No apparent association between bipolar disorder and cancer in a large epidemiological study of outpatients in a managed care population.

An association between bipolar disorder (BD) and cancer risk has been reported. The purpose of this study was to investigate this association through linkage analysis of a national HMO database and a national cancer registry. All members of the Leumit Health Services (LHS) HMO of Israel from 2000 to 2012 were included. Members with a recorded diagnosis of BD and a record of at least one written or dispensed prescription for pharmacotherapy for treatment of BD were classified as patients with BD. We linked the LHS population with the Israel National Cancer Registry database to capture all cases of cancer reported. Standardized incidence ratios (SIRs) for cancer in the BD population as compared with non-BD LHS members were calculated. A total of 870 323 LHS members were included in the analysis; 3304 of whom met the criteria for inclusion in the BD arm. We identified 24 515 and 110 cancer cases among members without BD and with BD, respectively. Persons with BD were no more likely than other HMO members to be diagnosed with cancer during the follow-up period [SIR, males=0.91, 95% confidence interval (CI): 0.66-1.22; SIR, females=1.15, 95% CI: 0.89-1.47]. Sensitivity analysis using different criteria for positive BD classification (lithium treatment alone or registered physician diagnosis) had no effect on the estimate of cancer risk. A nonstatistically significant association between breast cancer and BD among women was observed (SIR=1.24, 95% CI: 0.79-1.86). These findings do not corroborate previously reported associations between BD and elevated cancer risk.

Self esteem, dependency, self-efficacy and self-criticism in social anxiety disorder.

BACKGROUND: Social anxiety disorder (SAD) is characterized by fear and avoidance in social situations where one perceives being in danger of scrutiny by others. Low self-esteem, low self-efficacy, high self-criticism and high dependency are additional potential features of SAD, and thus their examination is warranted, as is the elucidation of their inter-relationship. METHOD: Thirty-two SAD subjects diagnosed with the Mini-International Neuropsychiatric Interview and 30 healthy controls, were administered the Liebowitz Social Anxiety Scale (LSAS), the Rosenberg Self Esteem Scale, the Depressive Experiences Questionnaire (DEQ) that assesses self-criticism, dependency and self-efficacy, and a socio-demographic questionnaire. We hypothesized that the SAD group would present higher scores of dependency and self-criticism and lower self-esteem and self-efficacy. We also hypothesized that low self-esteem, low self-efficacy, high self-criticism and high dependency will predict the severity of SAD. RESULTS: In line with the hypotheses, SAD patients had higher scores of self-criticism and dependency and lower scores of self-esteem. The social anxiety score correlated negatively with self-esteem and self-efficacy, and positively with dependency and self-criticism. Self-criticism, but not the other measures, predicted the total LSAS score. CONCLUSIONS: Self-esteem, self-criticism, dependency and self-efficacy are related to SAD and their relations should be examined in future studies that will employ larger samples. It is suggested to search for ways to affect these factors through cognitive-behavioral interventions and additional psychotherapeutic treatments. Research should also focus on the specific role of self-criticism in SAD.

Helicobacter pylori infection in patients with selective immunoglobulin E deficiency.

AIM: To investigate the prevalence and clinical characteristics of Helicobacter pylori (H. pylori)-infected dyspeptic patients with selective immunoglobulin E deficiency (IgEd). METHODS: All individuals who underwent serum total immunoglobulin E (IgE) measurement at the Leumit Healthcare Services (Israel) in 2012 were identified in an electronic database search (n = 18487). From these, selected case group subjects were ≥ 12 years of age and had serum total IgE < 2 kIU/L (n = 158). The control group was selected from a random sampling of the remaining subjects ≥ 12 years of age to obtain a case-control ratio of 1:20 (n = 3160). Dyspeptic diseases, diagnosed no more than 5 years before serum total IgE testing, were identified and retrieved from the electronic database using specific International Classification of Diseases diagnostic codes. Results of C(13)-urea breath tests were used to identify subjects infected with H. pylori. Categorical variables between case and control subjects were analyzed using Fisher's exact tests, whereas continuous variables were analyzed using χ (2) tests. RESULTS: Dyspepsia was present in 27.2% (43/158) of case subjects and 22.7% (718/3160) of controls. Of these, significantly more case subjects (32/43, 74.4%) than controls (223/718, 31.1%) were positive for H. pylori (P < 0.01). Esophagogastroduodenoscopy was performed in 19 case and 94 control subjects, revealing that gastritis was more prevalent in IgEd case subjects than in controls (57.9% vs 29.8%, P < 0.05). Furthermore, a significantly greater proportion of case subjects presented with peptic duodenal ulcers (63.2% vs 15.9%, P < 0.01). Histopathologic examination showed marked chronic inflammation, lymphoid follicle formation and prominent germinal centers, with polymorphonuclear cell infiltration of gastric glands, that was similar in case and control biopsy tissues. Finally, IgEd case subjects that underwent esophagogastroduodenoscopy were more likely to exhibit treatment-refractory H. pylori infections that require second-line triple antibiotic therapy (47.4% vs 11.7%, P < 0.01). CONCLUSION: IgEd is associated with higher rates of H. pylori-associated gastritis and peptic duodenal ulcers.

[Sexual behavior characteristics of clients attending the Israel AIDS Task Force anonymous clinic in Tel Aviv].

UNLABELLED: Until now, research on sexual behavior and HIV in Israel has been carried out mainly on the general population, and focused primarily on defining populations at risk, without adequate consideration given to the reasons bringing these populations to be tested, and their specific sexual behaviors. In Israel, one can choose whether to take an HIV test in confidential centers (giving one's name under medical confidentiality) or in anonymous centers (Israel AIDS Task Force in Tel Aviv and Beer Sheva, Levinsky Clinic in Tel Aviv and Haparsim Clinic in Haifa]. At least 21% of the clients of the anonymous testing centers in Israel belong to a high risk population in contrast to 2.6% in confidential clinics, and so, in this study, we hypothesize that characterization of sexual behavior patterns in anonymous testing centers might enable us to better characterize sexual behavior patterns in high risk populations. METHODS: In this cross-sectional study, we used questionnaires distributed in the clinics by the Israel AIDS Task Force in order to characterize their clinic's clients. The questionnaires were completed by the Israel AIDS Task Force consultants during the consultation period at which the anonymous test was performed. Data collected included: gender, age, testing history, specific sexual behaviors and reasons for applying for the current test. RESULTS: A total of 926 questionnaires were collected; 29.9% of them were of female patients. The average age was 29.47 years (1±8.66]; 21.3% of the clients were men who have sex with men [MSM]; only 2.3% of the clients belonged to other high risk populations. In all groups, the majority of the patients reported high risk sexual behavior (any sexual contact without a condom) and the average age for the first test was much higher than the average age of first sexual intercourse common in Israel. Women reported more participation in unprotected vaginal intercourse than heterosexual men, and a substantial part of MSM reported performing unprotected anal intercourse. More heterosexuals than MSM stated a new relationship as a reason for applying for the test, and more MSM than heterosexuals reported arriving for a routine check-up. CONCLUSIONS: There is a need for comprehensive programs encouraging testing for HIV in all age groups, focusing on Sthe ages 18-25 years, and encouraging the use of a condom as a preventive measure in all populations, especially women. We feel it is essential to emphasize the need for educational programs tailored for each sub-population's psychosocial characteristics and specific issues.

Selective IgE deficiency, immune dysregulation, and autoimmunity.

Selective IgE deficiency (IgED) is currently defined as a significant decrease in serum levels of IgE (<2 kIU/L) in a patient whose other immunoglobulin levels are normal. There are no published large-scale epidemiological studies regarding the prevalence of and clinical features of IgED. In the population-based case-control study, we investigated clinical and laboratory characteristics of patients with IgED. Case samples were drawn from all subjects (n = 18487), with serum total IgE measurement during 2012 at Leumit Health Care Services (Israel) and had serum total IgE of <2 kIU/L. The control group was randomly sampled from the remaining 18,261 subjects with a case-control ratio of four controls for each case (1:4). Comorbid diseases were identified by specific International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes given by the corresponding board-certificated physicians. Two hundred twenty-six subjects showed serum total IgE levels of <2 kIU/L; 68 (30.9%) were between the ages of 4 and 12 years (children) and 250 (69.1%) were ≥12 years old (adults). Matched control groups were selected for each age group. The children group was characterized by higher prevalence of asthma and hyperreactive airways disease; and both children and adult groups had significantly higher prevalence of chronic sinusitis, otitis media, autoimmune, and oncological diseases than their respective controls. Undetectable serum total IgE may serve as a marker of immune dysregulation and autoimmunity.

Unusual masturbatory practice as an etiological factor in the diagnosis and treatment of sexual dysfunction in young men.

INTRODUCTION: Masturbation is a common sexual activity among people of all ages throughout life. It has been traditionally prohibited and judged as immoral and sinful by several religions. Although it is no longer perceived as a negative behavior, masturbation is often omitted in the diagnostic inquiry of patients with sexual problems. AIMS: The aims of this study are to increase the awareness of clinicians to the importance of including questions regarding masturbatory habits in the process of sexual history taking, to analyze cases of male sexual dysfunction (SD) associated with unusual masturbatory practices, and to propose a practical tool for clinicians to diagnose and manage such problems. METHODS: A clinical study of four cases that include a range of unusual masturbatory practices by young males who applied for sex therapy is described. An intervention plan involving specific questions in case history taking was devised. It was based on detailed understanding of each patient's masturbatory practice and its manifestation in his SD. MAIN OUTCOME MEASURES: Effects of identifying and altering masturbatory practices on sexual function. RESULTS: The four men described unusual and awkward masturbatory practices, each of which was associated with different kinds of SD. The unlearning of the masturbatory practices contributed notably to improvement of their sexual function. CONCLUSIONS: The four cases in this study indicate that the detailed questioning of masturbatory habits is crucial for a thorough assessment and adequate treatment of sexual problems in men. We propose specific questions on masturbatory behavior as well as a diagnostic and therapeutic flowchart for physicians and sex therapists to address those problems.

Objective and subjective sexual outcomes in adult patients after hypospadias repair performed in childhood.

PURPOSE: We evaluated sexual function and psychosexual adjustment in adults who underwent hypospadias repair in childhood. MATERIALS AND METHODS: After receiving institutional review board approval, 119 of 449 adult patients (26.6%) who underwent hypospadias repair between 1978 and 1993 responded to questionnaires on penile appearance and sexual life. Patients were divided into 3 groups according to primary meatal location in childhood, including group 1-45 (37.8%) with glanular hypospadias, group 2-56 (48.2%) with distal hypospadias and group 3-18 (14%) with proximal hypospadias. RESULTS: All group 1 and 2 patients, and 11% in group 3 were satisfied with the penile appearance. Of group 1 patients 8.9% reported mild erectile dysfunction, as did 50% and 72.2% in groups 2 and 3, respectively. A total of 99 patients (83.2%) complained of premature ejaculation. All group 1 and 2 patients reported excellent self-esteem and relationship on the Self-Esteem and Relationship questionnaire. Most group 3 patients were satisfied with their relationship and only 1 (5.6%) was not satisfied. Two-thirds of the patients in groups 1 and 2 reported that sexual quality of life was excellent and the others described it as good. In group 3 sexual quality of life was somewhat decreased in all patients and 1 (5.6%) had poor sexual quality of life. Physical and mental component summaries were satisfactory in all patients reviewed. CONCLUSIONS: Our data show that the high incidence of mild erectile dysfunction and premature ejaculation should not be disregarded and requires appropriate counseling before surgery.

[Sexual function and dysfunction: from theory to practice].

Sexual dysfunctions are common phenomena in healthy as well as in ill populations. The introduction of PDE5-inhibitors gave primary health-care physicians and specialists a tool to treat erectile dysfunction. This focused the attention on the need of physicians to be trained to discuss helpfully sexual issues. Sexual dysfunctions are biopsychosocial phenomena with many causes, including specific diseases and some treatments. These dysfunctions can be a cause for much distress. It seems that nowadays people are more prepared to ask sexual questions than physicians are ready to discuss and answer them. In this issue of Harefuah, we present many aspects of a combined, multi-professional, biopsychosocial model, for identifying and treating sexual dysfunctions. We also propose some ideas that could serve medical professionals in their efforts to better deal with sexual matters.

Not only headache: higher degree of sexual pain symptoms among migraine sufferers.

Chronic illness and chronic pain can have profound negative effects on relationship and sexual satisfaction, yet the influence of migraine on sexuality has not been previously evaluated. To assess sexual functions in subjects with migraine compared to those with no migraine. We evaluated female university students using the Israeli sexual behavior inventory (ISBI). Migraine was diagnosed according to self-reported symptoms according to the IHS criteria. Several dimensions of female sexuality--desire, orgasm, sexual avoidance, interpersonal sexual relationship, health influence, satisfaction and pain were evaluated using a structured questionnaire. Thirty-three (23.9%) of the participants met the IHS criteria for episodic migraine with and without aura. Sexual activity, desire, orgasm and satisfaction from sexual life did not differ significantly between migraine sufferers and non-sufferers. Migraine patients reported lower ISBI scores, higher health influence on sexual life, higher levels of sexual pain and lower sexual satisfaction. Migraine negatively affected the sexual life of sufferers. Sexual pain disorder is more common among migraine sufferers compared to non-migraineurs.

Surrogate versus couple therapy in vaginismus.

INTRODUCTION: Women who do not have a cooperative partner cannot complete the usual therapeutic process in the treatment of vaginismus, because they cannot progress to the stage of practicing the insertion of the man partner's fingers and the insertion of a penis. AIM: To compare traditional couple therapy with therapy utilizing a surrogate partner. METHODS: The study was controlled and retrospective. Data were obtained from the treatment charts of patients who had come to the clinic for treatment of vaginismus. Sixteen vaginismus patients who were treated with a man surrogate partner were compared with 16 vaginismus patients who were treated with their own partners. MAIN OUTCOME MEASURES: Successful pain-free intercourse upon completion of therapy. RESULTS: One hundred percent of the surrogate patients succeeded in penile-vaginal intercourse compared with 75% in the couples group (P = 0.1). All surrogate patients ended the therapy because it was fully successful, compared with 69% in the couples group. Twelve percent of the couples group ended the therapy because it failed, and 19% because the couples decided to separate. CONCLUSIONS: Treating vaginismus with a man surrogate partner was at least as effective as couple therapy. Surrogate therapy may be considered for vaginismus patients who have no cooperative partner.

Transdermal testosterone gel prn application for hypoactive sexual desire disorder in premenopausal women: a controlled pilot study of the effects on the arizona sexual experiences scale for females and sexual function questionnaire.

INTRODUCTION: Several studies suggest that increased plasma testosterone can improve sexual function and desire in post-oophorectomy or postmenopausal women. However, side effects of chronic daily testosterone raise questions about the generalizability of this treatment approach. Sublingual testosterone was reported to cause testosterone levels to peak after 15 minutes and then decline to baseline levels within 90 minutes. Three to 4 hours after reaching testosterone peak, increased genital sensations and sexual lust were reported. AIM: We hypothesized that a single dose of testosterone given 4-8 hours prior to planned intercourse in women with hypoactive sexual desire disorder (HSDD) might increase desire without side effects associated with chronic use. METHODS: The design was randomized double-blind crossover. Premenstrual women with HSDD received eight packets of gel or identical placebo for use before intercourse twice weekly for 1 month. For a second month, the alternate treatment was given. MAIN OUTCOME MEASURES: Ratings were performed using the patient-rated Arizona Sexual Experiences Scale for females and the clinician-rated Sexual Function Questionnaire (SFQ-V1). RESULTS: Ten patients completed the study. On the five-item self-report Arizona, the item "How easily are you aroused?" was significantly improved on testosterone gel vs. placebo, P = 0.03. There were similar trends on the physician-rated SFQ-V1 "arousal-sensation" cluster. CONCLUSIONS: These preliminary results suggest that testosterone gel given prn before intercourse has effects on sexual arousal, and further research is needed to define dosage and time schedule to optimize this effect and determine its clinical relevance.

Sensitivity to carbon dioxide in drug-naïve subjects with post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) is currently classified as an anxiety disorder in DSM-IV, and as a neurosis or stress-related disorder in ICD-10. It shares many features with depression. Sensitivity to carbon dioxide (CO2), a classic provocation agent in the proto-typical anxiety disorder, panic disorder, has not been tested in PTSD. Twenty rigorously ascertained drug-naïve subjects with PTSD inhaled a single vital capacity inhalation of 35% CO2; before and after the inhalation they completed measures of PTSD and panic anxiety, and were rated for the presence of a panic attack. These results were retrospectively compared with those of 39 healthy volunteers and 17 patients with panic disorder previously studied by the same research group. PTSD symptoms were not exacerbated by CO2. Two out of twenty PTSD subjects panicked. PTSD subjects' responses were indistinguishable from those of healthy volunteers, and differed from those of subjects with panic disorder. The lack of sensitivity to carbon dioxide in PTSD subjects in the present study adds to the literature on the differences between PTSD and other anxiety disorders, and to that on the specificity of the CO2 challenge in panic disorder.

[Heart to heart: rehabilitation of sexuality in cardiac patients].

Heart disease in general and acute myocardial infarction involve sexual dysfunction caused by anxiety and by the same physiological problems that caused the heart problem, namely endothelial dysfunction. Unfortunately, many patients and their spouses hesitate to approach their doctor on issues related to their sexual concerns. Furthermore, the medical team in general and doctors in particular are irresolute in bringing up sexual issues when dealing with overall cardiac rehabilitation. Although patients can safely resume sexual activity at some point, only one in four actually return to their previous level of sexual activity. If we really want to assist in the rehabilitation of patients we have to advise them about resuming their sex life. Solving sexual problems can serve as a tool in primary, secondary and tertiary prevention of cardiac problems, as it can be used as an "arm swinger" for changing one's life habits. We urge increased research and treatment of sexual problems, in cardiac patients in general and in female patients in particular.

[A psychosocial view of a number of Jewish mourning rituals during normal and pathological grief].

This article describes the three stages of normal and pathological mourning, emphasizing the constellation embodied in Judaism for this process. These stages are: shock, acute mourning, working through and reconciliation. We present the important question: "How to define pathological mourning?" It is certainly not only a matter of extending beyond the accepted time limits of the mourning process, but also a question of the intensity of mourning in ones daily life, the degree of being preoccupied with it, and the degree of priority that this mourning process has in an individual's life. A number of forms of pathological mourning, during the three mentioned stages, are described, with special attention to Jewish mourning rituals, especially: The "rending of the garments" (Kriyah), the Kaddish, the Shiva, and the termination of mourning after a fixed period of time. One of the possible interpretations of these rituals is that they prevent and neutralize manifestations of aggression and violence. This is an analogue to the function of biological (genetic) rituals which according to the theory of Konrad Lorenz, also minimize the dangerous aggression between the species in nature. The religious ritual converts an aggressive behavior to a minimal and symbolic action, often re-directed, so that an originally dangerous behavior becomes a ritual with an important communicative function.

[Commercial sex work: psychiatric and medical aspects].

Commercial sex work has many medical and psychiatric implications. In recent years many papers on this matter have been published. However, many of these articles are based on opinions rather then on empiric fieldwork. Sex workers in the western world are not a major source of spread of venereal diseases. Nonetheless, it is important for medical decision makers to be aware of the health risks related to commercial sex work habits: for example. avoidance of condoms for oral sex, might be a risk factor for gonorrhea transmission. In field studies in Israel and abroad, it has been shown that sex workers are not always drug addicts or mentally ill; many of them see it as a legitimate form of work that is dictated by their needs, their social, personal and familial background. Commercial sex workers frequently suffer from emotional and somatic health problems that are often neglected. This review intends to examine the few empirical works that have been conducted on commercial sex workers. including our recent study performed in Israel.

Influence of the serotonin antagonist, metergoline, on the anxiogenic effects of carbon dioxide, and on heart rate and neuroendocrine measures, in healthy volunteers.

The mechanism of action of carbon dioxide (CO(2)) angiogenesis is unknown; only recently have possible serotonergic (5-HT) influences begun to be studied. In separate double-blind challenges 1 week apart, 14 healthy volunteers received two vital capacity inhalations each of 35% CO(2) and of air, once after a single capsule of placebo and once after a single capsule containing 4 mg of the 5-HT antagonist metergoline in a randomized crossover design. The inhalations were repeated 1 and 2 days after the ingestion of capsules, to investigate possible delayed effects of metergoline, and possible tolerance to repeated CO(2) after placebo. We observed increased anxiety, and a trend for increased plasma noradrenaline (NA), after CO(2). CO(2) anxiogenesis was significantly enhanced by metergoline. Heart rate increased after both gas mixtures following metergoline administration. Plasma prolactin levels were lower after metergoline. Responses to CO(2) did not differ between the day of placebo administration and the two subsequent days; on the days following metergoline administration there were almost no delayed effects. We hypothesize that 5-HT may function as an inhibitor of CO(2) anxiogenesis, and that this is opposed by the 5-HT antagonist, metergoline. Absence of tolerance after repeated CO(2) argues against psychological explanations of tolerance after other panicogens. Copyright 2001 John Wiley & Sons, Ltd.

Lack of association between joint hyperlaxity and, I: panic disorder, and II: reactivity to carbon dioxide in healthy volunteers.

This study attempted to replicate previous reports of associations between panic disorder and joint hyperlaxity. The authors also examined possible associations between reacitivity to carbon dioxide (CO(2)), a model for panic vulnerability, and hyperlaxity in healthy volunteers. One hundred and one patients with DSM-IV panic disorder and 39 healthy volunteers were assessed for hyperlaxity by Beighton's criteria. Healthy volunteers also received two vital capacity inhalations of CO(2). Thirteen (13%) patients had five or more hyperlax joints. This rate did not differ from that in the healthy volunteers. Anxiety in healthy volunteers, as measured by the NIMH self-rating scale, DSM-IV panic symptom scores, and 100 mm visual analog scales of anxiety, increased after CO(2) from a mean of 1.8 to 2.8 (not significant); from 0.5 to 4 ( p < 0.001) and from 8.7 to 11.6 mm ( p < 0.1), respectively. There were no associations between responses to CO(2) and hyperlaxity. Copyright 2001 John Wiley & Sons, Ltd.