Avner Cohen

Continuing medical education and primary physicians' job stress, burnout and dissatisfaction

The association between opportunities for continuing medical education (CME) and primary physicians’ job stress, burnout and job dissatisfaction has not been investigated. It was hypothesized that participation in CME activities and perceived opportunities at work for keeping up‐to‐date with medical and professional developments would be correlated negatively with job stress and burnout, and positively with job satisfaction.

Opaque nuclear proliferation

(1990). Opaque nuclear proliferation. Journal of Strategic Studies: Vol. 13, Opaque Nuclear Proliferation: Methodological and Policy Implications, pp. 14-44.

Raynaud's Phenomenon as a Manifestation of Parvovirus B19 Infection: Case Reports and Review of Parvovirus B19 Rheumatic and Vasculitic Syndromes

Infection with human parvovirus B19 is manifested as erythema infectiosum, transient aplastic crisis, or hydrops fetalis. Rheumatic manifestations include arthropathy and various vasculitic syndromes. Isolated Raynauds phenomenon due to parvovirus B19 has never been described. We report on 2 previously healthy sisters with new-onset Raynauds phenomenon accompanied by severe generalized polyarthralgia. A full workup was negative, except serology for parvovirus B19, which was positive. All symptoms gradually subsided within 3-5 months, and no recurrence has been noted during the 3 years since onset. We review all the studies in the English-language literature on parvovirus B19-induced rheumatic and vasculitic syndromes. We hypothesize that the pathogenesis of Raynauds phenomenon in our patients involved immune-mediated endothelial damage leading to platelet activation and vasoconstriction. We recommend that in cases of unexplained Raynauds phenomenon, serology for parvovirus B19 be included in the evaluation.

Successful withdrawal from analgesic abuse in a group of youngsters with chronic daily headache.

Abuse of ergotamine and analgesics is common in adults. It coexists with headache and can also induce headaches. Ten to 15% of patients attending headache clinics and 1% of the general population suffer from chronic daily headache due to medication misuse. Indeed, this phenomenon was recently regarded as an epidemic. Nonetheless, analgesic-induced headache in children and adolescents was first reported in 1998. We report on our experience with children and adolescents with daily or almost-daily headache concomitant with daily or almost-daily analgesic intake. Over a period of 3 years, we evaluated 26 children (19 girls and 7 boys) with chronic daily or near-daily headache related to daily analgesic intake. The mean age of the group was 14.2 years (range, 12-18), and the mean headache history duration was 1.6 years (range, 3 months to 4½ years). The mean number of headache days per month was 28.1 (range, 19-31). All patients had no history of migraine prior to the chronic headache phase according to the International Headache Society criteria. They were using at least one dose of analgesic drug for each headache, whereas 16 were using analgesic drugs daily. The weekly analgesic intake averaged 28.1 tablets (range, 19-41). The majority abused simple analgesics. Twenty-one took acetaminophen alone. Five took a combination; four took a compound containing acetaminophen, caffeine, and codeine; and the fifth patient took a compound containing aspirin, caffeine, and codeine. All patients were informed about the phenomenon of medication-induced headache and were encouraged to achieve drug withdrawal. Withdrawal led to complete cessation of all headaches in 20 patients. In 5 patients, the daily headache resolved; however, they suffered from intermittent episodic migraine attacks, which were frequent enough in 3 to initiate prophylactic medication. One adolescent continued to have daily headache. Analgesic-induced headache does occur in adolescents. Successful withdrawal from the offending analgesics was achieved without hospitalization or significant interference with daily life and with complete disappearance of the induced chronic daily headache in 25 of 26 patients. (J Child Neurol 2001;16:448-449).

Final height of girls with Turner's syndrome: correlation with karyotype and parental height

Final height of 75 adults with Turners syndrome (45 Israeli, 30 Italian), never treated with GH, was examined to see if a relationship with karyotype patterns and parental height existed. Patients were divided into five groups according to their chromosome pattern, as follows: group A = 45,X karyotype (34 patients); group B = mosaicism (11 with karyotype 45,X/46,XX and 7 with karyotype 45,X/ 46,XY); group C = deletion of all or part of Xp (19 patients); subgroup CI = 6 with complete deletion of Xp; subgroup C2 = 9 with mosaicism 45,X/46,X,i(Xq); subgroup C3 = 4 with 45,X/46,X,ring(X); group D = deletion of Xq (4 patients); pure gonadal dysgenesis (PGD) group = 9 patients with pure 46,XX gonadal dysgenesis. No statistical difference was noted between the mean height of the two national populations studied (Italian 142.2 ±5.7 and Israeli 143.0 ±7.2 cm). The mean heights of group D (148.9 cm; range 147–166.2) and the PGD group (156.0 cm; 141–171.5) were found to be significantly higher than those observed in groups A, B and C (p <0.03, p < 0.02 and p <0.02, respectively), even though gonadal distinction existed in all five groups. Subgroup CI, where a deletion of the entire Xp segment [46,X,i(Xq)] was present, was found to be the shortest group (median height 134.5; range 131.9–138 cm). No fixed pattern of correlation between final height and parental height was found within any of the groups studied but if we consider the mean final height of all Turner patients studied, without division into groups, it correlates well, but only with mothers’height and not with fathers’height. These data provide further confirmation that short stature in Turners syndrome is multifactorial and depends on the deletion of the distal portion of the short arm of chromosome X, on the lack of sex hormone secretion and, in part, on parental height.

Israel and Chemical/Biological Weapons: History, Deterrence, and Arms Control

In April 1948, David Ben-Gurion, Israel’s founding father and first prime minister, wrote a letter to Ehud Avriel, one of the Jewish Agency’s operatives in Europe, ordering him to seek out and recruit East European Jewish scientists who could “either increase the capacity to kill masses or to cure masses; both are important.”2 One of the scientists Avriel recruited was a 30-year old epidemiologist and colonel in the Red Army named Avraham Marcus Klingberg. In time, Klingberg became one of Israel’s leading scientists in the area of chemical and biological weapons (CBW). He was among the founding members and, subsequently, the deputy director of the Israel Institute of Biological Research (IIBR) in Ness Ziona, a dozen miles southeast of Tel Aviv.

Community-acquired enterococcal urinary tract infections in hospitalized children

The objectives of this study were to characterize community-acquired (CA) enterococcal urinary tract infections (UTIs) in a tertiary pediatric center and to determine risk factors for their occurrence, their association with renal abnormalities, their antibiotic susceptibility profile, and the appropriateness of the empiric antibiotic treatment, in comparison to those of Gram-negative UTIs. In a 5-year prospective clinical and laboratory study, we found that enterococcal UTIs caused 6.2% (22/355) of culture-proven CA UTIs. Compared with Gram-negative UTI, enterococcal UTI was associated with male predominance, higher rates of underlying urinary abnormalities (70 vs. 43.7%; p = 0.03) and inappropriate empiric antibiotic therapy (22 vs. 5.6%; p = 0.02), and mainly vesicoureteral reflux (53% of cases). This study highlights the importance of early detection of CA enterococcal UTIs because of their association with underlying urinary abnormalities and a high rate of inappropriate empiric antibiotic therapy. Renal imaging is recommended for children with enterococcal UTIs; Gram stain is suggested in selected cases to detect Gram-positive cocci for early diagnosis of enterococcal UTIs and initiation of appropriate antibiotics.

Exploring physician perceptions of the impact of emotions on behaviour during interactions with patients

BACKGROUND There is relatively little research on affective influences on physician behaviour, especially on prescribing and referrals. Affects include transitory moods and lasting emotions. OBJECTIVES We explored physician perceptions of the impact of four mood states on perceived rates of five behaviours: talking with patients, prescribing medications and referrals for laboratory tests, diagnostic tests and specialists. We also examined whether burnout modified the impact of moods on behaviour. METHODS A total of 188 family physicians responded anonymously to a self-reporting questionnaire that assessed the perceived rate of behaviours when in a positive, negative, tired and nervous mood and burnout level. RESULTS Five analyses of variance with repeated measures on mood states and contrast analyses computed the effects of mood and burnout on the behaviours. The mood factor was found significant for each of the behaviours, in all P < 0.001. The respondents reported that on good mood compared with negative mood days, they talked more, prescribed less and referred less. The burnout factor was also significant: high compared with low burnout physicians had higher perceived rates of all referral behaviours. Significant mood × burnout interactions indicated that the effects of mood were stronger among high compared with low burnout physicians. CONCLUSIONS The physicians perceived that their moods had different effects on different behaviours: the negative mood decreased talking and increased prescribing and referral behaviours and vice versa for the positive mood. Burnout intensified the effects of moods. The incremental effects of negative moods and burnout may impair quality of health care and may be costly to health services.

Parent‐dependent barriers to varicella immunization in Israel: the importance of adequate information

Aim: To examine the parent‐dependent barriers to varicella immunization in Israel.

Colchicine-induced myoneuropathy in childhood

Abstract Colchicine is used in the treatment of gouty arthritis, familial Mediterranean fever, amyloidosis, Behcet disease and dermatoses. Myoneuropathy is a rare side-effect reported either with intoxication or in elderly patients with chronic renal insufficiency causing elevated plasma drug levels. We report the first two cases of myoneuropathy in children, both taking appropriate doses of colchicine, and having normal renal function. The myoneuropathic changes were reversible after stopping treatment. The cause of colchicine myoneuropathy is unclear. Conclusion In children treated with colchicine, neuromuscular phenomena of unknown aetiology may be related to the drug, even with a lack of intoxication or renal insufficiency.