Alopecia areata: a long-term follow-up study of 104 patients.

BACKGROUND: Alopecia areata (AA) is a common autoimmune disease that considerably affects the quality of life. Although several studies have investigated the epidemiology, clinical characteristics and treatment of AA, limited recent data are available regarding its long-term course. OBJECTIVES: To evaluate the long-term course of AA in different age groups. METHODS: A retrospective evaluation of patients who were newly diagnosed with AA from 2008 to 2011 and had at least 7 years of follow-up. Data regarding the initial episode, treatment given, disease-free interval and relapses were analysed. RESULTS: A total of 104 cases were analysed: 31 childhood-onset, 63 adult-onset and 10 late-onset. At first episode, 88.5% of patients had mild, 3.8% moderate and 7.7% severe AA. Full or significant re-growth was observed in 74%, 94% and 100% of childhood-onset, adult-onset and late-onset AA patients, respectively. There was no re-growth in 13%, 3% and 0% of childhood-onset, adult-onset and late-onset patients, respectively. The duration of the initial episode and the disease-free interval negatively correlated with age. Systemic steroids were the most effective treatment for the primary episode. The frequency of relapses was high overall (52%, 44% and 30% in childhood-onset, adult-onset and late-onset, respectively), but significantly declined over time with a majority (79%) occurring within the first 4 years. The disease-free interval and relapse rate were not correlated with gender, disease severity at onset or treatment given. CONCLUSIONS: The prevalence of severe disease, duration of an initial episode and the rate of relapses decreased with an older age at onset. In addition, the outcome and the disease-free interval improved with age at onset. The frequency of relapses declined over time and most appear early on. The current treatment modalities do not seem to influence the long-term outcome.

Relation between ambient air quality and selected birth defects, seven county study, Texas, 1997-2000.

A population-based case-control study investigated the association between maternal exposure to air pollutants, carbon monoxide, nitrogen dioxide, ozone, sulfur dioxide, and particulate matter <10 microm in aerodynamic diameter during weeks 3-8 of pregnancy and the risk of selected cardiac birth defects and oral clefts in livebirths and fetal deaths between 1997 and 2000 in seven Texas counties. Controls were frequency matched to cases on year of birth, vital status, and maternal county of residence at delivery. Stationary monitoring data were used to estimate air pollution exposure. Logistic regression models adjusted for covariates available in the vital record. When the highest quartile of exposure was compared with the lowest, the authors observed positive associations between carbon monoxide and tetralogy of Fallot (odds ratio = 2.04, 95% confidence interval: 1.26, 3.29), particulate matter <10 microm in aerodynamic diameter and isolated atrial septal defects (odds ratio = 2.27, 95% confidence interval: 1.43, 3.60), and sulfur dioxide and isolated ventricular septal defects (odds ratio = 2.16, 95% confidence interval: 1.51, 3.09). There were inverse associations between carbon monoxide and isolated atrial septal defects and between ozone and isolated ventricular septal defects. Evidence that air pollution exposure influences the risk of oral clefts was limited. Suggestive results support a previously reported finding of an association between ozone exposure and pulmonary artery and valve defects.

The development of the complement system after 28 weeks' gestation.

OBJECTIVE: To assess the levels and development of the various complement components in preterm infants, particularly among those born before 34 weeks' gestation. SUBJECTS AND METHODS: We measured the complement system's activities (CH50 and AP50) as well as its various components (C1q,r,s, C2-C9, Factor B, and properdin) in 25 preterm infants [gestational age (GA) 28-33 weeks], 35 preterm infants (GA 34-36 weeks), 50 full-term newborn infants (GA 37-42 weeks), and 49 healthy adults as control subjects. RESULTS AND CONCLUSIONS: The results of these studies are: (i) complement levels and activity were significantly reduced in preterm and full-term neonates when compared with adult levels, with the exception of C7 which was within the normal range in most infants. C8 and C9 were the most markedly reduced at all gestational ages. (ii) Complement levels correlated significantly with gestational age, but not with birth-weight, type of delivery, or gender. (iii) Between 28 and 33 weeks' gestation, there appeared to be almost no development of the complement system.

Children with asthma in the emergency department: spectrum of disease, variation with ethnicity, and approach to treatment.

The role of the pediatric emergency department (ED) in the management of acute asthma was assessed by examining patterns of referrals, admissions, clinical patient evaluation, laboratory tests ordered, and treatment instituted. The functioning of the attending physicians with different degrees of seniority was also evaluated. One thousand thirty-six children with acute asthma (5.3% of all visits) were admitted to the ED during 1990. The mean age was 5.5 years, and the male to female ratio was 2.6:1. Fifty percent of the patients reported atopic disease in their immediate family, and upper respiratory tract infection preceding the attack was reported in 27% of patients. Significant differences were observed between Arab and Jewish patients: more Arab patients presented after physician referral (90 vs 33%) in morning hours (43 vs 26%), and after a longer duration of symptoms. Experienced physicians ordered fewer laboratory tests and treated the patients less aggressively than junior physicians. Patients treated by senior physicians stayed less time in the ED, and a smaller proportion of patients was hospitalized (4 vs 19%). Patients admitted by senior physicians had a longer period of hospitalization (4.7 vs 1.2 days). This study shows that ethnicity influenced the pattern of utilization of the ED and that the approach to care differed among junior and senior physicians.

Helicobacter pylori infection in rural settlements (Kibbutzim) in Israel.

BACKGROUND: Helicobacter pylori (HP) is accepted as a major cause of type B gastritis, which is strongly associated with peptic ulcer disease. Epidemiological studies have indicated a correlation of HP infection and socioeconomic class. METHODS: To determine the prevalence of HP infection and to evaluate symptoms and risk factors associated with HP infection in a rural population, 377 asymptomatic individuals were studied out of a random sample of 453 people. Subjects were randomly chosen in a ratio of 1:4 of all the adults over 30 years, living in eight communal settlements in Israel. Blood samples were taken and subjects answered a questionnaire in which sociodemographic information, clinical gastrointestinal background and the use of medication were included. A sensitive enzyme-linked immunoassay was used to determine antibodies to HP in serum. RESULTS: The overall prevalence of HP infection was 72%. In a multivariant discriminant analysis: age, country of origin and ethnic group were found to be the most closely associated variables for HP infection and the discriminant analysis succeeded in predicting correctly, in 62% of the population, whether they had or did not have HP infection. There was no significant difference with gender, occupation, educational level, blood group, smoking, gastrointestinal symptoms and use of medication. CONCLUSIONS: The prevalence of HP infection was higher than that in industrialized countries, but lower than in developing countries. The prevalence in a rural population was slightly higher than that of an urban population in Israel (65%). The country of origin and ethnic group influenced the prevalence of HP infection and not birth and growing up on the Kibbutz.

Acute asthma. Single dose oral steroids in paediatric community clinics.

The treatment of an acute asthma attack usually includes bronchodilators and often steroids. We studied 70 children who were randomly assigned to receive either single dose steroids (oral prednisone: 20-40 mg) or placebo on a double blind basis. The time course of the observation was 72 h. We demonstrate that a single dose of steroids, given orally in paediatric community clinics during an acute mild to moderate asthma attack, significantly improves the patient's course; deterioration was prevented, symptoms were relieved faster, and hospitalization was not required. We encourage paediatricians in the ambulatory clinics to follow this treatment modality and to give, in addition to other conventional therapy, a single oral dose of steroids early in the asthma attack, in order to relieve and shorten the child's distress.

Some aspects of the humoral immunity and the phagocytic function in newborn infants.

Newborn infants, particularly those born prematurely, are prone to develop life-threatening pyogenic infections. Different studies have demonstrated impairment of various aspects of the humoral immunity and the phagocytic activity of neutrophils in newborns. We conducted a comprehensive study evaluating the complement function (CH50 and AP50) and the level of the vast majority of the complement components (Clq, Clr, Cls, C2-C9, FB and properdin) in preterm and full-term newborn infants as compared to adults. Furthermore, we investigated the effect of autologous and heterologous serum on the bactericidal activity of neutrophils, by crossing newborn serum with adult cells and vice versa. Results showed that preterm and full-term newborns have an impaired complement activity as compared to adults (CH50 P < 0.05, AP50 < 0.01) and significantly reduced complement components except for C7, which was found to be normal in full-term infants and in most appropriate-for-gestational age preterm newborns at 34-36 weeks. A statistically significant correlation was found between gestational age and the level of most of the complement components. CH50 and AP50 also showed a positive trend which, however, was not statistically significant. No correlation was found between birthweight and complement activity or complement component levels. The neutrophil bactericidal activity of full-term newborns was about one-third that of adults (P < 0.001). Adult serum improved the bactericidal activity of newborn neutrophils by 93%, indicating a considerable neonatal humoral defect. Conversely, neonatal serum blunted the adult bactericidal activity by 86%. Our results support the fact that both humoral and phagocytic functions in newborn infants are impaired, which may possibly account for their increased tendency to develop severe pyogenic infections.

Endometrial changes with tamoxifen: comparison between tamoxifen-treated and nontreated asymptomatic, postmenopausal breast cancer patients.

Endometrial thickness, as evaluated by vaginal ultrasonography, and endometrial histologic findings, as well as demographic characteristics, health habits, and risk factors for endometrial cancer, were compared between 93 asymptomatic postmenopausal breast cancer patients who had been on tamoxifen treatment and 20 patients who had not. The mean ultrasonographic endometrial thickness in the women on tamoxifen treatment was 13.1 +/- 10.4 mm, which was significantly thicker than the 4.0 +/- 3.2 mm found in the nontreated women (P = 0.001). The frequency of endometrial pathological findings was remarkably high (35.5%) among the tamoxifen-treated patients, compared with nontreated patients (20.0%), with a P value of 0.058 and an odd ratio of 4.6. Thus, it is suggested that the remarkably high prevalence of pathological endometrial changes was due to the continuous and unopposed exposure of the endometrium to tamoxifen.

Endometrial changes in postmenopausal women treated with tamoxifen for breast cancer.

OBJECTIVE: To evaluate whether risk factors, other than tamoxifen, can be identified for the development of endometrial pathologies in postmenopausal breast cancer patients treated with tamoxifen. DESIGN: A cross-sectional study. SETTING: Department of Obstetrics and Gynaecology and Oncology Clinic, Sapir Medical Center, Kfar Saba, Israel. SUBJECTS: 77 asymptomatic postmenopausal women, treated with tamoxifen for breast cancer. Of these, 55 had no endometrial tissue and 22 had endometrial tissue obtained by biopsy. MAIN OUTCOME MEASURES: Demographic characteristics, health habits, risk factors, vaginal ultrasonographic evaluations of endometrial thickness and texture, and histologic evaluations of endometrial biopsies. RESULTS: Overall, there was a high rate (29%) of endometrial pathological change among the 77 asymptomatic postmenopausal women. There were no significant statistical differences in the features tested between the two groups. CONCLUSION: It is impossible to predict which postmenopausal women will develop pathological endometrial changes after treatment with tamoxifen and thus a routine periodic endometrial sampling-follow up is suggested for all postmenopausal women being treated with this agent.

Referral, admission, and discharge patterns in a pediatric emergency department in Israel.

The pediatric emergency department (PED) is an important component of the medical services provided by a hospital. The purpose of the study was to describe the patterns of referrals, admissions, and discharges in a PED to determine to what extent the PED is used solely as an emergency unit, as opposed to being used as a part of a set of primary care facilities. Data were recorded from 1200 patient charts, out of 19,000 visits to a PED in Israel in 1988. Variables such as age, sex, ethnicity, and distance between residence and hospital were checked. About half of the patients arrived during the morning shift. There was an inverse relationship between the distance from the patient's home to the hospital and the rate of visits to the PED. Fifty-eight percent of the total were self-referred; this rate increased to 84% during the night shift. Only one quarter of all children had additional laboratory or x-ray tests. Most of the diagnoses did not require emergency services. Eighty-one percent of the patients were discharged from the PED to their community physician. The rate of admissions was low (11%). This study shows that a large part of the PED work is actually primary care. Some of the demographic, cultural, and ethnic reasons for these patterns are reviewed.

Obstructing adenoids in adolescents: changing trends?

The number of adolescents undergoing surgery for obstructing adenoids has increased significantly in our practice in recent years. Over an 11-year period during which 539 adenoidectomies were performed, the mean age of patients increased progressively from 4.6 years in 1980 to 7.88 years in 1990. The median age gradually increased over the same period from 4 to 7 years, and the standard deviation from 4.95 to 19.38. Enlarged adenoids should be considered in the differential diagnosis of adolescents suffering from nasal obstruction, snoring or obstructive sleep apnea.

Seasonal pattern in the incidence of bleeding caused by peptic ulcer in Israel.

We have reviewed all endoscopies performed in our hospital between 1977 and 1986. During that period, 1337 endoscopies were performed to identify bleeding from peptic ulcers. Excluded were cases in which a predisposing factor was found, such as the use of ulcerogenic drugs. Also excluded were chronic or critically ill patients. The remaining 540 cases were reviewed. In 447 of those cases, the bleeding lesion was a duodenal ulcer, whereas, in 93 cases, a gastric ulcer was found (a ratio of 5:1). The seasonal variation in the incidence of bleeding from peptic ulcers was evaluated. We found a significant difference in bleeding in the cold and hot seasons, the incidence being significantly greater during the cold season (November until February). A similar pattern was found for bleeding from both duodenal and gastric ulcers.

Effects of the dipyridamole test on left ventricular function in coronary artery disease.

The dipyridamole stress test is used with thallium-201 to detect areas of inhomogeneity of blood flow that point to coronary artery disease (CAD). It is unclear whether dipyridamole produces inhomogeneous perfusion only or whether it actually decreases net flow in the obstructed vessels and produces true ischemia. It is also unclear what effect dipyridamole has on global and segmental left ventricular function. Therefore, ejection fraction, segmental wall motion and ventricular volume equivalents were measured before and after dipyridamole in 113 patients and 32 normal subjects. Ejection fraction responded in an abnormal fashion in 98 patients (87%), decreasing from 49 +/- 11% to 43 +/- 13% (p less than 0.0001), whereas it increased in 29 normal subjects (90%) from 57 +/- 6% to 64 +/- 10% (p less than 0.0001). Wall motion worsened distinctly in 75 patients (66%), and pressure/volume ratio deteriorated in 72%. The effect of dipyridamole lasted between 10 and 25 minutes, but was promptly reversed by aminophylline. These findings indicate that dipyridamole generally induces true ischemia in CAD. Furthermore, the degree of dysfunction is related to the angiographically assessed severity of CAD. The shortness of breath (seen in 10% of patients) may be partially explained by the findings, and it seems advisable to give aminophylline to every patient in order to promptly correct left ventricular dysfunction.

Demoralization and gender differences in a kibbutz.

Gender differences in demoralization (depressive symptoms) were examined in a first-ever true prevalence study conducted in a kibbutz. The unusual organizational arrangements of this commune, where women have achieved higher levels of equality than in most other societies, offered a laboratory-like opportunity to test the psychosocial factors imputed as a partial explanation for the higher rates of demoralization in women. Demoralization was studied using the 27-item scale of the Psychiatric Epidemiology Research Interview (PERI) in all of the adult population of a single kibbutz. The response rate was close to 95%. Univariate and multivariate analyses were conducted to assess the effects of key sociodemographic and kibbutz-related variables on gender differences. The results showed that women had higher mean scores and rates even after these variables were controlled. The female:male demoralization ratio was well within the range of results obtained in non-socialist Israeli urban settings. The paper concludes with a discussion on the tentative relevance of the study results for the interpretation of the 2:1 female-male ratio of depression found in the epidemiological literature.

Ultrasonic validation of residual bladder volume in postvaginal hysterectomy patients.

Transverse and sagittal bladder diameters were measured with real-time ultrasound in 80 patients (100 measurements) during the first 2 days of postvaginal hysterectomy to assess the residual bladder volume and compared with the catheterization volume for the same patients. The sonographic method, with a 97.7% specificity and a negative predictive value of 89.5%, proved to be specific enough to eliminate the necessity of routine catheterization for measuring residual bladder volumes of greater than or equal to 150 cm3, thus decreasing the incidence of some major postoperative complications that can occur due to unnecessary catheterization.

The epidemiology of demoralization in a kibbutz.

This article reports a true prevalence study of demoralization conducted in a kibbutz. This commune, which assures its members all their instrumental needs throughout the individual life span, is probably one of the few of its kind in the world. All adult members (n = 353) of a kibbutz affiliated with the most orthodox of the federations replied to a self-administered interview containing the Psychiatric Epidemiology Research interview 27-item Demoralization Scale. The response rate approached 95%. Univariate and multivariate analyses were conducted using demoralization rates and mean scores as dependent variables. The overall prevalence of demoralization was 25%. Women exhibited higher rates and mean scores. There was a clear association between occupational prestige scores and demoralization in both sexes. Discussion is based on the comparison between the study findings and those published in the literature, both in terms of the overall results and their pattern of association with key sociodemographic variables.

Photonastic Control of Leaflet Orientation in Melilotus indicus (Fabaceae).

Leaflet orientation in Melilotus indicus (L.) All. Is under photonastic control during the day and nyctinastic control during the night, but also exhibits a diaphototropic (solar-tracking) response. Detached leaves with the two lateral leaflets excised were used to study the solar-tracking capability of the terminal leaflet. Perception of the photonastic excitation is located in the pulvinule. The lower (abaxial) and upper (adaxial) surfaces perceive photonastic excitation, which results in concomitant contraction of the side exposed to light and/or expansion of the opposite side. Steady state laminar elevation is determined by the fluence rates of the light incident simultaneously on the opposite sides. Light sensitivity of the lower side exceeds that of the upper. Response to photonastic excitation of either side is affected by angle of incidence of the light, but angular dependence is restricted to a limited range of angle of incidence, which differs for the two sides. This may be accounted for by the different topography of the two pulvinar surfaces and the localization in them of the light-sensitive tissues.