Israel Medical Association Journal

Background: Breast cancer is one of the most prevalent malignancies in women, yet one of the most treatable. Early detection is essential to obtain the desired remission and longevity. Numerous studies have shown that periodic screen­ing for breast cancer can reduce mortality by 20-30%.

Objective: To assess the rates, compliance, character­istics as well as barriers in women regarding mammography screening.

Methods: The study group comprised a random sample of 702 women aged 50 or older from 5914 eligible women in two teaching clinics in southern Israel. Phone interviews using structured questionnaires were conducted.

Results: The mean age of the study population was 61 years. The vast majority of the women were not born in Israel. Sixty-three percent of the women had undergone a mammo­graphy screening, 48% in the past 2 years. Monthly self-breast examinations were performed by 12% of the women in the last 2 years. Significant factors associated with undergoing mammography were: more than 7 years since immigration, married, a higher education level, adequate knowledge about breast cancer and mammography, presence of past or current cancer, and cancer in relatives. The main reasons for not being screened was no referral (54%) and a lack of knowledge about breast cancer and mammography (19%) - conditions easily remedied by physician counseling.

Conclusion: The study suggests that promotional efforts should be concentrated on new immigrants and on less educated and unmarried women.

Background: Lower urinary tract symptoms are highly prevalent in older men, have been shown to affect men’s quality of life, and may be associated with more serious outcomes.

Objectives: To determine the prevalence of LUTS among men aged 50 years or older registered at family practice centers in Israel and to assess the effect of these complaints on different aspects of their life.

Methods: In a random sample cohort of men aged 50 years and older, fluent in Hebrew, drawn from those registered in four family clinics in Israel, patients identified with LUTS were interviewed by phone using a structured questionnaire.

Results: The prevalence of LUTS in our study was 21%. Less than a third of these patients had low severity LUTS (28%), 59% were rated moderate, and 13% had severe symptoms. Age had a positive correlation with the severity of LUTS, and increasing severity of symptoms had a negative effect on the daily function and quality of life of patients.

Conclusions: Our community-based study shows that LUTS is a common finding among men above the age of 50 (21%) and has a significant negative effect on their quality of life and daily function. Knowledge of these data should make primary care physicians more aware of this common problem and thus improve the treatment and quality of life of these patients by better identification and prompt treatment.

Background: Previous studies have documented that reduction in QT dispersion after thrombolytic treatment in acute myocardial infarction depends on reperfusion status as well as infarct site. Primary percutaneous transluminal coronary angioplasty as compared with thrombolytic therapy has been shown to result in higher patency rates of the infarct vessel.

Objectives: To evaluate whether primary PTCA has a more favorable effect on reducing QT dispersion in patients with acute MI as compared to thrombolytic treatment.

Methods: The study population included 42 consecutive patients (33 men, mean age 58 ± 11 years) with acute Ml (24 anterior wall, 18 inferior wall) who were treated with primary PTCA (group A, n 21) or thrombolytic therapy (group B, n = 21) at 3.9+2 hours after symptom onset. QT intervals were measured before and 24 hours after treatment.

Results: On the admission electrocardiogram, patients with anterior Ml had higher values of QT and QTc dispersions than patients with inferior Ml (52±9 vs. 36±9 msec, R<0.05 and 61+4 vs. 56+4 msec, P=0.002, respectively). There was a significant reduction in QT and QTc dispersions from admission to 24 hours in all patients (from 50+9 to 37+9 msec, P<0.001 and from 59+5 to 42+5 msec, P<0.001. respectively), and also in group A (from 49±8 to 32±5 msec. P<0.001 and from 58+5 to 38+3 msec, P<0.001, respec­tively) and in group B patients (from 51+10 to 42+10 msec. P<0.01 and from 60±4 to 46±5 msec, P<0.001, respec­tively). QT and QTc dispersions were found to be shorter in group A at 24 hours after treatment than in group B (32 + 5 vs. 42+10 msec, P<0.001 and 38+3 vs. 46+5 msec, P<0.001. respectively).

Conclusions: Reperfusion therapy with primary PTCA or thrombolytic agents reduces QT and QTc dispersions in acute Ml. QT and QTc dispersions after reperfusion treatment are shorter with primary PTCA than with thrombolytic therapy.

Objective: To investigate the clinical, laboratory and radiological findings of the disease.

Methods: During the years 1995-88 five patients with primary epiploic appendigitis were diagnosed at our institution. The clinical, laboratory and imaging results were summarized and compared to previously reported series. Emphasis was placed on the computed tomography findings, which are the gold standard for diagnosis.

Results: All our patients (two males and three females, mean age 47 years) presented with left lower quadrant abdominal pain. CT proved to be the imaging modality of choice in all patients by showing a pericolic fatty mass with an increased attenuation as compared to normal abdominal fat. In all cases the mass was surrounded by a high attenuation rim, and focal stranding of the fat was observed. In no case was there thickening of the adjacent bowel wall. This serves as an important, and previously unreported, clue for diagnosis.

Conclusion: Primary epiploic appendagitis is a relatively rare condition that may be clinically misdiagnosed, resulting in unnecessary surgical intervention. Judicious interpretation of CT may lead to early diagnosis and ensure proper conservative treatment.

Objective: To identify correlates for under-utilization of influenza immunization among the elderly.

Methods: A telephone survey was conducted among a random sample of patients aged 65 and over registered at a Jerusalem primary care community clinic. The 626 questionnaires were analyzed for associations of immunization receipt for the latest influenza season. Multivariate logistic regression was performed to identify independent correlates. Respondents were also asked what factors had influenced their decision about immunization.

Results: The most frequently reported influence on getting immunized was a physician's recommendation. Immunization was independently associated with the identity of the primary care physician (P0.0001) and with having visited the physician during the previous 3 months (P=0.0006). Immunization was more likely among persons who believed that it provides complete protection from influenza (P0.0001) and less likely among those who believed immunization can cause influenza (P0.0001). Higher immunization rates were also associated with being married (P=0.0031).

Conclusion: Through their influence on patient knowledge and the effect of their recommendation, primary care physicians play a pivotal role in determining immunization rates. Physicians should routinely discuss the effects of immunization and recommend it to the elderly.

Background: The aim of family medicine is to provide patients with comprehensive care within the biopsychosocial model. High job satisfaction is necessary to attract physicians to this specialty

Objective: To compare job satisfaction levels between primary physicians with training in family medicine and physicians without specialty training.

Methods: A self-report questionnaire, the "Task Profiles of General Practitioners in Europe," was mailed to a stratified random sample of 664 primary care physicians in Israel. The response rate was 77.6%. Bivariate and logistic regression procedures were used to analyze the data.

Results: Physicians with training in family medicine were less satisfied with the rewards for their work than general practitioners with no formal specialization in family medicine. Satisfaction with the intrinsic aspects of the work was found to be equal. Women and rural physicians were more satisfied than men and urban physicians.

Conclusion: Measures should be taken by health maintenance organizations to increase the level of job satisfaction of specialist-certified family physicians to avoid a crisis in the profession.
 

Background: *Previous descriptive studies have demonstrated the problematic nature of physicians' attitudes toward battered women. However, little empirical research has been done in the field, especially among the various medical specialties.

Objectives: To compare the approach and feelings of competence regarding the care of battered women between primary care and non-primary care physicians. The non-primary care physicians who are likely to encounter battered women in the ambulatory setting are gynecologists and orthopedists.

Methods: A self-report questionnaire formulated for this study was mailed to a random sample of 400 physicians working in ambulatory clinics of the two main health maintenance organizations in Israel (300 primary care physicians, 50 gynecologists and 50 orthopedists).

Results: In both physician groups, treating battered women tended to evoke more negative emotional states than treating patients with infectious disease. The most prevalent mood state related to the management of battered women was anger at her situation. Primary care physicians experienced more states of tension and confusion than non-primary care physicians and had lower perceived self-efficacy and self-competence in dealing with battered women.

Conclusions: Though both physician groups exhibited negative feelings when confronting battered women, the stronger emotion of the primary care physicians may indicate greater sensitivity and personal awareness. We believe that more in-service training should be introduced to help physicians at the undergraduate and postgraduate levels to cope both emotionally and professionally with these patients.

Background: Smoking rates have decreased in western countries as well as in Israel during the past 20 years.

Objectives: To estimate current rates of smoking and smoking cessation, and to assess factors associated with smoking and smoking cessation in family practice.

Methods: Prospective face-to-face interviews were conducted with 1,094 subjects, aged 16 years or older, registered in a family practice.

Results: Of all subjects studied, 746 (68.2%) were non-smokers, 237 (21.7%) were current smokers, and 111 (10.1%) had stopped smoking. Overall, 31.8% of the males and 13.8% of the females were current smokers, and 20.1% males and 2.4% females had stopped smoking. Current smoking and smoking cessation rates were significantly and inversely associated with age among males and females. Smoking rates were higher among males and females who were married, had 10-12 years of education, and among males of North African origin and females of Israeli origin. The number of cigarettes smoked per day was associated with smoking and smoking cessation in males, but not in females. The highest rate of quitting occurred among males who smoked 25 cigarettes per day. In a multiple regression analysis, gender and the number of cigarettes smoked per day were the most significant factors that predicted smoking cessation. The most common reason for stopping was the appearance of new signs of illness or the development of a new chronic disease, followed by a physician's recommendation to quit smoking.

Conclusions: Female smokers and male smokers who smoke less than 25 cigarettes per day are the least likely to quit smoking. Future programs should be designed for and targeted at these groups of patients.

Background: Over a 12 month period, the Israel Transplant Center doubled the number of donors by assigning a nurse coordinator to each of 22 hospitals around the country and by using kidneys from elderly donors.

Objective: To evaluate the impact of our "marginal donors" policy on the results immediately following transplantation.

Methods: Between October 1997 and September 1998, 140 cadaveric kidney transplantations from 72 donors were performed in Israel. We defined two groups of recipients: patients with immediate graft function and patients with either delayed graft function requiring >1 week of dialysis post-transplant or with primary graft non-function. We compared the following parameters between groups: donor and recipient age and gender, cause of donor’s death, length of stay in the intensive care unit, vasopressor dosage and creatinine levels before harvesting, cold ischemic time, and the number of recipient grafts.

Results: There were 102 recipients (72.8%) with immediate graft function and 38 with either PNF (n=13, 9.3%) or DGF (n=25, 17.9%). On regression analysis, donor age >50 year and retransplantation were significant risk factors for PNF or DGF (odds ratio 4.4 and 2.8, respectively). Of the 56 kidneys from donors >50 years old, 21 (37.5%) developed either PNF (n=9) or DGF (n=12).

Conclusions: We conclude that kidneys from donors over age 50 are at increased risk for graft non-function or delayed function. Better assessment of functional capacity of kidneys from “aged” donors may help to choose appropriate donors from that pool.

________________________________

PNF = primary graft non-function

DGF = delayed graft function

Background: Most countries today are experiencing an accelerated pace of population aging. The management of the elderly housebound patient presents a special challenge to the family physician.

Objectives: To investigate a series of home visits to housebound patients, the therapeutic procedures used, the equipment needed, and the diagnostic conclusions reached.

Methods: The details of 379 consecutive home visits to housebound patients were recorded by 91 family doctors serving 125,000 patients in Israel.

Results: The average age of the patients was 76.1 years. The vast majority of the visits were during office hours (94%). In 24.1% it was the doctor who decided to make the home visit on his/her own initiative. The most common initial reason for a home visit was undefined general symptoms, but the doctor was usually able to arrive at a more specific diagnosis after the visit. Medications were prescribed in 59.1% of the visits, and in 23.5% the medication was administered directly by the physician. The commonest drugs used were analgesics and antibiotics. In 19.3% of visits no action at all, other than examination and counseling, was undertaken. The equipment needed included prescription pads (73%), a stethoscope (81%), sphygmomanometer (74.9%), and otoscope/torch (30.6%). Only 15% of visits resulted in referral to hospital.

Conclusions: Home visits to housebound patients serve as a support to caregivers, provide diagnostic information, and help the family with the decision as to when hospitalization is appropriate. The specific medical cause for the patient being housebound had little effect on the process of home visiting.
 

Background: Streptococcal pharyngotonsillitis remains a common illness in children and can lead to serious complications if left untreated.

Objective: To evaluate the diagnostic and management approach of a sample of primary care physicians in the largest sick fund in Israel to streptococcal pharyngotonsillitis in children.

Methods: A questionnaire was mailed to all physicians who treat children and are employed by the General Health Services (Kupat Holim Klalit) in the Jerusalem District. The questionnaire included data on demographics, practice type and size, and availability of throat culture and rapid strep test; as well as a description of three hypothetical cases followed by questions relating to their diagnosis and treatment.

Results: Of the 188 eligible physicians, 118 (62.5%) responded, including 65 of 89 pediatricians (73%) and 53 of 99 family and general practitioners (53.5%). Fifty-six physicians (47.4%) had more than 18 years experience, and 82 (70%) completed specialization in Israel.  Mean practice size was 950 patients. Fifty-three physicians (43%) worked in Kupat Holim community clinics, 25 (21%) worked independently in private clinics, and 40 (34%) did both. A total of 91 (77%) had access to laboratory facilities for daily throat culture. The time it took for the results to arrive was 48 to 72 hours.  For the three clinical scenarios, 90% of the physicians accurately evaluated case A, a 1-year-old with viral pharyngotonsillitis, and 100 (85%) correctly diagnosed case C, a 7-year-old with streptococcal infection.  As expected, opinions were divided on case B, a 3-year-old child with uncertain diagnosis.  Accordingly, 75 (65.3%) physicians did not recommend treatment for case A, compared to 109 (92.5%) for case C.  For case B, 22 (19%) said they would always treat, 43 (36%) would sometimes treat, and 35 (30%) would await the result of the throat culture.  For 104 (88%) physicians the antibiotic of choice for case C was penicillin, while only 9 (7.5%) chose amoxicillin. However, the recommended dosage regimens varied from 250 to 500 mg per dose, and from two to four doses daily.  For case C, 110 physicians (93%) chose a 10 day duration of treatment.

Conclusions: The primary care physicians in the sample (pediatricians, general practitioners and family physicians) accurately diagnosed viral and streptococcal pharyngotonsillitis. However, there was a lack of uniformity regarding its management in general, and the dosage regimen for penicillin in particular.