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To examine and compare the medical burden of measles, influenza and COVID-19 outbreaks in the city of Bnei Brak, Israel.The study was conducted during 2018-2021. The numbers of hospitalisations for these infections and their complications were recorded. Hospitalisation rates were determined by using the number of children residing in Bnei Brak and hospitalised with these infections during the study period as the numerators. The denominators were the estimated paediatric cases of measles, influenza and COVID-19 in Bnei Brak and were calculated under both pragmatic and conservative assumptions.A total of 247, 65 and 32 children were hospitalised with influenza, COVID-19 and measles respectively. Complication rates were higher following measles than after influenza and SARS-CoV-2 infections. Hospitalisation rates were 10% for measles, 0.6%-1.2% for influenza and 0.15% - 0.25% for COVID-19 infections. Relative risks (RR) with 95% confidence intervals (CI) for hospitalisation following measles compared with COVID-19 ranged from 42 (26.3-67.3) to 70.1 (43.8-112.1), while the relative risks for influenza hospitalisation ranged from 2.5 (1.83-3.41) to 8.2 (6.0-11.2), compared with COVID-19 infection.Hospitalisation rates and direct medical burdens of measles and influenza were significantly higher than those of COVID-19 infection in children.

Feeling vigorous throughout the workday in a medical facility despite exposure to daily job-related stress is essential for productive work-related behavior and for the subjective well-being of health-care professionals. The current study explored the contribution of an intra-personal resource (i.e. coping flexibility) and an inter-personal resource (i.e. social support) to the explained variance of vigor among nurses and physicians. Two hundred two hospital personnel completed self-report questionnaires regarding personal and professional data, vigor, coping flexibility and social support. The results revealed that the intra-personal resource coping flexibility, was positively associated with vigor while the inter-personal resource social support was not found to be associated with vigor. In addition, older age and higher self-rated health positively associated with feeling vigor. The current study shed light on the role of intra-personal resources in feeling vigorous throughout stressful workdays that characterize the workplace of hospital personnel. Tailoring interventions that may enhance coping flexibility among hospital personnel can increase their vigor which in turn may beneficially contribute to their job performance.

Aim Condensation often occurs when providing humidified respiratory support. We examined conditions conducive to excess water formation in heated humified high-flow nasal cannula (HHHFNC). Methods An HHHFNC device, at 35 or 37°C, was attached with a nasal cannula to a reservoir and tested in five ambient conditions and flows. For Group A, tubing and collection bottle remained at room temperature (23°C). Group B, tubing and reservoir remained inside an incubator (31°C). Group C, tubing and reservoir remained at 33°C. In Group D, the HHHFNC was set to 35°C, the reservoir remained at 33°C, and the nasal cannula and tubing remained at 23°C. Group E, same as D, with HHHFNC at 37°C. Results The largest amounts of collected water were in groups A and E. Both had highest temperature differences. Median (range) was 4.9°C (4.1-6.9) and 4.0°C, collecting 38.4 (26.4-50.4) and 26.4 (19.2-50.4) ml/24 h, respectively. Smallest amounts of water were seen with lower temperature differences as in groups B, C, and D with 2.7 (1.9-4.7), 1.6 (1.2-2.1), and 2.0°C with 8.4 (0.0-33.6), 2.4 (0.0-14.4), and 9.6 (4.8-16.8) ml/24 h, respectively. Conclusion HHHFNC devices may produce clinically significant amounts of water reaching the upper airways. This may be prevented with appropriate device set-up.

Objective To estimate the reliability of the Apgar score (AS) and umbilical cord pH (UCP) as prognostic tools among very low birth weight (VLBW) infants. Study Design Retrospective study based on data of 1237 VLBW neonates born between 1997 and 2013 at one tertiary medical center. For each newborn, a complication score (CS) was calculated based on common complications of prematurity. Results The AS at 1 and 5 minutes correlated well with CS (correlation coefficients -0.47 and -0.52, respectively). No significant correlation was found between UCP and CS (correlation coefficient -0.08). Multi regression analysis revealed that the variables with the greatest prognostic contribution were birth weight, gestational age and prenatal steroid administration (beta values 0.277, 0.251 and 0.087, respectively). Conclusion The AS at 1 and 5 minutes, but not UCP, combined with gestational age, birth weight, and prenatal steroids, can be significant parameters for predicting prognosis among VLBW neonates.

Aim: To explore if there is an interaction effect between gender (men and women) and profession (nurses and physicians) in posttraumatic growth (PTG). Background: PTG is defined as a positive psychological change experienced as a result of struggling with highly challenging life circumstances. It may take the form of improved self-image, a deeper understanding of self, increased spirituality, and/or enhanced interpersonal relationships. Gender and profession were found separately to be associated with PTG, but to date were not examined under interaction effect. Methods: We employed a cross-sectional study conducted in the tertiary medical center in Israel using a convenience sample. One hundred and twenty-eight nurses and seventy-eight physicians gave their consent and agreed to fill out self-report questionnaires regarding personal and professional data and PTG Inventory. Findings: The correlation matrix revealed that being a woman was associated with higher PTG total scale (r = 0.242; P ≤ 0.001) and its subscales except for spiritual change that showed no evidence of statistical effect. Similar pattern was found for being a nurse with PTG total scale (r = 0.223; P ≤0.001) and its subscales except for relating to others that showed no evidence of statistical effect. However, the interaction effect revealed that among men, there was no difference in the level of PTG and its subscales based on profession (Physicians men = 62.54 (20.82) versus Nurses men = 60.26 (22.39); F = 9.618; P = 0.002). Among women, nurses had a significantly higher scores in PTG (Physicians women = 61.81 (18.51) versus Nurses women = 73.87 (12.36); F = 9.618; P = 0.002) and its subscales in comparison to physicians except for subscale relating to other. Conclusions: Our findings suggest implications for research and practice namely exploring PTG among nurses and physicians would benefit from applying interaction effect of gender and profession. For practice, advocating PTG within the health care organization is needed to be tailored with gender and professional sensitivity.

The reliability of Apgar scores and umbilical cord pH for predicting outcomes in very low birth weight (VLBW) neonates is controversial. A few studies have tried to identify the prognostic value of these measurements among VLBW and preterm infants. Forsblad et al. showed that the Apgar score had a prognostic value in preterm infants born at 25 weeks and that a high Apgar score was associated with survival, without neurological morbidity, in the first 180 days of life (1). Locatelli et al reported that the umbilical cord pH can be normal even if the Apgar score is low five minutes after birth (2).

Our hypothesis that inflammation in asthma involves production of ozone by white blood cells and that ozone could be an inflammatory mediator suggests that scavengers of reactive oxygen species (ROS), for example, electron-rich olefins, could serve for prophylactic treatment of asthma. Olefins could provide chemical protection against either exogenous or endogenous ozone and other ROS. BALB/c mice pretreated by inhalation of d-limonene before an ovalbumin challenge exhibited significant attenuation of the allergic asthma symptoms. Diminution of the inflammatory process was evident by reduced levels of aldehydes, reduced counts of neutrophils in the BAL fluid and by histological tests. A surprising systemic effect was observed by decreased levels of aldehydes in the spleen, suggesting that the examination of tissues and organs that are remote from the inflammation foci could provide valuable information on the distribution of the oxidative stress and may serve as guide for targeted treatment.

Many premature and full-term newborns receive prophylactic platelet transfusions to prevent bleeding, particularly the most prevalent one, i.e, intracranial hemorrhages. However, the platelet count threshold above which bleeding is prevented and the efficacy of platelet transfusion in thrombocytopenic neonates, have yet to be established. Therefore, inter-Neonatal Intensive Care Units (NICU) variations in treatment indications and practices are expected. Considerable inter-NICU variations will emphasize the need for guidelines on platelet transfusions to neonates and premature infants.To examine platelet products selection and indications for transfusion among neonatologists in Israel. Research and Methods: Electronic questionnaires addressing the choice of platelet products and the platelet count threshold for transfusion in various clinical settings were sent to 25 neonatal units.All 25 neonatal units responded (100% response rate). There was considerable variation in product selection among the different neonatal units. Up to 24% of the participating units reported selecting nontraditional products. Variation was also found in thresholds for platelet transfusion - several units used high thresholds while others used low ones. Traditional guidelines were followed in up to 64% of cases in selected clinical scenarios.There is considerable variation in both platelet product selection and platelet count thresholds for transfusion among the different neonatal units.A low threshold for platelet transfusion increases the risk for bleeding, whereas a high threshold increases the prevalence of complications from transfusion of blood products. Adherence to guidelines may prevent both such sequelae. Summary: Such variation in platelet transfusion among neonatologists emphasizes the need for an accepted policy. We recommend setting up a committee of neonatologists, pediatric hematologists and blood service experts which aims to establish an appropriate policy regarding the prevention of platelet transfusion sequelae in newborns.

Hypercalcemia is caused by many different conditions and may lead to severe complications. Loss-of-function mutations of CYP24A1, encoding vitamin D-24-hydroxylase, have recently been identified in idiopathic infantile hypercalcemia and in adult kidney stone disease. The aim of this study was to investigate the genetics and clinical features of both infantile and maternal hypercalcemia.We studied members of four unrelated Israeli families with hypercalcemia, namely, one woman during pregnancy and after delivery and three infants. Clinical and biochemical data were obtained from probands' medical charts. Genomic DNA was isolated from peripheral blood and CYP24A1 was sequenced.Typical symptoms of hypercalcemia associated with the intake of recommended doses of vitamin D developed in the infants and pregnant woman. Four different loss-of-function CYP24A1 mutations were identified, two of which are reported here for the first time (p.Trp134Gly and p.Glu315*). The infants from families 1 and 2, respectively, were found to be compound heterozygotes, and the infant from family 3 and the pregnant woman were found to be homozygous.This is the first report of maternal hypercalcemia caused by a CYP24A1 mutation, showing that not only infants are at risk for this complication. Our findings emphasize the importance of recognition, genetic diagnosis and proper treatment of this recently identified hypercalcemic disorder in this era of widespread vitamin D supplements.

Background Redox-active iron, a catalyst in the production of hydroxyl radicals via the Fenton reaction, is one of the key participants in ROS-induced tissue injury and general inflammation. According to our recent findings, an excess of tissue iron is involved in several airway-related pathologies such as nasal polyposis and asthma. Objective To examine the anti-inflammatory properties of a newly developed specific iron–chelating complex, Zn/Ga−DFO, in a mouse model of asthma. Materials and methods Asthma was induced in BALBc mice by ovalbumin, using aluminum hydroxide as an adjuvant. Mice were divided into four groups: (i) control, (ii) asthmatic and sham-treated, (iii) asthmatic treated with Zn/Ga−DFO [intra-peritoneally (i/p) and intra-nasally (i/n)], and (iv) asthmatic treated with Zn/Ga−DFO, i/n only. Lung histology and cytology were examined. Biochemical analysis of pulmonary levels of ferritin and iron-saturated ferritin was conducted. Results The amount of neutrophils and eosinophils in bronchoalveolar lavage fluid, goblet cell hyperplasia, mucus secretion, and peri-bronchial edema, showed markedly better values in both asthmatic-treated groups compared to the asthmatic non-treated group. The non-treated asthmatic group showed elevated ferritin levels, while in the two treated groups it returned to baseline levels. Interestingly, i/n-treatment demonstrated a more profound effect alone than in a combination with i/p injections. Conclusion In this mouse model of allergic asthma, Zn/Ga−DFO attenuated allergic airway inflammation. The beneficial effects of treatment were in accord with iron overload abatement in asthmatic lungs by Zn/Ga−DFO. The findings in both cellular and tissue levels supported the existence of a significant anti-inflammatory effect of Zn/Ga−DFO., Graphical abstract, Highlights Asthma pathophysiology was shown to be associated with iron overload. A therapeutic effect of the novel iron–chelating complexes was demonstrated. Histological and cytological markers of inflammation were studied. The complexes could be administered intranasally or by intraperitonneal injections.

The association between psychological distress and decision regret during armed conflict among hospital personnel is of interest. The objective of this study was to learn of the association between psychological distress and decision regret during armed conflict. Data was collected from 178 hospital personnel in Barzilai Medical Center in Ashkelon, Israel during Operation Protective Edge. The survey was based on intranet data collection about: demographics, self-rated health, life satisfaction, psychological distress and decision regret. Among hospital personnel, having higher psychological distress and being young were associated with higher decision regret. This study adds to the existing knowledge by providing novel data about the association between psychological distress and decision regret among hospital personnel during armed conflict. This data opens a new venue of future research to other potentially detrimental factor on medical decision making and medical error done during crisis.

Objective: To evaluate the effect of inhaled dexamethasone on hospitalization for respiratory syncytial virus (RSV) bronchiolitis. Study design: A double-blind, placebo-controlled study compared nebulization of dexamethasone versus nebulization of 0.9% saline. Both groups were treated with epinephrine nebulizations. Follow-up continued for 3 mo. Patients and methods: Sixty-one infants with bronchiolitis aged 3 to 12 mo were included. They were randomly allocated to nebulizations with 0.25 mg dexamethasone every 6 h (group 1) or an equivalent amount of normal saline (group 2). Results: No statistically significant differences with respect to clinical score, oxygen saturation, or IV fluid requirement between the groups were noted. Using Kaplan-Meyer's method, the cumulative proportion of in-hospital stay was significantly lower in group 1 compared with group 2, mainly in days 5 and 6 post-hospitalization (p

Multiple sulfatase deficiency (MSD) is a rare autosomal recessive inborn error of metabolism due to reduced catalytic activity of the different sulfatase. Affected individuals show neurologic deterioration with mental retardation, skeletal anomalies, organomegaly, and skin changes as in X-linked ichthyosis. The only organ that was not examined in MSD patients is the dentition.To evaluate the effect of the metabolic error on dental development in a patient with the intermediate severe late-infantile form of MSD (S155P).Histological and chemical study were performed on three deciduous and five permanent teeth from MSD patient and pair-matched normal patients.Tooth germ size and enamel thickness were reduced in both deciduous and permanent MSD teeth, and the scalloping feature of the DEJ was missing in MSD teeth causing enamel to break off from the dentin. The mineral components in the enamel and dentin were different.The metabolic error insults the teeth in the stage of organogenesis in both the deciduous and permanent dentition. The end result is teeth with very sharp cusp tips, thin hypomineralized enamel, and exposed dentin due to the break off of enamel. These findings are different from all other types of MPS syndromes.Clinically the phenotype of intermediate severe late-infantile form of MSD appeared during the third year of life. In children of parents that are carriers, we can diagnose the disease as early as birth using X-ray radiograph of the anterior upper region or as early as 6-8 months when the first deciduous tooth erupt and consider very early treatment to ameliorate the symptoms.

Background: The interaction of zinc deficiency and hypothyroidism has several reported presentations. The link between hypoglycemia and hypothyroidism is also known, but uncommon. For the last 40 years, the relationship between these two phenomena was illustrated in a handful of articles. To the best of our knowledge, the sequence of hypoglycemia, hypothyroidism and zinc deficiency has not yet been reported. Case presentation: We present a six-month-old boy with the unusual combination of these three conditions, his diagnostic evaluation and management. Conclusion: We suggest that the relationship between zinc and thyroid function should be considered in any case of severe intractable hypoglycemia and extensive skin eruption.

Aim: To analyze trends in childhood body mass index (BMI) in Israel between 1990 and 2000, and to determine the proportion of obese children using US and population-specific reference values. Methods: Cross-sectional data from 13 284 second- and fifth-grade schoolchildren were collected, including age, sex, height, weight, country of birth, and time since immigration. Age- and sex-specific BMI means and centiles were calculated, and the prevalence of obesity was determined using Israeli and US reference values. Results: BMI values at the 95th centile increased monotonously over time in all age and sex categories. Between 1990 and 2000, 95th centile values increased by 12.7% and 11.8% among second-grade boys and girls, respectively. Among fifth-grade children, 95th centile values increased by 10.2% and 8.4%, respectively. Among second graders in 2000, 11.4% of both boys and girls exceeded the BMI value recorded at the 95th centile in 1990. Among fifth-graders in 2000, 10.7% of boys and 11.1% of girls exceeded the 1990 BMI reference value (p for all comparisons

Background: The pathophysiology of asthma involves the action of inflammatory/allergic lipid mediators formed following membrane phospholipid hydrolysis by phospholipase A2 (PLA2). Cysteinyl leukotrienes are considered potent inducers of bronchoconstriction and airway remodelling. Ovalbumin (OVA) induced bronchoconstriction in rats is associated with increased secretory PLA2 (sPLA2) activation and cysteinyl leukotriene production, together with suppression of cytosolic PLA2 and prostaglandin E2. These processes are reversed when the animals are pretreated systemically with an extracellular cell impermeable sPLA2 inhibitor which also suppresses the early allergic reaction to OVA challenge. In this study we examine the capacity of the sPLA2 inhibitor to ameliorate inflammatory and allergic manifestations (early and late bronchoconstriction) of OVA induced allergic bronchitis in rats when the inhibitor was administered by inhalation to confine it to the airways. Methods: Rats sensitised with OVA were treated with the sPLA2 inhibitor hyaluronic acid-linked phosphatidyl ethanolamine (HyPE). The rats were divided into four groups (n = 10 per group): (1) naive controls (no sensitisation/no treatment); (2) positive controls (sensitisation + challenge with OVA inhalation and subcutaneous injection of 1 ml saline before each challenge; (3) sensitisation + challenge with OVA and HyPE inhalation before every challenge; and (4) sensitisation + challenge with OVA and treatment with subcutaneous dexamethasone (300 µg) before each challenge as a conventional reference. Another group received no treatment with HyPE during the sensitisation process but only before or after challenge of already sensitised rats. Pulmonary function was assessed and changes in the histology of the airways, levels of cysteinyl leukotrienes in BAL fluid, and the production of nitric oxide (No) and tumour necrosis factor α (TNFα) by BAL macrophages were determined. Results: Inhalation of HyPE markedly suppressed OVA induced early and late asthmatic reactions as expressed by bronchoconstriction, airway remodelling (histology), cysteinyl leukotriene level in BAL fluid, and production of TNFα and NO by BAL macrophages. OVA induced bronchoconstriction in sensitised non-pretreated rats was also inhibited by inhalation of HyPE either before or after the challenge. Conclusions: These findings confirm the pivotal role of sPLA2 in the pathophysiology of both the immediate allergic response and the inflammatory asthmatic process. Control of airway sPLA2 may be a new therapeutic approach to the treatment of asthma.

Fine particles are thought to pose a risk to health, especially for vulnerable groups such as children with asthma. These children are also known to be affected by meteorological and seasonal changes. We assessed the association between air pollution and lung function via peak expiratory flow (PEF), controlling for seasonal changes, meteorological conditions and personal physiological, clinical and sociodemographic measurements, in a panel of schoolchildren with asthma living near two power plants in Israel. Two hundred and eighty-five children with confirmed asthma performed PEF tests and completed a respiratory symptoms diary twice a day. Particulate matter

The assumption that ozone is not only a strong oxidant, but also an important inflammatory mediator, is heavily supported by the ample literature on the pulmonary toxicity and biological effects of environmental ozone and by the recent discovery that antibodies, human neutrophils, and inflammatory lesions catalyze the formation of ozone in vivo. We hypothesized that the pulmonary inflammation in asthma involves a vicious circle of ozone production and recruitment of white blood cells, which produce more ozone. Accordingly, we predicted that electron-rich olefins, which are known ozone scavengers, could be used for prophylactic treatment of asthma. In particular, volatile, unsaturated monoterpenes, could saturate the pulmonary membranes and thereby equip the airways with local chemical protection against either exogenous or endogenous ozone. Here we present experimental evidence using a sensitized rat model to support this hypothesis. Examination of the pulmonary function of sensitized rats that inhaled either limonene (unsaturated, ozone scavenger) or eucalyptol (saturated, inert to ozone) showed that limonene inhalation significantly prevents bronchial obstruction while eucalyptol inhalation does not cause any effect. The anti-inflammatory effect of limonene was also evident from pathological parameters, such as diminished peribronchiolar and perivascular inflammatory infiltrates.

This study investigated the effect of fine particulate matter (PM2.5) in ambient air on hospital admissions and emergency room (ER) visits among young children (0-3 yr) residing in 4 communities in southern Israel, within an area 5-25 km from the 2 power plants, which operate within 25 km of each other. Daily records of hospitalizations and ER visits for respiratory diseases at the 3 hospitals serving the region were examined for 9 mo, October 1, 2000-June 30, 2001. Mean PM2.5 concentrations for the four communities ranged from 11.6 to 28.1 microg/m3. Time series analysis revealed a statistically significant association (p0.05) between the numbers of hospitalizations and ER visits for respiratory symptoms and concentrations of PM2.5. This effect was evaluated for 0-3 lag days, directly, and for interactions with temperatures and seasonal parameters. The respiratory health of young children may be affected by 24 hr concentrations of PM2.560 microg/m3, the threshold proposed by both Israel and the United States.

Study objectives Accurate prediction of the effect of atmospheric changes, including pollutants, on emergency department (ED) visits for respiratory symptoms would be useful, but has proven difficult. The main difficulty is the limitation of the classical linear models and logistic regression with multiple variables to handle the multifactorial effect. Design and setting To predict ED visits, we have created a computer-based model called an artificial neural network (ANN) using a back-propagation training algorithm and genetic algorithm optimization. This ANN was fed meteorologic and air pollution input variables and trained to predict the number of patients admitted to the ED with respiratory symptoms of asthma, COPD, and acute and chronic bronchitis on the corresponding day. One thousand twenty data sets were extracted from an ED admittance database at the Barzilai Medical Center (Ashkelon, Israel), and randomized to a network training set (n = 816) and a test set (n = 204). Results The neural network performed best when the predictor variables used were temperature, relative humidity, barometric pressure, SO 2 , and oxidation products of nitric oxide, and the data presented as peak value 24 h prior to ED admission and the average during the 7 days before the ED visit. The neural network was able to predict the test set with an average error of 12%. Conclusion Based on meteorologic and pollution data, the use of an ANN can assist in the prediction of ED visits related to respiratory conditions.

Background: Vitamin A plays an important role in airways epithelial repair and differentiation. Allergen challenge induces epithelial damage and shedding, which cause an increase in repair activity. Objective: To examine whether repeated allergen challenges could increase vitamin A consumption in a rat model. Design: Allergic bronchitis was induced in 12 animals, and 12 rats remained naive. After 14 days, repeated allergen inhalation challenges were performed in the sensitized rats for 2 weeks. On day 16, allergen challenge was performed and bronchoconstriction was measured in all 24 rats. On day 30, all rats were killed. BAL was performed and ex vivo tumor necrosis factor (TNF)- and nitric oxide (NO) production was measured in the lavage cells. Liver, lung tissue, and serum were collected for measurement of vitamin A concentration. Results: The study rats showed severe bronchoconstriction after allergen challenge compared to the naive rats, and ex vivo TNF- and NO production was significantly higher in the sensitized rats. Serum and lung concentrations of vitamin A were not different among the two groups. However, the vitamin A liver concentration in the study rats was significantly lower compared to the naive rats. Conclusions: We conclude that vitamin A utilization is increased during repeated allergen challenge and allergic bronchitis, most probably due to increased demand for epithelial repair. (CHEST 2002; 122:1407–1411)

Background Several reports have suggested that early chest tube drainage (CTD) may not be necessary in the treatment of severe pleural empyema (PE) in pediatric patients if appropriate antibiotic therapy and supportive care are provided. Objectives A prospective open study to compare the short-term course of two treatment protocols of severe PE in pediatric patients. Study design One group of 32 patients was treated with early insertion of a chest tube for CTD, and a second group of 35 patients was treated by a repeated ultrasound-guided needle thoracocentesis (RUSGT). The severity of the empyema was assessed by chest radiograph, the amount of fluid drained, the number of days the patient had experienced a fever, and the duration of antibiotic treatment. Results No significant differences were found between the two groups (RUSGT vs CTD) in all of the following measurements: mean (± SD) duration of a temperature ≥ 39°C, 6.2 ± 2.4 vs 6.5 ± 1.8 days, respectively; mean duration of a temperature ≥ 38°C, 9 ± 3.9 vs 8.2 ± 4.5 days, respectively; fluid drained, 35.1 + 23.8 vs 30 ± 28.2 mL/kg, respectively; duration of antibiotic treatment, 30 ± 13.2 vs 30.2 ± 7.3 days, respectively; and length of hospitalization and home IV treatment, 22 ± 7.6 vs 24.2 ± 7.5 days, respectively. A failure to respond to treatment occurred in three patients in the RUSGT-treated group and in five patients in the CTD-treated group. The failure to respond occurred in the RUSGT-treated group only in those patients with very large empyemas that caused mediastinal deviation. Conclusion The treatment of PE by RUSGT is as efficacious as CTD, unless PE causes mediastinal deviation.

Real-time detection and classification of apneic episodes remain significant challenges. This study explores the applicability of a novel method of monitoring the respiratory effort and dynamics for rapid detection and classification of apneic episodes.Obstructive apnea (OA) and hypopnea/central apnea (CA) were induced in nine tracheostomized rats, by short-lived airway obstruction and administration of succinylcholine, respectively. Esophageal pressure (EP), EtCO2, arterial O2 saturation (SpO2), heart rate, and blood pressure were monitored. Respiratory dynamics were monitored utilizing three miniature motion sensors placed on the chest and epigastrium. Three indices were derived from these sensors: amplitude of the tidal chest wall displacement (TDi), breath time length (BTL), that included inspiration and rapid expiration phases, and amplitude time integral (ATI), the integral of breath amplitude over time.OA induced a progressive 6.42 ± 3.48-fold increase in EP from baseline, which paralleled a 3.04 ± 1.19-fold increase in TDi (P0.0012), a 1.39 ± 0.22-fold increase in BTL (P0.0002), and a 3.32 ± 1.40-fold rise in the ATI (P0.024). During central hypopneic/apneic episodes, each sensor revealed a gradual decrease in TDi, which culminated in absence of breathing attempts.Noninvasive monitoring of chest wall dynamics enables detection and classification of central and obstructive apneic episodes, which tightly correlates with the EP.

Objective: We conducted a retrospective study to determine the relationship between gastroesophageal reflux (GER) and large airways malacia in infancy. Methods: One hundred sixteen children referred for chronic respiratory problems who were between the ages of 3 and 28 months were investigated. All of them underwent flexible bronchoscopy and chest radiography. Eighteen children had laryngomalacia, 13 had tracheomalacia, and 23 had combined laryngotracheomalacia. During bronchoscopy, BAL was performed. An analysis of macrophages in the BAL fluid for lipid content was performed. Fifty-four children with laryngomalacia and tracheomalacia constituted the study group, and 62 children were in the control group. Reflux studies were obtained for 40 children from the study group and 41 from the control group. Results: In the study group, 28 children (70%) had GER documented by reflux studies compared with 16 children (39%) in the control group (p < 0.01). In the control group, GER was found mainly among those with recurrent bilateral pneumonia. The lipid-laden macrophage score was correlated with the documented GER. Conclusion: GER is prevalent among infants with large airways malacia, and treatment of this group with antireflux therapy should be considered. (CHEST 2001; 119:409 ‐ 413)

Epidural hematoma is a potentially life threatening event that demands prompt diagnosis and surgical treatment, usually following head trauma. We present a case of a 9-year-old boy with no history of head trauma, and who was diagnosed with epidural hematoma secondary to frontal sinusitis; and the medical literature was reviewed.

Introduction:The use of inhaled corticosteroids (ICS) via infant aerochamber in young, asthmatic children is increasing. However, concern has been raised about its long-term impact. Hypercalciuria is a known adverse effect of systemic corticosteroids.Objective:To determine whether ICS-induced hypercalciuria occurs in young, asthmatic children.Setting:Two outpatient clinics.Methods:Urinary calcium/creatinine ratio (UCa/Cr) was determined in 32 asthmatic children (age 6–36 mo) who were receiving inhaled budesonide or beclomethasone 200–600 μg/d for two to three months. A control group of asthmatic children within the same age range (n = 23) who did not receive ICS was included. None of the children were receiving oral corticosteroids, diuretics, antibiotics, or theophylline.Statistics:Student's t-test and χ2analysis.Results:The treated and control groups were similar with regard to age and male/female ratio. Mean ± SD UCa/Cr was significantly higher in the asthmatic children receiving ICS (0.23 ± 0.19 vs. 0.09 ± 0.07, respectively; p = 0.002). Fourteen (43.75%) of the treated patients had hypercalciuria (UCa/Cr >0.2) compared with only one (4.35%) in the control group (p = 0.002). Renal ultrasonography failed to demonstrate nephrocalcinosis in eight of the treated hypercalciuric patients.Conclusions:Treatment of young, asthmatic children with ICS may be associated with hypercalciuria. More studies are needed to evaluate the clinical significance of this finding.

Background: Chronic sinusitis (CS) is a common disease in children, especially those with allergies, that is caused by impaired drainage from the sinuses. Hypertonic NaCl solution has been shown to increase mucociliary clearance and ciliary beat frequency. Objective: We performed a randomized double blind study to compare the effect of nasal wash with hypertonic saline (HS) (3.5%) versus normal saline (NS) (0.9%) on CS. Methods: Thirty patients with CS aged 3 to 16 years were studied. They were randomly divided into two treatment groups matched by age and severity of the disease. Each individual was treated with either HS or NS for 4 weeks. All patients were evaluated by two clinical scores (cough and nasal secretions/postnasal drip [PND]) and by a radiology score at the beginning of the study and after 4 weeks. Results: The HS group improved significantly in all scores (average ± SD): cough score, from 3.6 ± 0.51 to 1.6 ± 0.74; nasal secretion/PND score, from 2.86 ± 0.35 to 1.6 ± 0.74; and radiology score, from 8.06 ± 1.28 to 2.66 ± 1.04. The NS treatment group showed significant improvement only in the PND score (from 2.66 ± 0.49 to 1.53 ± 0.83) but no significant change in both the cough score (from 3.53 ± 0.52 to 3.33 ± 0.49) and the radiology score (from 8.13 ± 1.25 to 7.86 ± 0.91). Clinical observation 1 month after the end of the study showed no change compared with the end of the study in both groups. Conclusion: HS nasal wash is an efficient treatment of CS.(J Allergy Clin Immunol 1998;101:602-5)

Childhood tuberculosis (TB) poses a high risk for morbidity and death. This study describes the characteristics of childhood TB in Israel and examines treatment outcomes. Data sources were the National TB Registry and the National Civil Census. Between 1999 and 2010, 416 children (aged

Identification of children at risk for adolescent overweight can assist in targeting interventions. Uncertainty remains regarding the validity of current body mass index (BMI) reference values in predicting future risk on a population basis. This study aimed to assess the validity of current childhood adiposity classifications in predicting adolescent overweight and obesity among Israeli youth.Historical cohort study.School-based childhood health studies and adolescent physical examinations.A total of 3 163 subjects surveyed first at age 8-15 and again at age 17-19.Age, sex, height, weight and BMI.Sensitivity, specificity, positive and negative predictive values, and relative risk of childhood adiposity classification.Childhood overweight and obesity showed low sensitivity and high specificity for predicting adolescent overweight and obesity. Positive predictive values were low and varied by age and sex, but negative predictive values were consistently high in both sexes and all ages (range 0.85-0.99). After adjusting for age and sex, both childhood overweight and obesity substantially increased the risk of adolescent overweight (relative risk [RR] 7.03 and 7.20, respectively) and adolescent obesity (RR 24.34 and 28.41, respectively).Childhood overweight and obesity are strong risk factors for adolescent overweight and obesity among Israeli youth. Normal weight children were at very low risk for adolescent overweight. These findings suggest that population-based health promotion aimed at maintaining normal weight among children should be given preference over risk-guided approaches targeting weight reduction among obese children.

Two children were admitted to the Emergency Department (ED) after ingesting a large amount of fruit of a plant identified as Jatropha multifida. They were mildly obtunded, had intractable vomiting, and seemed dehydrated. Intravenous fluid replacement and urine alkalinization were initiated. After stabilization, their 5-day hospital stays were uneventful except for a subclinical rise of liver enzymes. Jatropha species contain the toxalbumin ricin, which causes severe vomiting and diarrhea, dehydration, shock, and renal and hepatic impairment. Ricin also has cardiotoxic and hemolytic effects and several deaths have been documented. Children are attracted by the shape and the color of the Jatropha fruits. Mortality can be prevented by immediate fluid and electrolyte replacement.

Objective To evaluate the effects of exposure to air pollution by NOx and SO2 on the development of pulmonary function of children, characterized by different health status. Methods A cohort of 1181 schoolchildren from the 2nd to 5th grades, residing near a major coal-fired power plant in the Hadera district of Israel, were subdivided into three health status groups, according to the diagnosis given by a physician at the beginning of the study period in 1996: (a) healthy children; (b) children experiencing chest symptoms, and (c) children with asthma or spastic bronchitis. Pulmonary Function Tests (PFTs) were performed twice (in 1996 and 1999) and analyzed in conjunction with air pollution estimates at the children's places of residence and several potential confounders—height, age, gender, parental education, passive smoking, housing density, length of residence in the study area and proximity to the main road. Results A significant negative association was found between changes in PFT results and individual exposure estimates to air pollution, controlled for socio-demographic characteristics of children and their living conditions. A sensitivity analysis revealed a decrease in the Forced Expiratory Volume during the First Second (FEV1) of about 19.6% for children with chest symptoms, 11.8% for healthy children, and approximately 7.9% for children diagnosed with asthma. Results of a sensitivity test for the Forced Vital Capacity (FVC) were found to be similar. Conclusion Exposure to air pollution appeared to have had the greatest effect on children with chest symptoms. This phenomenon may be explained by the fact that this untreated symptomatic group might experience the most severe insult on their respiratory system as a result of exposure to ambient air pollution, which is reflected by a considerable reduction in their FEV1 and FVC. Since asthmatic children have lower baseline and slower growth rates, their PFT change may be affected less by exposure to air pollution, reflecting a well known relationship between pulmonary function change and height growth, according to which age-specific height is very similar for preadolescent children, but shifts upward with age during the growth spurt.

Background Patients with allergic rhinitis (AR) and perennial allergen sensitization are at increased risk for asthma. Objectives To determine the allergic profile of patients with clinical AR in regions of the coastal Mediterranean compared with the inland southern desert area of Israel and the impact of specific allergen sensitization on the prevalence of asthma in these patients. Methods Retrospective evaluation of medical records from patients referred for evaluation during 2002 and 2003 to the allergy clinics of 3 medical centers located in different geoclimatic areas. Results A total of 479 patients with AR were included (64% from the humid Mediterranean coast and 36% from the arid desert area), with a mean age of 32.8 years (range, 6-84 years). Sixty percent of the patients were male, and 33% had an additional diagnosis of asthma. Mite sensitization was 84%; cockroach, 34%; trees, 43%; weeds, 40%; grasses, 53%; and fungi, 30%. There were no significant differences in the prevalence of sensitization to any of the evaluated allergens except for weeds, which was higher in the arid region. A diagnosis of asthma was significantly associated with mite sensitization in the Mediterranean area (odds ratio, 2.24; 95% confidence interval, 1.14-4.4; P = .02) and mold sensitization in the arid climate zone (odds ratio, 2.18; 95% confidence interval, 1.05-4.6; P = .04). Conclusion Although sensitization to mites is high in the coastal areas and in the Negev desert-like environment, the presence of asthma in patients with AR is associated with mite sensitization in the humid environment but with fungal sensitization in the more arid environment.

Background Nasal potential difference (NPD) measurement is an electrophysiological test that assesses cystic fibrosis transmembrane conductance regulator (CFTR) activity and is a recognized diagnostic tool in CF. The aim of this study is to assess in the long term the role of NPD in patients whose diagnosis is questionable. Methods We performed follow up study on 70 patients with questionable CF (QCF) who were divided previously into two groups according to their NPD results: patients who likely have CF (QCF-CF) (n = 24), and those who likely do not have CF (QCF-non-CF) (n = 46). Results Sixty out of 70 patients were available for study. Sixteen patients in the QCF-CF group were being followed up at CF Centers as opposed to 1 in the QCF-non-CF group (P

Objective To identify the characteristics of CF patients with hemoptysis in Israel and to compare clinical features and risk factors to a control group of CF patients without hemoptysis. Design Retrospective chart review. Patients All CF patients in Israel who experienced hemoptysis between 2001 and 2005 and a control group of sex- and age-matched patients with no history of hemoptysis. Results 40/440 CF patients (9.1%) experienced hemoptysis during the study period, 50% were male. Ten patients (25%) were under 13 years old at the first hemoptysis episode. Pulmonary exacerbation was the precipitating factor in 90%. Twenty three patients showed moderate or major hemoptysis. 35/40 patients responded well to conservative therapy. Bronchial artery embolization (BAE) was performed in 5 patients with no recurrence of bleed within 24 h. However all of these patients experienced recurrent hemoptysis. One patient died during the follow-up period because of end stage lung disease. Pulmonary function tests, body-mass index, coagulation tests, pancreatic status, presence of bronchiectasis, sputum cultures and genetic mutations were similar in the two groups. A high incidence (57.5%) of associated diseases including cystic fibrosis related diabetes, cirrhosis and portal hypertension, and distal intestinal obstruction syndrome was found among hemoptysis patients, compared to only 5.2% in the control group ( p Conclusions Hemoptysis, even major, did not seem to be a risk factor for mortality in our patients. A higher incidence of hemoptysis was found in our pediatric patients compared to other series. BAE shows a high immediate rate of success in controlling hemoptysis, but does not prevent future disease.

Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis during infancy and is associated with subsequent wheezing and asthma, but the nature of this association is not fully understood. In that sense, RSV bronchiolitis may serve as a marker, reflecting predisposition of the individual for virus-induced wheezing early in life and/ or asthma later in life. This review discusses existing data on RSV infection and respiratory complications later in life, as well as the link between RSV and asthma.

The global spread of tuberculosis necessitates the development of an effective vaccine and new treatment modalities. That requires a better understanding of the differences in regulation of the immune responses to Mycobacterium tuberculosis between individuals who are susceptible or resistant to the infection. Previous immune studies in young Ethiopian immigrants to Israel did not demonstrate anergy to purified protein derivative or a Th2-like cytokine profile.To evaluate the profile of Th1 and Th2 cytokine production in immigrant TB patients, in comparison with asymptomatic control subjects.The present study included (part 1): 39 patients with acute TB (group 1), 34 patients with chronic relapsing TB (group 2), 39 Mantoux-positive asymptomatic TB contacts (group 3), and 21 Mantoux-negative asymptomatic controls (group 4). Patients were mainly immigrants from Eastern Europe and Ethiopia. Levels of interferon gamma, interleukin 2 receptor, IL-6 and IL-10 were measured in serum and in non-stimulated and PPD-stimulated peripheral blood mononuclear cell culture supernatants, using commercial ELISA kits. In addition (part 2), levels of IFNgamma and IL-12p40 were evaluated in 31 immigrant Ethiopian patients and 58 contact family members.Patients with acute disease tended to secrete more cytokines than contacts, and contacts more than chronic patients and controls, without a specific bias. None of the patients showed in vitro anergy. Discriminant probability analysis showed that from the total of 12 available parameters, a cluster of 6 (IFNgamma-SER, IFNgamma-PPD, IL-2R-SER, IL-10-SER, IL-10-NS and IL-6-PPD) predicted an 84% probability to become a TB contact upon exposure, 71% a chronic TB patient and 61% an acute TB patient. Family-specific patterns of IFNgamma were demonstrated in the second part of the study.Firstly, no deficiency in cytokine production was demonstrated in TB patients. Secondly, acute TB patients secreted more cytokines than contacts, and contacts more than unexposed controls. Thus, neither anergy nor a cytokine dysregulation explains susceptibility to acute TB disease in our cohort, although chronic TB patients produced less cytokines than did acute patients and less than asymptomatic contacts. Thirdly, a certain cytokine configuration may predict a trend of susceptibility to acquire, or not acquire, clinical TB. It is presently unclear whether this finding may explain the disease spread in large populations. Finally, the familial association of IFNgamma secretion levels probably points towards a genetic regulation of the immune response to Mycobacterium tuberculosis.

Effective surveillance of trends in paediatric overweight and obesity requires the establishment of valid cutoff values to identify children at risk. In Israel, standard values for childhood BMI-for-age are currently based on growth charts published by the US Centers for Disease Control and Prevention. However, the appropriateness of using US reference values in populations outside the US is questionable, due to inherent differences in ethnicity, culture and socioeconomic status. We recorded data from 9,988 children aged 6–12 selected by random cluster sampling within the framework of school-based health surveys conducted in Israel during the years 1997 and 2000. We constructed population-specific centile BMI-for-age curves valid for Israeli children, and compared these curves to current standard US and international reference values. Curves were constructed using LMS statistical curve smoothing methods. The data set of Israeli schoolchildren produced reference centiles substantially different than those based on US children. Israeli reference values were closer to centile curves published by the International Obesity Task Force. In conclusion, local and national health planners should recognize the intrinsic limitations associated with the use of “standard” reference values in defining paediatric overweight and obesity in dissimilar populations. The results of this large population-based study highlight the need for population-specific BMI-for-age reference values, in order to accurately describe the prevalence of paediatric overweight and obesity.

During the last decade, Israel, a country with low tuberculosis rates, absorbed some 900,000 new immigrants from TB-endemic countries.To analyze the specific impact of our screening procedures on active TB among children in Israel.We conducted a retrospective analysis of epidemiologic and clinical data of all children (aged 0-17) with TB notified to the Ministry of Health between 1990 and 1999.There were 479 children with TB (male/female ratio 1.36). Most cases (81.8%) were foreign born, predominantly (88.2%) immigrants from Ethiopia and, therefore, huge differences existed in TB incidence rates according to countries of origin. Some 80% were diagnosed within 3 years of arrival, mainly due to active case-finding. Pulmonary TB, with infiltrates on chest X-ray, was found in 49.5%. Extra-pulmonary TB sites were: intra-thoracic lymphadenitis (31.1%), extra-thoracic lymphadenitis (12.5%), bones (3.6%), pleura (1.3%), meninges (1%), and others (1%). Seventy percent had a tuberculin skin test reactionor =10 mm in size. Two (non-immigrant) children died of TB meningitis.Most of the pediatric TB cases occurred in recent immigrants and were diagnosed within 3 years of immigration. These data support our policy of active case-finding among new immigrants from Ethiopia and extensive contact evaluation for all TB cases.

To evaluate the effect of inhaled dexamethasone on hospitalization for respiratory syncytial virus (RSV) bronchiolitis.A double-blind, placebo-controlled study compared nebulization of dexamethasone versus nebulization of 0.9% saline. Both groups were treated with epinephrine nebulizations. Follow-up continued for 3 mo.Sixty-one infants with bronchiolitis aged 3 to 12 mo were included. They were randomly allocated to nebulizations with 0.25 mg dexamethasone every 6 h (group 1) or an equivalent amount of normal saline (group 2).No statistically significant differences with respect to clinical score, oxygen saturation, or IV fluid requirement between the groups were noted. Using Kaplan-Meyer's method, the cumulative proportion of in-hospital stay was significantly lower in group 1 compared with group 2, mainly in days 5 and 6 post-hospitalization (p0.038). A subgroup of prematurely born children in group 1 had a shorter hospitalization period (6.5+/-1.7 d) compared with group 2 children (9.1+/-1.9) (p0.018). Follow-up revealed similar wheeze and hospitalization rates in the two groups.Inhaled dexamethasone may reduce the length of hospitalization among infants with acute viral bronchiolitis, especially among those born prematurely.

Summary Background Asthma treatment per Global Initiative for Asthma (GINA) guidelines targets airway remodeling and achievement of normal lung function. Objective To study inhaled steroid therapy on airway remodeling and achievement of normal lung function. Subjects and set up Asthmatic patients were followed over 5 years .The children were divided into two groups. Group I (148 children-treated group) consisted of all the children using inhaled steroids on a regular basis and group II (50 children-untreated group) included patients with mild intermittent asthma who did not use inhaled steroids and were treated with bronchodilators as needed. Detailed medication and compliance history were recorded and the children underwent regular pre- and post-bronchodilator spirometry and physician examination. Results The incidence of airways remodeling as defined by the low FEV 1 /FVC post-bronchodilator was markedly increased over the 5-year period in the untreated group compared to the treated group. In the treated group the FEV 1 /FVC ratio post-bronchodilator decreased from 35% to 20.9% ( P 0.0 0 9 % ) compared with the untreated group where the number of children with low FEV 1 /FVC post-bronchodilator increased from 10% to 28% by the end of the study period. Conclusion Patients with mild asthma who do not receive regular inhaled steroids are at increased risk for airway remodeling. Therefore, we recommend that children with mild intermittent asthma undergo regular pulmonary function testing and that if any deterioration is detected in the FEV 1 /FVC ratio post-bronchodilators; preventative inhaled corticosteroid therapy be initiated.

Vasopressin is an alternative drug to adrenaline in intractable ventricular fibrillation. However, vasopressin can cause significant bradycardia, resulting in reduced cardiac output. We investigated whether pre-treatment with atropine abrogates vasopressin-induced bradycardia in a beating-heart canine model.Five adult mongrel dogs received endotracheal vasopressin (1.0 U/kg) with or without endotracheal atropine (0.02 mg/kg) or a placebo (10 ml saline) after being anesthetized and ventilated. Hemodynamic variables and arterial blood gases were determined. Each dog (studied 3 times, one week apart) served as its own control.Endotracheal vasopressin produced early and significant (p0.05) bradycardia (from 55+/-7 mmHg to 35+/-5 beats/min) compared with controls, starting one minute post-injection and lasting one hour. In contrast, in atropine-pretreated animals the heart rate increased significantly (p0.05) for as long as one hour post-atropine and vasopressin administration. In addition, animals treated with vasopressin with or without atropine exhibited a significant rise in diastolic blood pressure (from 83+/-5 to 160+/-15 and from 83+/-3 to 108+/-10 mmHg, respectively). Systolic and mean blood pressures also increased significantly compared with controls. Blood gases remained unchanged in all groups.Endotracheal administration of vasopressin can cause protracted bradycardia. Pretreatment with atropine can abrogate this effect. We suggest that atropine administration be considered when vasopressin is administered during cardio-pulmonary resuscitation. Further studies are warranted to evaluate the effect of vasopressin and atropine in a closed-chest model of cardio-pulmonary resuscitation.

Phospholipase A2 (PLA2) hydrolyzes cell membrane phospholipids (PL) to produce arachidonic acid and lyso-PL. The PLA2 enzymes include the secretory (sPLA2) and cytosolic (cPLA2) isoforms, which are assumed to act synergistically in production of eicosanoids that are involved in inflammatory processes. However, growing evidence raises the possibility that in airways and asthma-related inflammatory cells (eosinophils, basophils), the production of the bronchoconstrictor cysteinyl leukotrienes (CysLT) is linked exclusively to sPLA2, whereas the bronchodilator prostaglandin PGE2 is produced by cPLA2. It has been further reported that the capacity of airway epithelial cells to produce CysLT is inversely proportional to PGE2 production. This seems to suggest that sPLA2 and cPLA2 play opposing roles in asthma pathophysiology and the possibility of a negative feedback between the two isoenzymes. To test this hypothesis, we examined the effect of a cell-impermeable extracellular sPLA2 inhibitor on bronchoconstriction and PLA2 expression in rats with ovalbumin (OVA)-induced asthma. It was found that OVA-induced bronchoconstriction was associated with elevation of lung sPLA2 expression and CysLT production, concomitantly with suppression of cPLA2 expression and PGE2 production. These were reversed by treatment with the sPLA2 inhibitor, resulting in amelioration of bronchoconstriction and reduced CysLT production and sPLA2 expression, concomitantly with enhanced PGE2 production and cPLA2 expression. This study demonstrates, for the first time in vivo, a negative feedback between sPLA2 and cPLA2 and assigns opposing roles for these enzymes in asthma pathophysiology: sPLA2 activation induces production of the bronchoconstrictor CysLT and suppresses cPLA2 expression and the subsequent production of the bronchodilator PGE2.