differences of categorical variables. Logistic regression models were used for multivariate analyses. A total of 442 visits in a 21-month period were included in the study. The overall proportion of non-attendance at the pediatric allergy clinic was 33.0%. Jewish rural patients had 19.4% non-attendance; Jewish urban patients had 35.6% non-attendance; and Bedouin patients had 57.1% non-attendance (p < 0.001). Non-attendance was higher in spring and winter (43.5% and 36.7%, respectively) than in summer and autumn (26.9% and 26.5%, respectively) (p = 0.016). Non-attendance was not significantly influenced by gender, age, hour of the appointment or waiting time for the appointment. A multivariate logistic regression model demonstrated that the ethnic origin of the patients and the season of the year were significantly associated with non-attendance. We conclude that in children attending allergy clinics, factors that determine non-attendance include the ethnic origin of the patients and the season of the year.

Background Previous reports have shown an association between psoriasis and the metabolic syndrome, but there are only a few studies on the association between psoriasis and diabetes. Objectives To study the association between psoriasis and diabetes. Methods A cross-sectional study was performed utilizing the database of Clalit Health Services (CHS). Patients who were diagnosed with psoriasis were compared with CHS enrolees without psoriasis regarding the prevalence of diabetes. Patients with diabetes were identified using the CHS chronic diseases registry. Chi-squared tests were used to compare categorical parameters. Logistic regression models were used for multivariate analyses. Results The study included 16 851 patients with psoriasis and 74 987 subjects without psoriasis (control patients). The proportion of diabetes was significantly higher in patients above 35 years (P

During the last 20 years, a dramatic increase in antibiotic resistance among pneumococci has been observed and linked to increasing antibiotic consumption [1-4]. Several studies have suggested that reduction in antibiotic consumption leads to a reduction in the antibiotic resistance of Streptococcus pneumoniae in the community [2, 5-7]. However, other studies could not demonstrate such an effect [8-10]. The relationship between antibiotic consumption and resistance is complex. Some antimicrobial agents select resistant pneumococcal strains more effectively than others [8, 11-15]. Moreover, the rate of the decrease in resistance expected after a decrease in antibiotic use depends on both the fitness cost of resistance for the bacteria and the extent of the reduction in consumption [16, 17]. If fitness cost is minimal or if the reduction in antibiotic use is small, antibiotic resistance may continue increasing, albeit perhaps more slowly, or it may decline gradually. However, if resistance exacts a strong fitness cost (with respect to transmissibility) on the bacteria, then a quick and significant decrease in resistance would be expected after a major decrease in antibiotic consumption [18]. A recent study in rats suggested that penicillin resistance in S. pneumoniae, particularly high-level resistance, carries a substantial fitness cost [19]. Another recent study showed a fitness cost of fluoroquinolone-resistant mutants of S. pneumoniae [20]. A complicating factor is the presence of dual and multiple resistance, because reduction mainly in the use of a single antibiotic may not result in the expected reduction in resistance, because of coselection of resistance caused by the continued use of other antibiotics [18]. Surveillance of antibiotic prescriptions in children

Background: Previous reports have shown an association between inflammatory diseases such as systemic lupus erythematosus or rheumatoid arthritis and the metabolic syndrome. Recent data demonstrate that psoriasis is an inflammatory disease, suggesting that psoriasis may be one of the components of the metabolic syndrome. Objective: To assess the association between psoriasis and the metabolic syndrome. Methods: A cross-sectional study was performed utilizing the database of the Clalit Health Services. Case patients were defined as patients with a diagnosis of psoriasis vulgaris. Controls were randomly selected from the list of Clalit Health Services enrollees. The proportions of components of the metabolic syndrome (ischemic heart disease, hypertension, diabetes, obesity and dyslipidemia) were compared between case and control patients by univariate analyses. χ2 tests were used to compare categorical parameters between the groups. Logistic and linear regression models served to measure the association between psoriasis and the metabolic syndrome. Results: The study included 16,851 patients with psoriasis and 48,681 controls. In the case group, there were 8,449 men (50.1%) and 8,402 women (49.9%), with a mean age of 42.7 years (SD = 20.3, range = 2–111). Diabetes mellitus was present in 13.8% of the patients with psoriasis as compared to 7.3% of the controls (p < 0.001). Hypertension occurred in 27.5% of the patients with psoriasis and in 14.4% of the controls (p < 0.001). Obesity was present in 8.4% of the patients with psoriasis as opposed to 3.6% of the controls (p < 0.001). Ischemic heart disease was observed in 14.2% of the patients with psoriasis as compared to 7.1% of the controls (p < 0.001). Multivariate models adjusting for age, gender and smoking status of the patients demonstrated that psoriasis was associated with the metabolic syndrome (OR = 1.3, 95% CI = 1.1–1.4), ischemic heart disease (OR = 1.1, 95% CI = 1.0–1.2), diabetes mellitus (OR = 1.2, 95% CI = 1.0–1.3), hypertension (OR = 1.3, 95% CI = 1.2–1.5) and obesity (OR = 1.7, 95% CI = 1.5–1.9). Limitations: The study is designed as a case-control study, thus an association alone was proven and not causality. Conclusion: Our findings demonstrate a possible association between psoriasis and the metabolic syndrome. Appropriate treatment of the metabolic syndrome may be an important part of the management of patients with psoriasis.

Monilethrix is a structural defect of the hair shaft usually inherited in an autosomal dominant fashion and caused by mutations in the hHb1, hHb3, and hHb6 keratin genes. Autosomal recessive inheritance in this disease has been sporadically reported. We encountered 12 Jewish families from Iraq, Iran, and Morocco with microscopic findings of monilethrix, but with no evidence of vertical transmission. Since no mutations were found in these three hair keratin genes, we examined nine chromosomal regions containing gene clusters encoding skin and hair genes. On chromosome 18q, a common haplotype in the homozygous state was found among all seven Iraqi patients, but not in 20 controls (P

Background Early diagnosis and treatment of depression are of vital importance in dermatological patients. Objective Our purpose was to evaluate the prevalence of depression among patients visiting a dermatology clinic in southern Israel. Methods Patients who visited the dermatology clinic were interviewed using the Mini International Neuropsychiatric Interview screening tool. Results The study included 384 patients. The screening questionnaire identified 37 patients (9.6%) with major depression, 3 patients (0.8%) with minor depression, and 74 patients (19.3%) with depressive symptoms. Higher prevalence of depression was found among widowers, among divorced or separated patients, and in unemployed patients. Depression was significantly associated with the perception of severity and suffering induced by the skin diseases. Limitations The study was conducted in a cross-sectional design. To confirm causality, a longitudinal study should be conducted. Conclusion Depression should be a consideration by dermatologists in the effective management of skin diseases.

Inappropriate laboratory ordering is a problem affecting medical systems worldwide. An intervention was called for as a result of increasing laboratory costs. Thus, we aimed to assess the impact of introducing computerized laboratory routines to a computerized primary care setting. The study included 380 primary care physician practices of Clalit Health Service (HMO) southern district (CHS-SD) in Israel, caring for 470,000 members. Consensus laboratory routines order sets were electronically introduced into all physicians' computerized medical record (CMR) software, after consensus and internal marketing process. The primary findings were that a previously observed annual increase in laboratory test utilization was stopped, a 2% reduction in total number of tests and a 4 % reduction in the total number of tests per age adjusted person was observed. In conclusion the wide use of CMRs and communication technology combined with an appropriate organizational process can be used to increase appropriate utilization of laboratory tests.

Background Tinea pedis is a common infection in soldiers. However, prevalence and risk factors for tinea pedis in soldiers were investigated in only a few studies. Objectives To investigate the prevalence and risk factors for tinea pedis in Israeli soldiers. Methods A cross-sectional study including interviews, clinical skin examination and mycological tests was performed in Israeli soldiers. The presence of tinea pedis was assessed using the Athlete's Foot Severity Index (AFSI), a scoring system that was developed in order to evaluate the presence and severity of tinea pedis. In soldiers with clinical evidence of tinea pedis (AFSI > 1), scrapings were taken for direct microscopic examination (20% KOH preparation) and fungal culture. Statistical analyses were performed using chi-square or Fisher's exact test for dichotomous variables (as needed), or t-tests for continuous variables. Logistic regression was used for multivariate analyses of dichotomous variables. Results Two hundred and twenty-three soldiers were included in the study: 205 men (91.9%) and 18 women (8.1%). Mean age was 19.6 years (SD 1.0 year). Clinical point prevalence was 60.1%. Mycological point prevalence was 27.3%. Further analyses were performed using the clinical point prevalence. Univariate analyses demonstrated that the prevalence of tinea pedis varied with the setting of military training (basic training: 70.3%, advanced infantry training: 81.5%, armor commander training: 56.4% and armor officer training: 34.8%) and was associated with male gender, frequency of sock changes and the length of military service. A multivariate analysis demonstrated that tinea pedis was associated with the setting of the military training (OR 1.6, 95% CI 1.2–2.1) and male gender (OR 4.3, 95% CI 1.4–13.8); however, there was no association with hygiene measures (e.g. frequency of changing socks or sleeping with socks) or the length of military service. Conclusion Tinea pedis is highly prevalent in Israeli soldiers. Association of tinea pedis with the setting of military training suggests that contagious spread may be an important risk factor. We suggest that environmental interventions should be planned to in order to decrease the morbidity of tinea pedis among soldiers.

Intake of drugs is considered a risk factor for psoriasis. The aim of this study was to investigate the association between drugs and psoriasis. A case-control study including 110 patients who were hospitalized for extensive psoriasis was performed. A control group (n = 515) was defined as patients who had undergone elective surgery. A case-crossover study included 98 patients with psoriasis. Exposure to drugs was assessed during a hazard period (3 months before hospitalization) and compared to a control period in the patient's past. Data on drug sales were extracted by data mining techniques. Multivariate analyses were performed by logistic regression and conditional logistic regression. In the case-control study, psoriasis was associated with benzodiazepines (OR 6.9), organic nitrates (OR 5.0), angiotensin-converting enzyme (ACE) inhibitors (OR 4.0) and non-steroidal anti-inflammatory drugs (NSAIDs) (OR 3.7). In the case-crossover study, psoriasis was associated with ACE inhibitors (OR 9.9), beta-blockers (OR 9.9), dipyrone (OR 4.9) and NSAIDs (OR 2.1). Extensive psoriasis may be associated with intake of ACE inhibitors, NSAIDs or beta-blockers.

To identify patients with depression, in primary care clinics in Israel, using the MINI (Mini-International Neuropsychiatric Interview) as a screening tool and to evaluate the health services utilization and costs of the patients identified.Phone interviews (between 1997 and 2000) and health services utilization data extracted from computerized databases.Three primary care clinics belonging to Clalit Health Services (HMO).A random sample of 2755 patients, aged 21-65.MINI score results, utilization data.The study included interviews with 2507 patients. The screening questionnaire identified 5.9% with major depression, 1.6% with minor depression and 14.3% with depressive symptoms. Higher rates of depression were found among women, immigrants, secular or traditional religious Jews, and the unemployed. Those identified with major depression had higher health services utilization and costs. Logistic regression analysis showed that depression was related to older age, female gender, fewer years of education and among seculars. Depressed patients had significantly more somatic comorbidity.Health services utilization and costs of people identified as depressed by the screening tool were higher. Depressive patients had higher comorbidity, which might be partially responsible for the higher cost.

Background Anogenital pruritus is defined as an itch localized to the anus, perianal, and genital skin. Anogenital pruritus is usually a symptom of an underlying disorder of the skin or mucosa or a consequence of anorectal pathology. When no demonstrable cause is found, anogenital pruritus is often described as "idiopathic". Objective To investigate the role of lumbosacral radiculopathy in the pathogenesis of anogenital pruritus. Methods Included in the study were consecutive patients with anogenital pruritus. Radiographs and nerved conduction studies were performed in all patients. Needle electromyography studies and computerized tomography were performed when necessary. Nerve conduction studies included measurement of distal sensory and motor latency, conduction velocity, and F-responses of the peroneal and tibial nerves. Patients with confirmed radiculopathy were treated with paravertebral injection of a mixture of triamcinolne acetonide and lidocaine. Response to the injections was assessed using visual analogue scales by the patients. Mean scores before and after treatment were compared using paired t tests. Results Included in the study were 20 patients with anogenital pruritus. There were 18 men (90%) and 2 (10%) women. The mean age was 52.7 years (standard deviation [SD] 11.7 years). In 16 patients (80%), radiographs demonstrated degenerative changes of the lower spine. In 16 patients (80%) the presence of lumbosacral radiculopathy was confirmed by nerve conduction studies. Fifteen patients (75%) were treated with paravertebral injections, with significant decrease in mean pruritus score as assessed by the patients (6.3 [±2.8]; 4.5 [±2.7], before and after treatment, respectively, P =.033). Conclusion "Idiopathic" anogenital pruritus may be attributable to lumbosacral radiculopathy. Paravertebral blockade may be used for alleviation of symptoms in patients with anogenital pruritus.

Pityriasis amiantacea (PA) is an inflammatory disease of the scalp characterized by asbestos-like shiny scales that bind to the proximal part of the hair shaft. PA may be an isolated disorder or a reaction pattern associated with other inflammatory disorders. Previous reports did not demonstrate a clear association between PA and bacterial infections. A controlled prospective study was performed to identify the role of bacterial skin infections in patients with PA. In all patients, bacterial cultures were taken from the scalp. A group of 32 patients with various other scalp disorders served as a control group. Thirty-two patients were included in the study. There were 30 women (93.8%) and 2 men (6.2%) with a mean age of 23.1 years (SD 11.9 years). Twenty-five patients (78.1%) were of Bedouin origin and 7 were of Jewish origin (21.9%). Staphylococcus aureus was isolated in 26 patients with PA (81.3%) as compared with 1 patient (3.1%) from the control group (p=0.0001). The patients were treated by a combine...

Background: Brachioradial pruritus (BRP) is a localized pruritus of the dorsolateral aspect of the arm. BRP is an enigmatic condition with a controversial cause; some authors consider BRP to be a photodermatosis whereas other authors attribute BRP to compression of cervical nerve roots. Objective: We sought to investigate the presence of neuropathy in patients with BRP. Methods: We performed electrophysiologic studies of the median, ulnar, and radial nerves in consecutive patients with BRP, including measurement of sensory and motor distal latency, conduction velocity and F responses of the median and ulnar nerves, and sensory distal latency of the radial nerves in both upper limbs. Results: Included in the study were 7 patients, 5 men and 2 women, with an average age of 58.3 years (range: 42-72 years). Of the patients, 4 (57%) had abnormal F responses that were diagnostic for cervical radiculopathy, and 3 of these patients had prolonged distal latencies of the nerves tested, which may be interpreted as sensory motor neuropathy secondary to chronic radiculopathy. The fourth patient had polyneuropathy secondary to diabetes mellitus. Conclusion: BRP may be attributed to a neuropathy, such as chronic cervical radiculopathy. The possibility of an underlying neuropathy should be considered in the evaluation and treatment of all patients with BRP. (J Am Acad Dermatol 2003;48:825-8.)

Selective immunoglobulin E (IgE) deficiency (IgED) is defined as serum levels of IgE more than or equal to 2 kIU/L and is associated with immune dysregulation and autoimmunity. This study aimed to investigate a prevalence of atherosclerotic cardiovascular disease (ASCVD) in population with IgED. Within the electronic patient record (EPR) database of Leumit Health Care Services (LHS) in Israel, data capture was performed using IBM Cognos 10.1.1 BI Report Studio software. The case samples were drawn from the full study population (n = 18,487), having any allergy-related symptoms and/or those requesting antiallergy medications and performed serum total IgE measurement during 2012 at LHS. All subjects aged more than or equal to 40 years old, with serum total IgE less than 2 kIU/L were included in case group. Control group was randomly sampled from the remained subjects, with a case-control ratio of 10 controls for each case (1:10). The comorbid cardiovascular diseases during less than or equal to 10 years before serum total IgE testing were identified and retrieved using specific International Classification of Diseases, 9th Revision, Clinical Modification diagnostic codes. There were 103 in case and 1030 subjects in control group. Compared with control group patients, the case group had significantly more arterial hypertension [34 (37.7%) versus 187 (18.2%), p < 0.001], ischemic heart disease (IHD) [26 (25.2%) versus 87 (8.4%), p < 0.001], carotid stenosis [5 (4.9%) versus 7 (0.7%), p = 0.003], cerebrovascular disease (CVD) [3 (2.9%) versus 5 (0.5%), p = 0.029], and peripheral vascular disease (PVD) [4 (3.9%) versus 9 (0.9%), p = 0.024]. IgED is associated with higher prevalence of arterial hypertension and ASCVD.

SummaryBackground Psoriasis may have a severe impact on patients' quality of life (QOL) in several ways, an impact mediated by the mental or physical difficulties they have to deal with during the course of the disease and the various treatment regimens. In addition, psoriatic patients often suffer from experiences of stigmatization (EOS) related to the disease. Objectives This study was designed to test the hypotheses that psoriasis patients report higher levels of stigmatization than a comparison group, and that their EOS play a role in mediating the impact of the severity of psoriasis on their QOL. Methods One hundred patients with psoriasis (study group) and 100 patients with mixed skin problems (comparison group) were matched according to age, sex and education. All subjects answered questionnaires on EOS and QOL. A dermatologist diagnosed the diseases and measured severity scores. The Psoriasis Area and Severity Index score was used for psoriasis and a linear severity score for the comparison patients. The mediating effect of EOS was analysed using structural equation modelling (SEM). SEM is a multivariate statistical method used to examine the consistency of a theory relating one group of variables (termed a ‘latent construct’) to another: in the present study, the relationship between EOS and QOL. Results Psoriatic patients were found to report significantly higher levels of EOS related to the disease, compared with the comparison group. No significant differences were found regarding QOL or severity of disease. Clinical severity of psoriasis was found to correlate negatively with QOL in psoriasis patients. EOS were found to have a complete mediating effect for the severity of disease on the QOL in patients with psoriasis. This result was not found among the comparison group patients. Conclusions The results of this study indicate that psoriasis patients experience higher levels of stigmatization than do other dermatological patients, and that these EOS mediate the association between disease severity and patients' reported low levels of QOL. Treatment of psoriatic patients should consider these results and should include tools for psychosocial intervention.

We developed a simple scoring system to evaluate the severity of tinea pedis (Athlete's foot severity score, AFSS). The AFSS consists of a clinical evaluation, using a three-point scale, of erythema and scaling in the plantar and interdigital spaces of the feet, and counts of interdigital spaces involved. Each foot is evaluated separately. The validity of the AFSS was assessed in 224 soldiers of the Israel Defense Force using mycological cultures as the main outcome measure and subjective assessment of pruritus as the secondary outcome measure. Mycological examinations were performed in 106 patients who had clinical evidence of tinea pedis. AFSS was significantly associated with culture results (P

AIM: To investigate the prevalence and clinical characteristics of Helicobacter pylori (H. pylori)-infected dyspeptic patients with selective immunoglobulin E deficiency (IgEd). METHODS: All individuals who underwent serum total immunoglobulin E (IgE) measurement at the Leumit Healthcare Services (Israel) in 2012 were identified in an electronic database search (n = 18487). From these, selected case group subjects were ≥ 12 years of age and had serum total IgE < 2 kIU/L (n = 158). The control group was selected from a random sampling of the remaining subjects ≥ 12 years of age to obtain a case-control ratio of 1:20 (n = 3160). Dyspeptic diseases, diagnosed no more than 5 years before serum total IgE testing, were identified and retrieved from the electronic database using specific International Classification of Diseases diagnostic codes. Results of C13-urea breath tests were used to identify subjects infected with H. pylori. Categorical variables between case and control subjects were analyzed using Fisher’s exact tests, whereas continuous variables were analyzed using χ2 tests. RESULTS: Dyspepsia was present in 27.2% (43/158) of case subjects and 22.7% (718/3160) of controls. Of these, significantly more case subjects (32/43, 74.4%) than controls (223/718, 31.1%) were positive for H. pylori (P < 0.01). Esophagogastroduodenoscopy was performed in 19 case and 94 control subjects, revealing that gastritis was more prevalent in IgEd case subjects than in controls (57.9% vs 29.8%, P < 0.05). Furthermore, a significantly greater proportion of case subjects presented with peptic duodenal ulcers (63.2% vs 15.9%, P < 0.01). Histopathologic examination showed marked chronic inflammation, lymphoid follicle formation and prominent germinal centers, with polymorphonuclear cell infiltration of gastric glands, that was similar in case and control biopsy tissues. Finally, IgEd case subjects that underwent esophagogastroduodenoscopy were more likely to exhibit treatment-refractory H. pylori infections that require second-line triple antibiotic therapy (47.4% vs 11.7%, P < 0.01). CONCLUSION: IgEd is associated with higher rates of H. pylori-associated gastritis and peptic duodenal ulcers.

BACKGROUND: Ciclopirox olamine is a broad spectrum antifungal agent that has been shown to be effective in treating various cutaneous fungal infections. However, little information is available on the effect of ciclopirox olamine on seborrheic dermatitis, a common skin disorder associated with increased cutaneous fungal density. AIM: The purpose of the study was to determine the effectiveness and safety of 1% ciclopirox olamine shampoo for the treatment of scalp seborrheic dermatitis. METHODS: The study was designed as a prospective, double-blind, randomized, placebo-controlled clinical study and was performed in the dermatology institute of Clalit Health Services, southern district, Israel. Patients were randomly divided into a ciclopirox olamine shampoo treatment group and a placebo (vehicle) shampoo treatment group. The shampoo was applied twice a week, 5 min for each application (after first shampooing and rinsing the hair). Patients were treated for a period of 4 weeks and examined on enrollment, aft...

BACKGROUND: The mainstay of mild to moderate acne treatment is topical antibiotics. A new combination of 2% erythromycin and 1% bifonazole was tested in a double-blind trial against erythromycin alone. METHODS: A total of 207 acne patients were recruited into the study and 157 (76%) completed the full trial protocol of 12 weeks of treatment. In all, 74 patients applied the combination solution (erythromycin + bifonazole) once a day and 83 patients applied erythromycin solution twice a day. Outcome parameters measured were lesion-count (open and closed comedones, papules and pustules) and acne grading using the Cook's acne scale, carried out at the initial visit, and at the 4, 8 and 12-week follow-up visits. RESULTS: Both treatment groups improved significantly over baseline and showed continuous improvement throughout the trial, with the erythromycin + bifonazole group showing better improvement than the erythromycin group. At the end of 12 weeks, open comedones, closed comedones, papules and pustules wer...

Pilonidal sinuses usually occur in the sacrococcygeal area in young men, and occasionally can be found in other ectopic sites. We present a retrospective case review on unusual locations of pilonidal sinuses in the past 4 years. The lesion sites were as follows: one on the penis, two on the scalp, two on the abdomen, one on the neck, two in the groin and two in the axilla. Abdominal and penile lesions are uncommon, but the other locations reported are unusually rare. To our knowledge, the groin has not been reported previously as a site of a pilonidal sinus, although the histological appearance of hidradenitis suppurativa may well resemble it. When trying to clarify the pathogenesis of these occurrences, we found that recurrent hair removal was a common characteristic of the patients we contacted, and this may have been the initiating trauma.

Cutaneous leishmaniasis is a protozoal infection generally considered to be limited to the skin. In Israel, the disease is common in geographically defined areas and is caused predominantly by Leishmania major. Sporotrichoid subcutaneous spread has been reported but is uncommon. We describe a patient with rheumatoid arthritis, treated with methotrexate and prednisone, in whom numerous rheumatoid nodules concomitant with cutaneous leishmaniasis were found, mimicking sporotrichoid spread of the disease. In a rheumatoid nodule that was examined by electron microscopy, Leishmania parasites were found at intracellular and extracellular locations. This observation supports the hypothesis that cutaneous leishmaniasis parasites persist after clinical cure of the disease and may re-emerge as a result of immunosuppression.

Various Aloe vera extracts are widely used in a variety of over-the-counter skin products, but only a few studies have been conducted to provide support for the use of Aloe vera (A. barbadensis), o...

The efficient retrieval of medical information is essential for all functional aspects of a health system. Such retrieval is possible only by coding data (as it is produced or after it is produced) and entering it into a data-base. The completeness and accuracy of retrieved information depend, therefore, on the coding system employed. The main coding system that is in use in Israel is the ICD-9: International Classification of Diseases and its clinical modification (ICD-9-CM). Using such a statistical classification system for coding has met the basic needs for statistical and administrative purposes, but causes distortion and loss of information. With the recent growth and availability of information technology, more detailed data can be coded and processed than was possible before. A detailed nomenclature system such as SNOMED (the Systematized Nomenclature Of Human and Veterinary Medicine) can be used as a coding system that enables a more comprehensive and flexible medical information data base. This article discusses some aspects of coding medical information and suggests that a national revision of medical coding systems be considered as the computerized-patient-record is further developed and implemented.

After a new formulation of levothyroxine was distributed in Israel, side effects were reported to the Ministry of Health generating extensive media coverage. The purpose of this study was to determine whether the new formulation was associated with a change in thyroid-stimulating hormone (TSH) levels of treated patients and to evaluate the effect of the extensive media coverage on the incidence of laboratory test performance.Retrospective-cohort and crosssectional analysis.All patients from the Leumit Health Services of Israel treated with levothyroxine between October 2009 and February 2012 were included in the study. A retrospective cohort was constructed of patients treated and maintained within the desired target range (0.35-5 mIU/L) from January to July 2010. A longitudinal analysis was conducted to calculate the monthly distribution of TSH levels from laboratory tests during routine care over 26 months. Data were stratified by cohort and noncohort patients.Data were captured for 18,106 levothyroxine-treated patients; 1140 were included into the retrospective cohort. In both subpopulations a sharp rise in the number of tests performed monthly is observed at the peak of media coverage during October and November 2011. In the retrospective cohort the proportion of TSH results within target range fell to a low of 67.5% during December 2011, with 25.3% between 5.01 and 20 mIU/L. Results20 mIU/L then peaked at 3.8% indicating an increase in patients who stopped taking levothyroxine.These results demonstrate the power of mass media to influence patient behavior and to foment a public health scare.

Growth factor receptors with tyrosine kinase activity mediate paracrine and autocrine growth regulation of normal and malignant cells. The epidermal growth factor receptor (EGF-R) is a tyrosine kinase transmembrane protein that is overexpressed by many epithelial malignancies, including transitional cell and renal cell carcinoma. Ligand-induced stimulation of cell growth depends on activation of the tyrosine kinase activity of the EGF-R. Tyrphostins are small molecular weight compounds that have been shown to preferentially inhibit the EGF-R tyrosine kinase and thus may inhibit EGF-R-dependent cell growth. We examined the effect of two tyrphostins, RG14620 and AG555, on the proliferation of three transitional cell carcinoma lines (RT4, J82, and T24) and three renal cell carcinoma lines (A-498, Caki-1, and Caki-2). Both tyrphostins inhibited proliferation of all six cell lines in a dose-dependent fashion. They were equally effective with IC50s ranging between 3 and 16 μM. Complete inhibition of growth was achieved at tyrphostin concentrations between 10 and 30 μM. Although both tyrphostins inhibited proliferation of T24 transitional carcinoma cells in growth assays, only RG14620 but not AG555 was found to specifically inhibit EGF-R autophosphorylation in this cell line. These results suggest that other intracellular targets in addition to the EGF-R are affected by these agents. In summary, tyrphostins are potent growth inhibitors for urological malignancies.

Autocrine activation of the epidermal growth factor (EGF) receptor on keratinocytes has been recognized as an important growth regulatory mechanism involved in epithelial homeostasis, and, possibly, hyperproliferative diseases. Insulin-like growth factor (IGF)-1 and insulin have been shown to be paracrine keratinocyte mitogens that bind to the type I IGF receptor which is expressed on actively proliferating keratinocytes in situ. In this report, we demonstrate that IGF-1/insulin induced production of keratinocyte-derived autocrine growth factors that bind to the EGF receptor. Increased steady-state mRNA levels for transforming growth factor alpha (TGF-alpha) and for amphiregulin (AR) were observed upon incubation of keratinocytes with mitogenic concentrations of IGF-1. IGF-1 also induced production and secretion of TGF-alpha and AR proteins as detected by immunoassays. An EGF receptor antagonistic monoclonal antibody abolished the mitogenic effect of IGF-1 on cultured keratinocytes. These results suggest that stimulation of keratinocyte growth of IGF-1 requires activation of an EGF receptor-mediated autocrine loop.

In this study, twenty-eight South Indian medicinal plants were screened for their anti-fungal activity against six species of fungi (Trichophyton mentagrophytes, T. rubrum, T. soudanense, Candida albicans, Torulopsis glabrata, and C. krusei). Three plant species extracts, Celastrus paniculatus, Eriodendron anfractuosum and Ficus glomerata showed inhibitory activity. An aqueous extract of galls of Terminalia chebula showed inhibitory effects on three dermatophytes (Trichophyton spp.) and three yeasts (Candida spp.). Seeds extract of T. chebula inhibited only the growth of T. glabrata. An aqueous extract of T. chebula showed inhibitory effects higher than those measured in ethanol extracts. It is therefore suggested that tannins are plausible candidates for the anti-dermatophytic effects of T. chebula. Chebulinic acid, a known tannin of T. chebula was tested and found not inhibitory, thus a search for the active compound is needed.

Three vector-borne diseases, Mediterranean spotted fever, cave fever, and simple cutaneous leishmaniasis, are endemic to Israel. These diseases may pose a significant health hazard to visitors to this area. The objective of this article is to supply the essential information concerning these diseases to physicians who are unfamiliar with them, with the intention of preventing disease by better traveler education and enabling prompt recognition and treatment outside the endemic areas. Mediterranean spotted fever is a rickettsiosis transmitted by a dog tick and presenting as a high fever with headache and typical rash. Cave fever is a borrelial infection transmitted by a soft tick and presenting as a relapsing febrile disease. Both diseases can be prevented by avoiding endemic areas and ticks, and respond well to treatment with tetracycline. Cutaneous leishmaniasis is a protozoan infection of the skin transmitted by the sandfly and presenting as an indurated erythematous cutaneous nodule. It responds to topical paromomycin and to intralesional or systemic sodium stibogluconate, but the best policy is to take the proper precautions and avoid infection.

Pyogenic granuloma is a benign vascular, inflammatory proliferation that appears following minor trauma in children. The exact pathogenesis of pyogenic granuloma is unknown, but its formation is closely related to minor trauma, chronic irritation, and hormonal influences. We present a unique case of a pyogenic granuloma that appeared in an infant following circumcision.

Old World cutaneous leishmaniasis (CL) is a widespread and potentially disfiguring protozoa1 infection, caused by the infection of dermal macrophages with Leishmania parasites. Despite the various implemented measures to prevent the disease, there is a steady number of infected individuals who seek treatment. Systemic treatments available are very often unjustified owing to their toxicity (e.g., pentavalent antimonials) or to their variable efficacy (e.g., ketoconazole). Topical treatment, the obvious way to treat a localized skin disease, still poses a challenge. Paromomycin-containing preparations have proven effective in some cases (El-On et al., 1985), but not in others (KLAUS et al., 1994; BEN SALAH et al., 1995), and often cause substantial skin irritation. Amphotericin B (AmB), a potent antileishmanial antibiotic, has not been previously delivered topically to dermal lesions. We have recently reported preliminary results showing that a colloidal dispersion of AmB and cholesteryl sulphate, in the presence of 5% ethanol and in the absence of glucose, has significant therapeutic effect in the treatment of CL lesions. The presence of glucose, on the other hand, inhibited the therapeutic effect (VARDY et al., 1999). Here we present results obtained in 1999-2000 on the treatment of 17 patients with AmB, in a prospective placebo-controlled study. Each patient had at least 1 placebo-treated and 1 AmB-treated lesion.

Policy development to manage new off-label uses of medications is an issue relevant to health policy stakeholders internationally. Retrospective drug utilization analyses may be useful to identify practice trends in the use of drugs for unapproved (off-label) uses. Since drug use evaluations (DUE) are generally performed for expensive medications or when safety concerns warrant increased scrutiny, patterns of off-label use of inexpensive drugs will probably be undetected. Tamoxifen citrate, an estrogen receptor antagonist, is indicated in Israel exclusively for palliative [sic: meaning adjuvant] treatment of breast cancer. This DUE was motivated by observations that tamoxifen may be used off-label for indications without evidence of safety or efficacy.To assess the extent of off-label prescribing of tamoxifen and ascertain what evidence is available supporting the use of the drug for the off-label indications observed.A retrospective DUE of tamoxifen was performed for the 12 months of calendar year 2008 in a 650,000-member HMO in Israel for patients who received at least 1 prescription for tamoxifen. All patients for whom tamoxifen was dispensed in 2008 were identified from pharmacy claims data. The HMO's electronic patient record (EPR) was subsequently queried to identify the diagnoses of patients who received tamoxifen and exclude those patients who had a diagnosis code (ICD-9-CM 174.x or 175.x) for breast cancer. An EPR chart review was also performed to identify and exclude patients who had a diagnosis or treatment of breast cancer that was recorded in free text. For the patients who did not have a diagnosis code or free-text description of breast cancer, the recorded off-label diagnoses and ICD-9-CM codes in the EPR during the visit when tamoxifen was first prescribed were tabulated. A literature search was conducted to collect information supporting the use of tamoxifen for the observed off-label indications. We defined the use as "supported" if studies were found in PubMed, Cochrane database, or Micromedex that supported the clinical decision to use the drug for the off-label indication.877 patients were treated with tamoxifen in 2008 of whom 826 (94.2%) had a diagnosis of breast cancer, and 51 patients (5.8%) received the drug from 41 physicians in 7 medical specialty categories for 25 different off-label diagnoses. Of these 25 diagnoses, 33 patients (64.7% of 51 patients with off-label use) received tamoxifen for 8 diagnoses that were associated with some evidence to support their off-label use. Malignant neoplasm of ovary (n = 13) and female infertility (n = 13) were the most commonly recorded indications with some evidence to support off-label use. Of the 13 women treated for infertility, 9 (69.2%) had been treated with clomiphene citrate prior to being treated with tamoxifen, suggesting that some physicians may be experimenting with tamoxifen as second-line treatment.Tamoxifen was found to be used off-label in only 5.8% of the patients who received the drug in 2008 in this HMO, and only 18 patients (2.1%) received tamoxifen for a diagnosis that did not have some supporting evidence of efficacy. Since off-label prescribing of tamoxifen was found to be relatively rare, this HMO did not impose a prior authorization requirement for this drug and instead added an edit in the EPR to block off-label prescribing by requiring the physician to register a diagnosis of breast cancer.

To ascertain whether revocation of a prior authorization (PA) requirement by the Leumit Health Fund of Israel resulted in inferior rates of glycosylated hemoglobin (A1C) testing among new users of expensive diabetes medications.Electronic patient record (EPR) database study.Data on new users of the target drugs and on A1C testing in these patients were extracted from EPR databases for the 6-month period after the revocation. The proportion (95% confidence interval [CI]) of patients who obtained at least 1 A1C test during the 4 months before initiation of treatment was calculated. The data were stratified by month to detect possible trends in rates of testing during the period after the policy change.After the PA requirement was rescinded, A1C testing among incident users of the target drugs dropped from 100% during the PA period to rates ranging from 85.6% (95% CI, 79.7%-91.5%) to 94.4% (95% CI, 90.8%-97.9%). Statistically significant variance in monthly rates of testing was not observed.Prior authorization has been successfully implemented in the managed care setting studied to obtain 100% performance of a laboratory test necessary to monitor drug therapy outcomes in patients with diabetes mellitus. When PA is implemented as a quality assurance strategy, its revocation should be accompanied by continuing education efforts designed to maintain optimal adherence to recommendations for appropriate care.

Objective. The objective of this study was to assess opioid use during 7 years (2000–2006) among Clalit Health Services (CHS) members. Design. Purchasing data of opioids authorized for use in Israel were obtained from the computerized databases of CHS. Patient demographics and cancer morbidity were also extracted. The data were analyzed by converting the purchased opioids to oral morphine equivalents (OMEs). Setting. CHS is the largest health maintenance organization in Israel (3,774,600) and insures almost 54% of the Israeli population. Patients. All CHS members who purchased an opioid at least once during the 7-year study period (2000–2006). Intervention. There were no interventions in this study. Outcome Measures. The ourcome measures of this study were total OME purchased per year, OME (mg) per capita/per year, and OME (mg) daily dose. Results. There were 119,562 patients who purchased an opioid at least once (3.2% of CHS population). Of them, 57.4% were women, 69.0% aged 65 years and above (average age 56.05 years ± 26.7), 7.7% purchased opioids for more than 12 months, and 81.3% purchased opioids for only 1–4 months. A 96% increase in total OME purchased was found between 2000 and 2006 (from 56.4 kg to 110.6 kg). The annual OME purchased per capita increased from 15.7 mg in the year 2000 to 29.3 mg in 2006. The total number of patients who received at least one opioid prescription increased by 60%, while the growth in total number of CHS members was smaller (4.8%). Conclusions. There is a growing use of opioids at CHS during the 7-year period, a potential indicator of the progress made in improving accessibility and availability of opioids in our health care organization in Israel.

Physicians are the backbone of every medical system. Physician function and behavior have a major impact on the function and outcomes of medical systems. Physician behavior is influenced by sets of incentives that are an inherent part of the medical system. Incentives may be divided into three groups: 1) moral incentives, i.e. professionalism, empathy, sense of mission; 2) social incentives, i.e. reputation, laws, administrative restrictions and work environment; 3) financial incentives, i.e. payments, salaries and bonuses. Physician behavior is influenced by a combination of all three types of incentives and not by a single incentive. The material incentive has more influence on recruitment while the social incentive has a stronger influence on retainment and attrition reduction. This article discusses the modern physician's environment in view of incentive sets and its impact on the medical system.

Frequent attendance affects delivery and cost of effective health services, quality of care, and burden on primary care physicians. The aim of this study was to investigate factors associated with frequent attendance, as well as types of health care utilization, in a Bedouin primary care setting.A case-control study was conducted on adult frequent attenders (FAs) and controls in a primary care clinic serving a Bedouin population in southern Israel. Social, demographic and clinical data were manually extracted by reviewing the clinic's computerized medical records. The associations between these factors and frequent attendance were analyzed.The study included 118 cases and 121 controls (59% female, mean age: 39.6 +/- 14.9 years). FAs were more likely to use consultation referrals, prescriptions, investigative studies, laboratory tests, and emergency department referrals than controls and were prescribed more sick-leave days than controls. Controlling for age and gender, FAs were significantly more likely to have a chronic disease (OR = 4.46, 95% CI: 1.86-10.71), use chronic medications (OR = 3.31, 95% CI: 1.57-6.99), have a musculoskeletal disease (OR = 2.08, 95% CI: 1.02-7.49) and be of African Bedouin ethnicity (OR = 2.77, 95% CI: 1.02-7.49).FAs in a Bedouin community pose a special challenge for the primary care clinic, as they are more likely to be chronically ill, and utilize referrals to various services and consultations more frequently than controls.

The Beer Sheva Psoriasis Severity Score is a novel instrument for the assessment of psoriasis severity, designed for use in routine clinical conditions.To identify the main factors of the BPSS.The sample used to study the BPSS comprised 70 patients with psoriasis vulgaris treated by climatotherapy at the Dead Sea. Psoriasis severity was assessed using BPSS and PASI (Psoriasis Area and Severity Index). Factor analysis was used to identify the main factors of BPSS. Internal consistency analysis was performed. Correlation matrices were generated to compare BPSS factors.Factor analysis demonstrated that BPSS included six factors that explained 74.0% of the variance as follows: patient assessment 26.0%; physician assessment 13.2%; palms and soles involvement 11.9%; genitals, nails, and pruritus 9.0%; face involvement 7.3%; and scalp involvement 6.6%. Total scale Cronbach's alpha was 0.76; alpha for the factors ranged between 0.39 and 0.81.The major factors of BPSS were identified. BPSS may be used as a comprehensive tool for measuring psoriasis severity.