Fentanyl patch sufficient analgesia for only one day.
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Administration, Cutaneous↗
Biomedical subjects
Pesach Shvartzman
Publications and source records attributed to Pesach Shvartzman.
Triptans--why once?
OBJECTIVE: To evaluate triptan use patterns in a large Israeli HMO district. BACKGROUND: Triptans, 5HT(1B/1D) agonists, provide an effective and safe relief of headache and accompanying symptoms during an acute migraine attack. METHOD: We retrospectively reviewed the computerized prescription filling data of 1498 patients who filled a first triptan prescription between July 2003 and June 2004. RESULTS: During a 1-year follow-up period, 841 patients (56.1%) purchased triptans only once. Single-time users were significantly more prevalent among men and in patients younger than 30 or older than 70 years. CONCLUSIONS: It seems that many migraine patients choose not to use triptans after their first experience with the drug.
Adult↗
Keeping track of deaths in general practice--an audit?
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Ambulatory Care Facilities↗
Introducing co-payment for consultant specialist services.
BACKGROUND: Full medical coverage may often result in overuse. Cost-sharing and the introduction of a co-payment have been shown to cause a reduction in the use of medical services. OBJECTIVES: To assess the effects of the recently introduced co-payment for consultant specialist services on patient utilization of these services in southern Israel. METHODS: Computerized utilization data on specialist services for 6 months before and 6 months after initiation of co-payment were retrieved from the database of Israel's largest health management organization. RESULTS: A decrease of 4.5% was found in the total number of visits to Soroka Medical Center outpatient clinics and 6.8% to community-based consultants. An increase of 20.1% was noted in the number of non-actualized visits to the outpatient clinics. A decrease of 6.2% in new visits to hospital outpatient clinics and 6.5% to community clinics was found. A logistic regression model showed that the residents of development towns and people aged 75+ and 12-34 were more likely not to keep a prescheduled appointment. CONCLUSION: After introduction of a modest co-payment, a decrease in the total number of visits to specialists with an increase in "no-shows" was observed. The logistic regression model suggests that people of lower socioeconomic status are more likely not to keep a prescheduled appointment.
Adolescent↗
Depression in dermatological patients identified by the Mini International Neuropsychiatric Interview questionnaire.
BACKGROUND: Early diagnosis and treatment of depression are of vital importance in dermatological patients. OBJECTIVE: Our purpose was to evaluate the prevalence of depression among patients visiting a dermatology clinic in southern Israel. METHODS: Patients who visited the dermatology clinic were interviewed using the Mini International Neuropsychiatric Interview screening tool. RESULTS: The study included 384 patients. The screening questionnaire identified 37 patients (9.6%) with major depression, 3 patients (0.8%) with minor depression, and 74 patients (19.3%) with depressive symptoms. Higher prevalence of depression was found among widowers, among divorced or separated patients, and in unemployed patients. Depression was significantly associated with the perception of severity and suffering induced by the skin diseases. LIMITATIONS: The study was conducted in a cross-sectional design. To confirm causality, a longitudinal study should be conducted. CONCLUSION: Depression should be a consideration by dermatologists in the effective management of skin diseases.
Adult↗
Verbal and physical violence towards hospital- and community-based physicians in the Negev: an observational study.
BACKGROUND: Over recent years there has been an increasing prevalence of verbal and physical violence in Israel, including in the work place. Physicians are exposed to violence in hospitals and in the community. The objective was to characterize acts of verbal and physical violence towards hospital- and community-based physicians. METHODS: A convenience sample of physicians working in the hospital and community completed an anonymous questionnaire about their experience with violence. Data collection took place between November 2001 and July 2002. One hundred seventy seven physicians participated in the study, 95 from the hospital and 82 from community clinics. The community sample included general physicians, pediatricians, specialists and residents. RESULTS: Ninety-nine physicians (56%) reported at least one act of verbal violence and 16 physicians (9%) reported exposure to at least one act of physical violence during the previous year. Fifty-one hospital physicians (53.7%) were exposed to verbal violence and 9 (9.5%) to physical violence. Forty-eight community physicians (58.5%) were exposed to verbal violence and 7 (8.5%) to physical violence. Seventeen community physicians (36.2%) compared to eleven hospital physicians (17.2%) said that the violence had a negative impact on their family and on their quality of life (p < 0.05). The most common causes of violence were long waiting time (46.2%), dissatisfaction with treatment (15.4%), and disagreement with the physician (10.3%). CONCLUSION: Verbal and/or physical violence against physicians is common in both the hospital and in community clinics. The impatience that accompanies waiting times may have a cultural element. Shortening waiting times and providing more information to patients and families could reduce the rate of violence, but a cultural change may also be required.
Adult↗
Complex Regional Pain Syndrome type I following radial artery cardiac catheterization.
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Amitriptyline↗
The impact of structured laboratory routines in computerized medical records in a primary care service setting.
Inappropriate laboratory ordering is a problem affecting medical systems worldwide. An intervention was called for as a result of increasing laboratory costs. Thus, we aimed to assess the impact of introducing computerized laboratory routines to a computerized primary care setting. The study included 380 primary care physician practices of Clalit Health Service (HMO) southern district (CHS-SD) in Israel, caring for 470,000 members. Consensus laboratory routines order sets were electronically introduced into all physicians' computerized medical record (CMR) software, after consensus and internal marketing process. The primary findings were that a previously observed annual increase in laboratory test utilization was stopped, a 2% reduction in total number of tests and a 4 % reduction in the total number of tests per age adjusted person was observed. In conclusion the wide use of CMRs and communication technology combined with an appropriate organizational process can be used to increase appropriate utilization of laboratory tests.
Diagnostic Techniques and Procedures↗
Home death--the caregivers' experiences.
The objectives of this study were to evaluate caregivers' experiences concerning the care of a terminally ill loved one at home, and to compare the death experiences of caregivers with and without access to homecare programs. The primary caregivers of all the patients who died of cancer 6-18 months before the study period (1999-2001) in the Negev area were contacted. This group included 240 caregivers of patients who died in the home palliative care program and 404 caregivers of patients who died with no access to a home palliative care program. A total of 159 caregivers were interviewed, 76 from the home palliative program and 83 who had no access to a palliative care program. Death at home occurred for 80.3% of patients with access to homecare and 20.5% of those without access. Despite the fact that caring for a loved one at home was a greater financial and emotional burden, there was a greater overall satisfaction with the caring experience of those whose loved ones died at home and had access to the homecare program. Given appropriate professional support systems, home-based care at the end of life is preferable to most caregivers.
Adolescent↗
Rates of functional bowel disorders among Israeli Bedouins in rural areas compared with those who moved to permanent towns.
BACKGROUND & AIMS: Half of Israeli Bedouin society has undergone a transition from nomadic existence to permanent towns, causing cultural and social upheaval. The aim was to compare rates of irritable bowel syndrome (IBS) and functional bowel disorders (FBDs) between Israeli Bedouins still living under rural conditions with those in permanent towns. METHODS: Interviews were conducted in Arabic by trained Bedouin interviewers at 8 Bedouin clinics. The same interviewers surveyed the 2 sectors under identical sampling and interviewing conditions at the same time. FBDs were diagnosed by Rome II criteria. RESULTS: One thousand seven hundred fifty-five Bedouins participated, 1018 from permanent towns and 737 from rural areas. Sixty percent were female (58.2% for rural and 62.0% for towns). The mean age was 39.1 +/- 14.1 years (39.0 +/- 14.3 years for towns, 39.2 +/- 13.9 years for rural; P = NS). The mean level of education was 4.3 +/- 5.4 years (4.6 +/- 5.6 years for towns, 3.7 +/- 5.2 years for rural; P < .0001). IBS was diagnosed in 9.4% of town and 5.8% of rural Bedouins ( P < .01). In contrast, rural Bedouins had significantly higher rates of functional abdominal bloating (7.9% vs 2.8%, P < .0001) and a marginally higher rate of functional constipation. Bedouins living in towns attributed their gastrointestinal symptoms to stress more than rural Bedouins did ( P < .05). Stress and poor global feeling of well-being were significant contributors for IBS in logistic regression models for both sectors. CONCLUSIONS: Bedouins living in permanent towns have significantly higher rates of IBS than rural Bedouins. Although these findings might be associated with the stressful social upheaval that they have undergone, further study is needed to substantiate this point.
Adolescent↗
Health services utilization by depressive patients identified by the MINI questionnaire in a primary care setting.
OBJECTIVES: To identify patients with depression, in primary care clinics in Israel, using the MINI (Mini-International Neuropsychiatric Interview) as a screening tool and to evaluate the health services utilization and costs of the patients identified. DESIGN: Phone interviews (between 1997 and 2000) and health services utilization data extracted from computerized databases. SETTING: Three primary care clinics belonging to Clalit Health Services (HMO). PARTICIPANTS: A random sample of 2755 patients, aged 21-65. MAIN OUTCOME MEASURES: MINI score results, utilization data. RESULTS: The study included interviews with 2507 patients. The screening questionnaire identified 5.9% with major depression, 1.6% with minor depression and 14.3% with depressive symptoms. Higher rates of depression were found among women, immigrants, secular or traditional religious Jews, and the unemployed. Those identified with major depression had higher health services utilization and costs. Logistic regression analysis showed that depression was related to older age, female gender, fewer years of education and among seculars. Depressed patients had significantly more somatic comorbidity. CONCLUSIONS: Health services utilization and costs of people identified as depressed by the screening tool were higher. Depressive patients had higher comorbidity, which might be partially responsible for the higher cost.
Adult↗
"Bread madness" revisited: screening for specific celiac antibodies among schizophrenia patients.
PURPOSE: A possible association between gluten consumption and schizophrenia has been reported. The objective was to compare patients with chronic schizophrenia and matched controls for sociodemographic variables, prevalence of celiac-specific anti-endomysial antibodies and disease-related variables. SUBJECTS AND METHODS: The study group was comprised of 50 consecutive patients diagnosed with schizophrenia, 18 years of age and older attending the out-patient clinic of the Mental Health Center in Beer-Sheva, Israel. The control group was comprised of mentally normal volunteers who came to primary care clinics for blood tests unrelated to gastrointestinal tract complaints and who were not diagnosed with celiac disease. Known celiac patients and those who refused to participate, did non-speak Hebrew or were incoherent were excluded from the study. All participants in both groups underwent a blood test for anti-endomysial IgA antibody and completed a questionnaire. RESULTS: Each group was comprised of 50 participants. There were no significant differences between the groups in gender, BMI or country of birth. The mean age of the study group was significantly higher than the controls. All tests for anti-endomysial antibody in both groups were negative. DISCUSSION AND CONCLUSIONS: In contrast to previous reports, we found no evidence for celiac disease in patients with chronic schizophrenia as manifested by the presence of serum IgA anti-endomysial antibodies. It is unlikely that there is an association between gluten sensitivity and schizophrenia.
Celiac Disease↗
Pain control in ambulatory cancer patients--can we do better?
To evaluate the degree of pain control among ambulatory cancer patients visiting the outpatient clinics of three oncology centers in south Israel, these patients were interviewed using the Brief Pain Inventory translated into Hebrew (BPI-Heb). Patients suffering from pain at least three times a week or reporting taking daily analgesics during the last two weeks were enrolled. Non-Hebrew speakers and patients too frail or ill were excluded. The study population included 218 subjects. Substantial pain was experienced by 77%, the majority was not adequately treated (81%), and 75% were undermedicated. The daily living activities of the majority of patients (64%) were moderately to severely impacted. Pain control was not associated with any of the sociodemographic or previous treatment profile variables, or by physicians' pain assessment. The physicians' and the patients' ratings of the extent to which pain interfered with the patients' activities fully agreed (+/-2) in fewer than half of the patients. Physicians estimated more severe pain levels, but underestimated its impact on everyday life. These data indicate that better pain control for ambulatory cancer patients is needed and that more information about patients' pain and its impact should be solicited. Further training of care providers is needed to improve the relief from cancer pain and the quality of life of patients.
Adult↗
Diagnosis of ambulatory community-acquired pneumonia. Comparison of clinical assessment versus chest X-ray.
OBJECTIVES: When evaluating patients with respiratory tract infections (RTI), physicians have to judge and decide whether the patient has pneumonia or not. This decision is usually made by clinical assessment alone and/or by performing a chest X-ray. The aim of this study was to determine the reliability of physicians' judgements relating to the presence of pneumonia in RTI patients by clinical assessment alone compared with chest X-ray. DESIGN: A prospective, clinical study. SETTING: Primary care clinics and a university hospital in southern Israel. SUBJECTS: Two-hundred-and-fifty ambulatory patients with febrile RTI were included in a prospective study. On the basis of a medical interview and physical examination alone physicians were asked to make judgements relating to the study question, and these judgements were compared with the results of chest X-rays. RESULTS: Physicians' judgements of pneumonia had a sensitivity of 74% (49-90%), a specificity of 84% (78-88%), a negative predictive value of 97% (94-99%) and a positive predictive value of only 27% (16-42%), compared to the results of chest X-ray. CONCLUSION: We conclude that the ability of physicians to negate X-ray confirmed pneumonia by clinical assessment in febrile adult RTI patients is good, but that their ability to successfully predict this condition is poor.
Adult↗
Acute otitis media--a brief explanation to parents and antibiotic use.
BACKGROUND: Acute otitis media (AOM) is a common self-limiting disease in children. Antibiotic use is controversial. Physicians in the USA and in Israel prescribe antibiotics almost universally, while physicians in other countries report good outcome without any treatment. Parents' expectation is an important factor influencing a physician's decision to prescribe antibiotics. OBJECTIVES: Our aim was to assess whether a brief explanation to parents regarding the self-limited nature of AOM and the controversy regarding antibiotic prescription for the disease will influence the parents' decision regarding antibiotics use. METHODS: Parents of the children participating in the study in two primary care clinics belonging to HMO-Clalit Health Services (CHS) in the southern district of Israel were randomly assigned to an intervention (44) and control (37) group. The intervention group received the brief explanation. The two groups received prescription for antibiotics. The subjects comprised 81 children aged 3 months to 4 years visiting the family practice clinics and diagnosed with AOM. The rate of antibiotics purchase, using the prescription given and the factors influencing the decision were evaluated. RESULTS: Fewer parents administered antibiotics to their children in the intervention group compared with the control group (37% versus 63%, respectively, P < 0.0001). Mother's education level was the only factor found to be significantly lower in the group that eventually purchased antibiotics (P < 0.05). CONCLUSIONS: In children with AOM, a brief explanation by the family physician to the child's parents about the disease and the expected spontaneous recovery could decrease antibiotic use by approximately 50%.
Acute Disease↗
[Clinical psychophysiology in the primary care system].
In the beginning of the 21st century, a need for a different medical approach arises among the medical systems in the world. This new attitude, beyond laboratory tests, imaging procedures, and pharmacological treatment, emphasizes the significance of the role of the patient, and transfers the control to the patient himself and his/her family. This is the biopsychosocial medical approach. In such a system the medical staff considers not only the traditional biological factors, but also the mental and environmental factors, when it plans the treatment course. The lack of consideration of the real medical and psychological needs of the patient can result in misuse of essential resources. It can also lead to the frustration of the patient and the medical personnel. Clinical psychophysiology is a treatment implementation of the biopsychosocial approach, and it is supposed to meet the biological and psychological needs of the patient. The biopsychosocial method integrates physiological treatments and behavior-cognitive care. The article describes in detail various processes of the clinical psychophysiology, according to the current professional literature. We conclude that the clinical psychophysiology might be useful in treating many problems in primary medicine, such as chronic pain, hypertension, sleep disturbances, and attention disorders. The primary care system is the optimal place to practice the biopsychosocial method, and the challenge is to develop the appropriate doctrines, which would enable the medical staff to help the patients in need. In the article we discuss in details five strategies which allow broader use of the instruments of the clinical psychophysiology: 1) Expansion of doctors education; 2) Allied health professionals involvement; 3) Integration of behavioral medical treatment in primary care; 4) Causing effective modification with minimal medical staff contiguity; 5) Referral for follow-up treatment. The clinical psychophysiology, in the framework of primary care, is a powerful integration of the biomedical and bio-social models.
Delivery of Health Care↗
[Mothers know best].
BACKGROUND: Nutrition has a critical effect on the infant's brain development during pregnancy and the first 18 months of life. Inappropriate diet can cause infant mortality. Research has shown that medical professionals lack the required knowledge regarding nutrition and that there are no suitable instructional programs on this subject for them. OBJECTIVES: To examine the knowledge and attitudes of gynecologists, pediatricians and nurses who work in mother and child health clinics of "Maccabi" Healthcare Services in Israel concerning infants' and pregnant women's nutrition and to compare these findings to the public's general knowledge. METHODS: The study population consisted of gynecologists and pediatricians who work in "Maccabi" Healthcare Services throughout the country and all the nurses at the family healthy clinics. In addition, a sample of mothers attending six different family health clinics was recruited. Four structured questionnaires were created for each group in the study population (gynecologist, pediatricians, nurses and mothers). The questionnaires included questions that evaluated the knowledge and attitudes toward infants' nutrition. RESULTS: The mothers showed high level of knowledge (67% correctly answered 3 or more of the 4 questions, compared to 51% of nurses, 27% or pediatricians, 38% of gynecologists, p < 0.01). The physicians showed a higher level of knowledge in the questions related to their specialty. When asked about the effect of nutritional instruction on the infants' health, the pediatricians answered correctly at a higher rate than the other study groups (74% of pediatricians answered correctly 3 out of 3 questions, compared to 60% of gynecologists, 47% nurses, p < 0.01). Professionals believe that they can train mothers on nutritional issues. CONCLUSIONS: Appointing a nutritionist to the mother and child clinics should be considered, as the professional caregivers of pregnant women and infants were found to be lacking in sufficient knowledge in certain aspects of nutrition for these populations.
Female↗
Effects of guided written disclosure of stressful experiences on clinic visits and symptoms in frequent clinic attenders.
BACKGROUND: Psychosocial variables such as major stressful life events/daily stressful events have been associated with health care utilization. OBJECTIVE: Our aim was to examine the effects of a guided disclosure protocol (GDP) of past traumas on symptoms and clinic visits among frequent clinic attenders. METHODS: Forty-one frequent clinic attenders (> or =2 visits/3 months) took part. Patients were randomly assigned individually to either a casual content writing control group (n = 19) or a trauma content writing experimental GDP group (n = 22). GDP patients wrote about an upsetting event chronologically (day 1), verbally described their thoughts and feelings and described the event's impact on life (day 2), and finally wrote about their current perspective on and future coping with the event (day 3). Three months later, patients were reassessed blindly for symptoms and clinic visits, and an average of 15 months later they were assessed blindly for clinic visits again. RESULTS: Compared with controls, GDP patients reported lower symptom levels at 3 months (2.3 versus 5.2), and made fewer clinic visits during the 3 (1.3 versus 3.0) and 15 month (5.1 versus 9.7) follow-ups. The percentage of GDP patients making > or =10 visits during the 15 month follow-up was smaller (10%) than among controls (33%). CONCLUSIONS: The findings extend previous findings to frequent clinic users, using a new form of written disclosure aimed at shifting trauma from implicit to explicit memory. The GDP may be an inexpensive additional intervention in primary care for reducing symptoms and clinic visits among frequent clinic users.
Adult↗