Biomedical subjects
Publications and source records attributed to P Shvartzman.
Cardiac tachyarrhythmias are common in thyrotoxicosis. We report an uncommon case of a 53-year-old woman with Grave's disease who developed second degree A-V block while euthyroid on propylthiouracil. The most likely mechanism is an autoimmune response causing infiltration of the cardiac conduction pathways.
STUDY OBJECTIVES: The incidence and prevalence of pertussis in adults have increased in recent years. It has been shown that previously immunized adults and adolescents are the main sources of transmission of Bordetella pertussis. The aim of this study was to describe the clinical presentation and the clinical course of pertussis in children and young adults who were immunized previously against B pertussis. DESIGN: Retrospective study. SUBJECTS: Children and young adults who were reported by local physicians to the Department of Epidemiology in the Israeli Ministry of Health with serologically confirmed pertussis and who were immunized previously were included. Information sought included personal data, epidemiologic data, signs and symptoms, laboratory results, initial diagnosis, and treatment. RESULTS: In the 95 previously immunized patients with serologically confirmed pertussis (mean age [+/- SD], 8.9 +/- 4.4 years old; range, 5 to 30 years old), the mean duration from onset of symptoms until the final diagnosis of pertussis was 23 +/- 15 days. The disease was usually atypical and generally mild. All the described patients had cough, usually prolonged, lasting 4 +/- 3.6 weeks. Only 6% had the classic whoop. The mean WBC count was 8.7 +/- 2.6 cells/mm6, and the lymphocyte count was 40 +/- 12%. Two patients were admitted to the hospital for severe pneumonia. Among the reported cases, the proportion of patients between the ages of 10 and 45 years increased from 6.5% during the period from 1971 to 1980, to 26% during the period from 1980 to 1990, and to 38% during a 1989 outbreak. CONCLUSIONS: Pertussis in previously immunized individuals is usually characterized by an atypical and relatively mild clinical course. Patients suffer mainly from a prolonged and persistent cough. Early diagnosis may lead to prompt administration of therapy. Prophylaxis of exposed persons might be effective in decreasing both severity and transmission of the disease.
Family physicians often encounter patients with acute knee trauma. Radiographs of injured knees are commonly ordered, even though fractures are found in only 6 percent of such patients and emergency department physicians can usually discriminate clinically between fracture and nonfracture. Decision rules have been developed to reduce the unnecessary use of radiologic studies in patients with acute knee injury. The Ottawa knee rules and the Pittsburgh decision rules are the latest guidelines for the selective use of radiographs in knee trauma. Application of these rules may lead to a more efficient evaluation of knee injuries and a reduction in health costs without an increase in adverse outcomes.
BACKGROUND: Incidence rates for malignant melanoma in Israel are rising steadily, and the kibbutz population is at increased risk for this malignancy. OBJECTIVES: To assess the risk factors for malignant melanoma among kibbutz members compared to matched healthy controls. METHODS: We conducted a case-control study of 168 malignant melanoma patients and 325 healthy controls, matched by age and gender. Data were collected on three categories of risk: demographic, personal (e.g., skin, eye and hair color), and environmental/behavioral (e.g., sun exposure, use of sunscreens). RESULTS: There were no differences between the groups regarding sociodemographic data. Significantly more patients than controls had fair, vulnerable skin (P < 0.001), light eyes (P < 0.05), and fair hair (P < 0.001). There was no difference in family history of malignant melanoma or other cancers. Patients with malignant melanoma had significantly more additional skin lesions (e.g., keratoses) (P < 0.001). More patients than controls recalled having been exposed to the sun for long periods when they were 6-13 years of age. A conditional logistic regression analysis showed that fair hair, fair vulnerable skin, and additional skin lesions were independently associated with malignant melanoma (P < 0.01). CONCLUSIONS: The main target population for interventions to reduce the incidence of malignant melanoma among kibbutz members should be individuals with these risk factors. A history of increased exposure to the sun from age 6 to 13 should also be taken into account as an independent risk factor.
Substance abuse is one of the most serious problems in Israel. Recent studies show the situation is getting worse. The deleterious outcomes of psychoactive substance abuse include crime, car accidents, physical and mental illness, violence and work injuries. 48 family physicians in the Negev completed a questionnaire which included training, diagnostic and treatment skills, attitudes, knowledge and need for training in this field. 38 family physicians (81%) had had no training, most (96%) indicated the importance of such training. 34 (71%) said that their medical skills could not cope with the problems of addiction, and 29 (64.5%) claimed that the quality of care of addict patients is reduced because of lack of knowledge and diagnostic skills. These findings support the conclusion that efforts should be invested in training family physicians in the field of psychoactive drugs, licit and illicit.
CONTEXT: Surveys carried out among users of medical services can be a useful tool for health care organizations in designing proper services. Specifically, patients' views of direct access to specialists can be useful to health organizations considering the gatekeeper model. OBJECTIVE: To assess patients' opinions about direct access to specialists and referral to specialists through their primary care physician. DESIGN: An intercept survey, in which patients were interviewed at the randomly selected service provision sites, was carried out in 3 districts in Israel during 1995. A total of 1445 and 1289 patients were interviewed in primary care and specialty clinics, respectively. SETTING: Primary care and specialty clinics in 3 regions in Israel serving 750000 members of Kupat Holim Clalit, Israel's largest sick fund. PARTICIPANTS: Hebrew-speaking members of Kupat Holim Clalit who visited the primary care or specialty clinics in the 3 regions during the study period. MAIN OUTCOME MEASURES: Rate of preferences for direct access to specialists and preferences for referral through primary care physician. RESULTS: Fifty-two percent of the respondents preferred direct access to specialists, while 48% preferred a referral from their primary care physician. Multivariate logistic regression analysis indicated that the preference for direct access was significantly lower among patients older than 45 years (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.62-0.91); patients whose primary care physician was a specialist in family medicine (OR, 0.80; 95% CI, 0.67-0.97); and patients who were satisfied with their primary care physician (OR, 0.34; 95% CI, 0.27-0.44). Preference for direct access was significantly higher among more highly educated patients (OR, 1.38; 95% CI, 1.16-1.65) and patients residing in Jerusalem (OR, 2.46; 95% CI, 2.05-2.95) and those younger than 45 years who were dissatisfied with their family physician or a primary care physician who was not board certified. If direct access was not available, 33% of respondents would leave the sick fund and 48% would remain; 19% did not know. CONCLUSIONS: Informing sick fund members, particularly the younger and more educated among them, about the advantages of consulting with the primary care physician, as well as providing specialty training in family medicine to primary care physicians, may reduce patients' preference for direct access to specialists.
Malignant bowel obstruction occurs in about 10% of those with advanced abdominal cancer and in about 25% of those with advanced pelvic cancer. Such patients usually develop nausea, vomiting, constipation, abdominal dilatation and colicky pain. Traditional therapy consists of intravenous fluids and decompression by duodenal tube, gastrostomy or operation but postoperative mortality is high. Treatment requires hospitalization and therefore such patients have not been considered candidates for home care. Palliative medical techniques can cope with this syndrome and allow home care. Hypodermoclysis, non-prokinetic antiemetics like haloperidol and scopolamine, octeotride, corticosteroids, and narcotics for severe abdominal pain can alleviate symptoms. Medications can be combined and infused subcutaneously in a syringe driver and patients can remain with their families in their natural environment. Such techniques can give these patients who have short life expectancies reasonable quality of life.
This study compares Israeli primary care physicians with those of European countries. In Israel a larger proportion of those in primary care are women. The Israeli physicians see many patients a day, but almost never make home visits. They also report for work the fewest hours a day, but spend 21 hours a month in continuous medical education. (more than Europeans?) The Israeli primary care physician scores high in screening for breast cancer and blood cholesterol level, but very low in the fields of minor surgery and alcohol and smoking prevention, contraception, nutrition counseling and normal pregnancy follow-up. Residency training and education may be inadequate, and more emphasis has to be put on the health system and recognizing environmental influences.
A prospective study was conducted over a 3-month winter period in three general practice clinics in an urban population in southern Israel to identify the etiological agents of respiratory tract infections (RTI) in adults. RTI was defined as an acute febrile illness with cough, coryza, sore throat or hoarseness. Serum samples were taken from all patients in both the acute and convalescent phases of their illness. Tests were conducted for detection of 17 microorganisms known to cause RTI, including serological tests for 16 known pathogens. An etiological diagnosis was established in 80 (66%) of the 122 patients who participated in the study. The distribution of the etiological agents was as follows: influenza B virus in 27 (22%) patients. Chlamydia pneumoniae in 22 (18%), Legionella spp. in 15 (12%), Mycoplasma pneumoniae in 13 (11%), influenza A virus in 11 (9%), Bordetella pertussis in 9 (7%), adenovirus in 4, Epstein Barr virus in 4, Haemophilus influenzae in 3, beta-hemolytic streptococci in 3, Streptococcus pneumoniae in 2, respiratory syncytial virus in 2, parainfluenza 1 virus in 2 and parainfluenza 2 virus in 1. No patients were found to be infected with Coxiella burnetii, Moraxella catarrhalis or parainfluenza 3 virus. More than one pathogen was identified in 27 (34%) patients in whom an etiological diagnosis was established. It is concluded that RTI is caused by a broad spectrum of etiological agents, a considerable number of patients having evidence of infection with more than one pathogen. The therapeutic significance of these findings should be elucidated in further studies.
OBJECTIVES: We aimed to explore patients' attitudes towards family physicians' and nurses' appearance. METHODS: One hundred and sixty-eight patients from three teaching Family Medicine clinics in Beer-Sheva, Israel, were interviewed in the clinics regarding the medical staff's dress code. They were also asked to choose one picture for either a male or female physician which, in their opinion, was the most suited for their own family physician, from a selection of pictures of the same male and female doctors dressed in different attires. RESULTS: One hundred and twenty-six patients (75%) replied that the attire of the physician had no influence on their decision in choosing their own family doctor. Fifty-two per cent of the patients preferred the doctor in a white coat and 71 % had the same preference for the nurse. Older age was associated with increased preference for a white coat. The dressing items which scored high for male doctor were a name tag, a formal suit or a shirt with a tie and sports shoes. For a female doctor a name tag, short haircut, trousers and sports shoes ranked highly. Long hair, earrings, and sandals scored low for a male physician, while mini-dress, shorts and tight clothes scored low for a female physician. CONCLUSION: About half of patients still prefer the doctor to be dressed in a white coat. Patients prefer a more formal dressing for male and female physicians in family medicine clinics. Most of the patients claimed that the attire of the physician had no influence on their choice of family physician.
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The use of sunscreen in the Negev population was assessed. The study population included 1458 subjects, mean age 35.5 +/- 14.2 years, half born in Israel and 25% in East Europe. Two-thirds were exposed to the sun 1-2 hours a day and 13% 4 hours a day or more. Only about 15% used sunscreen while shopping, 69% used it at the beach, and less than half applied it to children being sent to school. Sunscreen use was greater in women (p < 0.000001), especially those with sensitive skin (p < 0.0001) and red hair (p < 0.0001). No significant association was found with age, education or country of birth.
A worrisome connection between driving and drinking was found in 166 people randomly surveyed in public places in Beer Sheba. 80% of the study population stated that they drink alcoholic beverages. Of these, 45% reported drinking at least once a week, and 21% drank 3 glasses/cans at each drinking bout. We noted a trend among those who drank frequently to drink greater amounts. Of the sample, 110 interviewees stated that they had a driver's license and that they drank alcoholic drinks. 39% reported driving after a number of alcoholic drinks, and 23% of them did so invariably or frequently. 5% drank while driving. The drinkers exhibited a high-risk behavioral pattern, remaining in the car with friends (53%) or relatives (16%) also under the influence of alcohol. Those who are aware of the influence of alcohol on their driving skills and the danger of being involved in car accidents, moderate their consumption of alcohol. The results of the study confirm our hypothesis that there is an upswing in the phenomenon of high-risk driving connected with drinking alcoholic beverages.
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OBJECTIVES: The aim was to assess the awareness and knowledge of family physicians about diagnostic and clinical features of fibromyalgia syndrome (FS), and to evaluate the contribution of rheumatology education to the improvement of this knowledge. METHODS: A detailed questionnaire on FS was completed by 172 family physicians. A composite score, based on five items, was constructed to quantitatively assess knowledge of FS (maximum score of 5). A comparison was made between physicians exposed to extensive education on FS (in Beer Sheva medical centre) and physicians without such exposure (in other centres). RESULTS: Ninety-six per cent of the physicians claimed to be familiar with FS. They recognized most of the FS-related symptoms, but had limited knowledge of the diagnostic criteria, treatment modalities and prognosis. Only 55% knew that FS is associated with widespread pain and 25% were familiar with the point count criterion. Physicians trained in Beer Sheva scored significantly higher than those trained elsewhere: 3.0 +/- 1.2 versus 2.4 +/- 1.2, respectively (P = 0.006), and their knowledge of FS treatment was significantly better. CONCLUSION: Family physicians in Israel are quite unfamiliar with the diagnostic criteria of FS, though educational exposure improves their awareness and knowledge.
The need to perform "routine" radiographs after every case of ankle trauma has been repeatedly questioned, since less than 15 percent of ankle injuries are found to involve a significant fracture. Several authors have proposed guidelines to define clinical characteristics that may help physicians identify patients with a higher probability of having a fracture on the radiograph. The Ottawa ankle rules are the latest guidelines developed for the management of ankle injuries. These highly sensitive decision rules may allow a significant reduction in the number of ankle radiographic series ordered and may decrease patients' waiting times and costs without an increased rate of missed fractures or patient dissatisfaction.
The aim of this study is to describe the first 3 years of functioning of a home hospice care unit in an urban community in Israel. This home hospice unit is the only palliative care facility available in the Negev area, the southern region of Israel. During the first 3 years, the team took care of 139 cancer patients, age range 28-92 years, mean 64.1 and median 67 years. The mean duration of care was 53.1 days. Every patient had on average 42.7 home visits and telephone contacts. About 8% of all contacts were beyond regular working hours. More than three quarters of the patients were suffering pain on admission. In 50% of the patients pain was controlled by 120 mg morphine daily, and in 73% of the patients pain was controlled with doses up to 320 mg morphine in 24 h. Altogether there were 438 hospitalization days for these patients with an average of 3.6 days per patient since admitted to the unit. The rate of death at home was 88.5%. As a result of the team's experience, new approaches to patient care were implemented in the fourth year of operation of this care facility, of which one of the most important is inclusion of palliative medicine in the curriculum for Family Medicine residents.