Objectives: Research and theory suggests that socioeconomic status may affect diabetes control. We investigated the effect of socioeconomic status and ethnicity on glycated hemoglobin (HbA1c) in Arab and Jewish children with type 1 diabetes mellitus in northern Israel.
Methods: Data were collected from medical records of 80 Arab and 119 Jewish children attending a pediatric diabetes clinic in a tertiary health care center. Multivariate regression analysis was used to assess factors independently affecting HbA1c level.
Results: Mean age was 12.9±4.7 years. Arab families had more children compared to Jewish families (3.7±1.5 versus 2.9±1.2, respectively, P=0.0007). Academic education was significantly less common in Arab families (25% versus 66.2%, respectively, P=0.0001). Income of Jewish parents was significantly higher compared to that of Arab parents (7,868±2,018 versus 5,129±906 NIS/month, respectively, P=0.0001). Mean age at diagnosis of diabetes was 9.6±4.6 years and disease duration was 3.4±2.3 years in both groups. Half of Arab and Jewish children were treated with multiple insulin injections and half with insulin pumps. Mean number of self-glucose testing/day was higher in Jewish children than in Arab children (4.7±2.5 versus 4.0±1.5, respectively, P=0.033). Mean HbA1c was above recommendations, 9.5% (12.6 mmol/L) in Arab children and 8.7% (11.3 mmol/L) in Jewish children (P=0.004). In multivariate analysis, disease duration (P=0.010) and ethnicity (P=0.034 for Arabs versus Jews) were independently associated with HbA1c.
Conclusions: Both Arab and Jewish children failed to meet HbA1c goals, but this effect was significantly greater for Arabs. Ethnicity remained a predictor of failure even following adjustment for potential confounders.
Objective of the work: Pancreatic cancer (PC) is a deadly disease that is most commonly diagnosed at an incurable stage. Early diagnosis is the most important factor for improving prognosis. Evidence is beginning to accumulate that screening and surveillance may lead to the early detection of precursor lesions and/or pancreatic cancer in asymptomatic individuals. Proper screening methods and identification of such precursor lesions may enable effective pre-emptive interventions to prevent further fatalities. The primary objective of this project was to examine the feasibility of identifying precursor or early cancerous lesions in high-risk individuals by endoscopic ultrasound (EUS) screening to prevent the deaths from pancreatic cancer.
Research aim: Pancreatic cancer screening guidelines, based on consensus opinions, have been applied in various tertiary centers around the world; however, evidence for effectiveness is lacking. At Rambam Health Care Campus, we have established a cohort of high-risk individuals, and we report our local 10-year experience results of screening for pancreatic cancer.
Methods: Between 2008 and 2018, a cohort of 123 asymptomatic high-risk individuals came for annual/biannual EUS screening for pancreatic cancer. Retrospective and prospectively collected data were obtained, analyzed, and compared on the basis of several variables. These variables include age at beginning of screening, gender, smoking, obesity, diabetes, and presence of tumor markers, as well as the patients’ personal and family history of cancers. Findings on each EUS are described.
Results: Three patients out of 123 underwent potentially life-saving surgery as a result of this screening program. All of these three had only one first-degree relative (FDR) with pancreatic cancer at the time of their first screenings, but two eventually had a second FDR with PC. Findings from 296 EUS exams regarding smoking, obesity, and other risk factors are presented. Minor, possibly trivial, EUS findings are found to be common. Detection of precursor pancreatic lesions is feasible with EUS screenings.
Conclusions: Adherence was an important limiting factor in screening. Better stratification of patients according to specific risk factors, including thorough genetics and family history, may direct when and how to initiate screening. International collaborations, such as the International Cancer of Pancreas Screening (CAPS) Consortium, of which Rambam is a collaborating partner, are needed to collate evidence for impact of screening to prevent pancreatic cancer morbidity and mortality, and are essential to achieve proof of concept. Different countries with varying health-care systems and budgets can find variance of appropriateness of screening procedures.
All natural animals and plants are holobionts, consisting of the host and microbiome, which is composed of abundant and diverse microorganisms. Health and disease of holobionts depend as much on interactions between host and microbiome and within the microbiome, as on interactions between organs and body parts of the host. Recent evidence indicates that a significant fraction of the microbiome is transferred by a variety of mechanisms from parent to offspring for many generations. Genetic variation in holobionts can occur in the microbiome as well as in the host genome, and it occurs more rapidly and by more mechanisms in genomes of microbiomes than in host genomes (e.g. via acquisition of novel microbes and horizontal gene transfer of microbial genes into host chromosomes). Evidence discussed in this review supports the concept that holobionts with their hologenomes can be considered levels of selection in evolution. Though changes in the microbiome can lead to evolution of the holobiont, it can also lead to dysbiosis and diseases (e.g. obesity, diarrhea, inflammatory bowel disease, and autism). In practice, the possibility of manipulating microbiomes offers the potential to prevent and cure diseases.
This research letter presents our study, which sought to evaluate the differences in the prevalence of self-reported symptoms of depression, anxiety, and loneliness between younger and older generations at the time of the COVID-19 pandemic. Since the younger generation is generally less accustomed to facing and dealing with adversity and illness, we hypothesized that adolescents and younger adults would have a higher prevalence of depression, anxiety, and loneliness as compared to the older generation. It must be emphasized that this survey was conducted during the first COVID-19 lockdown that occurred in Israel from mid-March 2020 to early-May 2020. This was a time when businesses were closed, individuals and families were isolated at home with very limited social contact, and feelings of fear and panic were fueled by the electronic media.
The Jews in Western Europe during the middle ages were often perceived as distinct from other people not only in their religion, but also by virtue of peculiar physical characteristics. Male Jews were circumcised, which made them physically distinct in the sexual realm. They were believed to have a flux of blood due to hemorrhoids that was thought to more abound in Jews because they consumed salty foods and gross undigested blood, and were melancholic. By the late medieval and early modern periods, the male menstru¬ation motif had become closely connected to the theory of the four humors and the balance between bodily fluids. Men in general were thought of as emitting extra heat, whereas women were considered to be phys¬ically cooler. While most men were generally able to reduce their heat naturally, there was a perception that womanish Jewish males were unable to do so, and thereby required “menstruation” (i.e. a literal discharge of blood) in order to achieve bodily equilibrium. The Jewish male image as having menses due to bleeding hemorrhoids was an anti-Semitic claim that had a religious explanation: Jews menstruated because they had been beaten in their hindquarters for having crucified Jesus Christ. This reflection is one of the first biological-racial motifs that were used by the Christians. Preceding this, anti-Semitic rationalizations were mostly religious. However, once these Christians mixed anti-Semitism with science, by emphasizing the metaphorical moral impurity of Jews, the subsequent belief that Jewish men “menstruated” developed—a belief that would have dire historical consequences for the Jewish communities of Europe until even the mid-twentieth century. This topic has direct applicability to current medical practice. The anti-Semitic perspec¬tive of Jewish male menstruation would never have taken hold if the medical community had not ignored the facts, and if the population in general had had a knowledge of the facts. In the same way, it is important for present-day scientists and healthcare professionals to understand thoroughly a topic and not to deliberately ignore the facts, which can affect professional and public thought, thereby leading to incorrect and at times immoral conclusions.
Coronavirus disease 2019 (COVID-19) is a global respiratory disease with unique features that have placed all medical professionals in an alarming situation. Preeclampsia is a hypertensive disorder of pregnancy affecting 8%–10% of India’s pregnant population. Assuming that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) enters host cells through the angiotensin-converting enzyme 2 (ACE2) receptor, the resulting symptoms are due to vasoconstriction, caused by disturbances in the renin–angiotensin system (RAS). Other features of preeclampsia include endothelial dysfunction due to placental ischemia, leading to imbalances in angiogenic and antiangiogenic factors which result in increased blood pressure, proteinuria, altered hepatic enzymes, renal failure, and thrombocytopenia, amongst others. The increased prevalence of preeclampsia that was seen among mothers with SARS-CoV-2 infection might be due to misdiagnosis, as COVID-19 and preeclampsia have coincidental medical features. The major similarities of SARS-CoV-2-infected and preeclamptic women are a rise in pro-inflammatory cytokines, and increased serum ferritin and thrombocytopenia. Therefore, differential diagnosis might be difficult in pregnant women with COVID-19 who present with hypertension and proteinuria, thrombocytopenia, or elevated liver enzymes. The most promising markers for earlier diagnosis of preeclampsia is soluble endoglin (sEng), pregnancy-associated plasma protein-A (PAPP-A), soluble fms-like tyrosine kinase 1 (sFlt-1), and placental growth factor (PlGF). Due to placental hypoxia, sFlt-1 will be overproduced, thus inhibiting PlGF, and this alteration will be observed in the circulation five weeks or more before the onset of symptoms. The sFlt-1/PlGF ratio may also be modified via infectious states, but unregulated levels of those mediators are related to placental insufficiency. Hence, pregnant women with COVID-19 may develop a preeclampsia-like syndrome that might be differentiated properly by angiogenic markers to avoid unnecessary interventions and induced preterm labor.
Today, in the 21st century, most people are aware of the term genocide. However, few people are aware that this term only entered the English language in the 1940s, as a result of the dedicated work of a brilliant and successful man who deprived himself of a private family life so that he could be free to fight for his ideas. Although Raphael Lemkin was instrumental in the recognition of genocide by the United Nations, he died too early and was buried with no honor. This paper reviews the life and work of Raphael Lemkin, and his triumph in seeing genocide recognized as a crime.
Background: Hyperinsulinemia and insulin resistance occurs in obese patients with primary hypertension independent of diabetes and obesity. This study was aimed at assessing serum fasting insulin levels, the homeostatic model assessment for insulin resistance (HOMA-IR), and serum lipid levels in non-obese patients with primary hypertension when compared to normotensive subjects.
Methods: This observational study comprised 100 patients over 18 years of age, divided into two groups. The hypertensive group comprised non-obese patients with primary hypertension (n=50); the normotensive group comprised normotensive age- and sex-matched individuals (n=50). Patients with diabetes, impaired fasting glucose, obesity, and other causative factors of insulin resistance were excluded from the study. Serum fasting insulin levels and fasting lipid profiles were measured, and insulin resistance was calculated using HOMA-IR. These data were compared between the two groups. Pearson’s correlation coefficient was used to assess the extent of a linear relationship between HOMA-IR and to evaluate the association between HOMA-IR and systolic and diastolic blood pressures.
Results: Mean serum fasting insulin levels (mIU/L), mean HOMA-IR values, and fasting triglyceride levels (mg/dL) were significantly higher in the hypertensive versus normotensive patients (10.32 versus 6.46, P<0.001; 1.35 versus 0.84, P<0.001; 113.70 versus 97.04, P=0.005, respectively). The HOMA-IR levels were associated with systolic blood pressure (r value 0.764, P=0.0005).
Conclusion: We observed significantly higher fasting insulin levels, serum triglyceride levels, and HOMA-IR reflecting hyperinsulinemia and possibly an insulin-resistant state among primary hypertension patients with no other causally linked factors for insulin resistance. We observed a significant correlation between systolic blood pressure and HOMA-IR.
Background: Patellar instability comprises a group of pathologies that allow the patella to move out of its trajectory within the trochlear groove during walking. Symptomatic patients who need surgery commonly undergo soft tissue procedures such as medial patellofemoral ligament repair to strengthen the ligaments that hold the patella in place. However, soft-tissue repairs may be insufficient in patients suffering from patellar maltracking, which is characterized by an unbalanced gliding of the patella within its route. In these patients, a different approach is advised. We aim to provide the mid-term clinical outcomes of the Fulkerson distal realignment operation in selected patients with non-traumatic patellar maltracking.
Methods: The clinical outcomes of the Fulkerson distal realignment operation performed in 22 knees of 21 patients were evaluated by a self-administered subjective International Knee Documentation Committee (IKDC) score and the Tegner–Lysholm knee scoring scale.
Results: Before surgery, the median IKDC score was 52, and the median Tegner–Lysholm score was 56. Following surgery (mean follow-up 48 months, range 24–156), the median IKDC and the Tegner–Lysholm scores were 67 and 88, respectively. The improvement was statistically significant (P=0.001 and P=0.002 for IKDC and Tegner–Lysholm scores, respectively). Associated procedures included patella microfracture due to grade III–IV cartilage lesion (International Cartilage Repair Society grading system) in four patients, retinacular releases in three patients, medial capsular augmentations in two patients, and medial patellofemoral ligament reconstruction in two patients. One patient with Ehlers–Danlos disease required excessive medialization of the tibial tuberosity. Surgery-related complications occurred in three patients.
Discussion: Surgical correction of patellar maltracking with Fulkerson distal realignment combined with associated procedures in individual patients was associated with an increase in subjective and functional clinical scores at medium-term follow-up. Particular attention should address pathologies associated with patellar maltracking and managed accordingly.
Level of evidence: 4c (case series).
Breast cancer is a common malignancy and a common cause of cancer-related mortality in women. Pre-treatment workup of breast cancer does not routinely include positron emission tomography scans. We aimed to review cases of women with breast cancer and a synchronous second primary malignancy. We present three cases of women with non-metastatic cancer in whom a synchronous second primary malignancy was found. Synchronous, second primary malignancies which were identified included rectal cancer, gastrointestinal stromal tumor, and non-small cell lung cancer. All second primary malignancies were identified by a PET-CT scan. In conclusion, PET-CT may be used for detection of secondary primary malignancies in select breast cancer patients.
