Israel Medical Association Journal

Background: Non-gonococcal urethritis is the most common clinical diagnosis for men seeking care at sexually transmitted disease clinics.

Objective: To identify the pathogens involved in NGU[1] among males attending an Israeli STD clinic.

Methods: During 19 months spanning September 1996 to July 1998 we investigated a cohort of 238 male patients attending the Bnai Zion Medical Center STD[2] clinic with a clinical presentation of urethritis. Intraurethral swab specimens were tested for Neisseria gonorrhea, Ureaplasma urealyticum, Mycoplasma hominis, and Trichomonas vaginalis by culture and for herpes simplex virus by antigen detection. First voiding urine for Chlamydia trachomatis was done by polymerase chain reaction. The specific seropositivities of HSV[3] types 1 and 2 were tested by enzyme-linked immunosorbent assay.

Results: From among 238 males with dysuria or urethral discharge an etiology for urethritis was found for 71 (29.8%). N. gonorrhea was recovered in only three men (4.2%). In the remaining 68 NGU patients C. trachomatis (35/68, 51.5%) and U. urealyticum (31/68, 45.6%) were the most common infecting and co-infecting pathogens (P < 0.0001). M. hominis and T. vaginalis were found in 9/68 (13.2%), and 1 patient, respectively. HSV was recovered from the urethra in 7/68 males (10.3%) – 3 with HSV-1, 2 with HSV-2, and 2 were seronegative for HSV. None of these males had genital lesions. Although a single etiologic agent was identified in 45/68 infected men (66.2%), co-infection was common: 2 organisms in 15 (22%) and 3 organisms in 8 (11.8%).

Conclusion: C. trachomatis and U. urealyticum were the most common infecting and co-infecting pathogens in this cohort of men with NGU. Unrecognized genital HSV infections are common in males attending our STD clinic and symptomatic shedding of HSV occurs without genital lesions. Still, the microbial etiology in this group remains unclear in many patients despite careful microbiologic evaluation.

During September 2002, Israel began its current revaccination program against smallpox, targeting previously vaccinated “first responders” among medical and emergency workers. In order to identify the potential strengths and weaknesses of this program and the conditions under which critical decisions were reached, we conducted a SWOT analysis of the current Israeli revaccination program, designed to identify its intrinsic strengths and weaknesses, as well as opportunities for its success and threats against it. SWOT analysis – a practical tool for the study of public health policy decisions and the social and political contexts in which they are reached - revealed clear and substantial strengths and weaknesses of the current smallpox revaccination program, intrinsic to the vaccine itself. A number of threats were identified that may jeopardize the success of the current program, chief among them the appearance of severe complications of vaccination. Our finding of a lack of a generation of knowledge on smallpox vaccination urgently calls for improved physician education and dissipation of misconceptions that are prevalent in the public today.

The threat of a disease outbreak resulting from biologic warfare has been of concern for the Israeli health system for many years. In order to be prepared for such an event the health system has formulated doctrines for various biologic agents and defined the logistic elements for the procurement of drugs. During the last 4 years, and especially after the West Nile fever epidemic in 2000, efforts to prepare the healthcare system and the relevant organizations were accelerated. The Director-General of the Ministry of Health nominated a Supreme Steering Committee to fill in the gaps and upgrade the preparedness of the health system for an unusual disease outbreak. This committee and its seven subcommittees established appropriate guidelines, communication routes among different organizations, and training programs for medical personnel. The anthrax outbreak in the United States found the healthcare system in the hub of the preparation process, and all modes of action were intensified. Further work by hospitals, primary care clinics and all other institutes should be initiated to maintain a state of proper preparedness.

Recent events have significantly increased concern about the use of biologic and chemical weapons by terrorists and other countries. Since weapons of mass destruction could result in a huge number of casualties, optimizing our diagnostic and therapeutic skills may help to minimize the morbidity and mortality. The national demands for training in medical aspects of nuclear, biologic and chemical warfare have increased dramatically. While Israeli medical preparedness for non-conventional warfare has improved substantially in recent years especially due to extensive training programs, a standardized course and course materials were not available until recently. We have developed a core curriculum and teaching materials for a 1 or 2 day modular course, including printed materials.

Background: Ventilator-dependent patients represent an increasing clinical, logistic and economic burden.  An alternative solution might be monitored home care with high-tech ventilatory support systems. 

Objectives: To explore the implications of such home-care management, such as its impact on quality of life and its cost-effectiveness, and to assess the practical feasibility of this mode of home care in Israel.

Methods: We surveyed 25 partly or fully home-ventilated patients (17 males and 8 females), average age 37.6 years (range 1–72), who were treated through a home-care provider during a 2 year period.

Results: Most patients (n=18) had a neuromuscular respiratory disorder.  The average hospital stay of these patients prior to entry into the home-care program was 181.2 days/per patient.  The average home-care duration was 404.9 days/per patient (range 60–971) with a low hospitalization rate of 3.3 ± 6.5 days/per patient.  The monthly expenditure for home care of these patients was one-third that of the hospital stay cost ($3,546.9 vs. $11,000, per patient respectively).  The patients reported better quality of life in the home-care environment, as assessed by the Sickness Impact Profile questionnaire. 

Conclusions: Home ventilation of patients in Israel by home-care providers is a practical and attractive treatment modality in terms of economic benefits and quality of life.
 

Southern Sinai, a mountainous desolated arid area, is inhabited by Bedouin nomad tribes composed of Arabic-speaking Moslems. Until the Six Day War between Egypt and Israel in 1967, healthcare services in the region were based on traditional medicine performed by the Darvish, a local healer. Over the course of Israeli rule (1967-1982) an elaborate healthcare service was established and maintained, providing modern, up to date, comprehensive medical services that were available to all free of charge.

Background: Acute appendicitis is one of the most common conditions requiring surgical intervention. Open appendectomy has been a safe and effective operation for acute appendicitis for more than a century. Recently, several authors proposed that the new technique of laparoscopic appendectomy should be the preferred treatment for acute appendicitis. However, unlike laparoscopic cholecystectomy, LA[1] has not yet gained popularity.

Objectives: To compare open with laparoscopic appendectomy for length of operation, complications, postoperative pain control, length of hospitalization, and hospital costs.

Methods: A sample of 194 patients who underwent OA[2] and LA during 1995 was randomly selected for the study. Patients' demographic data, preoperative laboratory and physical values, histopathologic diagnosis of removed appendix, mean operating time, length of hospitalization, and postoperative pain control and complications were reviewed.

Results: Acute appendicitis was confirmed in 66% of patients. The groups were similar demographically (gender and mean age). We could not find any statistical differences in intraoperative and postoperative complications and use of antibiotics. The operative time was longer in the OA group (62.4 vs. 57.3 minutes), but the difference was not statistically significant (P=0.075). The hospital stay was 2.5 days in the LA group and 2.7 days in the OA group. Higher operative costs were observed in the LA group.

Conclusion: Laparoscopic appendectomy is comparable to open appendectomy with regard to complications, length of operation, hospital stay, but it is more costly. Laparoscopic appendectomy does not offer any significant benefit over the open approach.

Background: The importance of health promotion and disease prevention in health policy and clinical practice is widely accepted in many countries. However, a large number of medical schools do not dedicate a significant part of their curriculum to these aspects. In Israel, there are no reports on the training of the future physician towards his or her role as health promoter in general, or in the areas of cardiovascular and cancer diseases specifically.

Objectives: To examine the preparation of Israel medical students for the role of health promoter in cancer and cardiovascular diseases.

Methods: The study was carried out over 2 years in two of the four medical schools in Israel: the Sackler Faculty of Medicine at Tel Aviv University and the Faculty of Health Sciences at Ben Gurion University in Beer Sheva. The students (n=172, 70% response rate) were surveyed during 1999-2000 by means of a questionnaire, which included assessment of their training towards the role of health promoter, their clinical experiences and exposure to patients at different stages of illnesses at various medical sites, and the specific skills and relevant knowledge they acquired.

Results: Most of the students’ learning experiences occurred in hospitals with patients at the treatment stage and little time was dedicated to prevention, especially in the community. They demonstrated better knowledge, skills and satisfaction with their learning experiences in CVD than in cancer; and reported having insufficient exposure to several common cancer diseases and lacking examining skills for early detection of cancer. The students in Beer Sheva had significantly more interaction with patients at different stages of CVD and acquired more examination skills than the Tel Aviv students.

Conclusions: A change in the curriculum is urgently needed: namely training medical students in community settings and preparing them to promote the well-being of their patients, including prevention. Attention should be given to launching new learning modes in the pre-clinical and clinical curriculum. We propose that: a) pre-clinical courses include prevention techniques in CVD and cancer, problems of cancer patients, and some examining skills; and b) the clinical phase should integrate oncology concepts and total cancer and CVD care into existing clerkships in the hospitals and in the community.
 

Background: Which medical specialties do Israeli medical graduates choose? Answers to this question can serve as an essential means of evaluating both Israeli medical education and the healthcare system.

Objectives: To determine the distribution of medical specialty choice, its change over time and the posible influence of the medical school on the choice; to study the graduates’ gender, gender variability in specialty choice of family medicine as a career among the graduates as a group, by medical school, gender, and time trends.

Method: The study population comprised all graduates of the four medical schools in Israel during 16 years: 1980-1995 inclusive. Data were obtained from the four medical schools, the Israel Medical Association’s Scientific Council, and the Ministry of Health. Data allowed for correct identification of two-third of the graduates.

Results: A total of 4,578 physicians graduated during this period. There was a significant growth trend in the proportion of women graduates from 22.6% in 1980 (lowest: 20.0% un 1981) to 35.3 in 1995 (highest: 41.5% in 1991). Overall, 3,063 physicians (66.8%) started residency and 1,714 (37.4%) became specialists. The four most popular residencies were internal medicine. Ten percent of Israeli graduates choose family medicine.

Conclusions: The overall class size in Israel was stable at a time considerable population change. Women’s place in Israeli medicine is undergoing significant change. Family medicine is one of the four most popular residencies. Amonitoring system for MSC in Israel is imperative.
 

Background: Most of the published documents proposing teaching objectives for undergraduate clerkships were prepared by expert bodies. Seldom have the clinical teachers, who are critical to the learning process and to the implementationof the  teaching objectives, been the actual proponents of its core content.

Objective: To develop a national-scale proposal of teaching, objectives for the family medicine clerckship in medical school, using a consensus method and the actual, community-based teachers as the expert body.

Method: The Delphi method was chosen for that purpose. In the first round all 189 family medicine teachers in Israeli medical schools were asked to propose five teaching objectives. In the second round the objectives, which were generatedin the first round, were characterized by key words and were send to the participants as a second round for ranking according to their importance.

Results: A total of 116 family medicine teachers (61.38%) responded in the first round and 91 of the 116 (78.5%) in the second round. They formulated 51 teaching objectives listed in order of importance, covering a wide array of themes and including knowledge, attitude and skills objectives. The most important objectives were common problems in primary care, recognition of the biopsychosocial model, and understanding the importance of the doctor-patient relationship. The structure of the list provides a uniqe insight into the relative importance of each objective in the context of the whole core content of the clerkship.

Conclusions: Constructing a proposal for teaching objectives is feasible using the Delphi method and the field instructors as the selecting body. The process and its results can provide faculty with relevant and important suggestions on the content and structure of the family medicine clerkship.
 

Background: Many women stop smoking before or during pregnancy, or while breast-feeding (nursing).

Objectives: To assess the relation between breast-feeding and smoking habits.

Methods: A survey was conducted among 920 women attending family health clinics (group 1) and a maternity department (group 2) on their breast-feeding and smoking habits.

Results: A total of 156 women (16.95%) smoked during pregnancy. A significant correlation was found between breast-feeding and not smoking after delivery (P=0.009 in group 1, P=0.03 in group 2). A higher tendency to nurse was found among women with an uneventful pregnancy, who vaginally delivered a singleton at term weighing 2,500-4000 g, and who received guidance on breast-feeding.

Conclusion: Professional guidance in favor of breast­feeding is crucial to increase the rate of nursing. Encouraging breast-feeding will probably decrease the rate of cigarette smoking.
 

Background: When encountering complaints of pain in the area of the Achilles tendon, the clinician seldom reaches a correct and precise diagnosis based solely on the grounds of physical examination and standard X-rays.

Objectives: To assess the usefulness of ultrasound in diagnosing pathologies of the Achilles tendon.

Methods: We conducted a retrospective review of patients presenting at our orthopedic clinics.

Results: Sonography was used to evaluate 41 patients with achillodynia. This modality enabled the diagnoses of 19 abnormal tendons (46%), peritendinous and other lesions a complete rupture in two patients (5%) a partial rupture of the Achilles tendon in 3 (7%) various degrees of calcification of the tendon in 7 (17%) and peritendinous lesions discerned by the tendon’s hypoechoic regions with disorganized arrange­ment of collagen fibrils in 4 patients (10%). Other lesions included tendonitis (3 patients, 7%), retrocalcaneal bursitis (3 patients, 7%), lipoma (1 patient, 2%), and foreign bodies (2 patients, 5%). The mean diameter of the pathological tendons was 10.4 +2.7 mm, while normal tendons measured 5.2 +0.8 mm (P<0.001).

Conclusion: As in many other soft tissue lesions, ultrasonography is a useful tool in the evaluation of the underlying pathology in patients presenting with achillodynia.

Background: Israel lacks a systematic surveillance of sports injuries, and knowledge of risk factors and specific patterns of injury is inadequate. In order to promote prevention of sports-related injuries, the magnitude of the problem must first be identified and the incidence and severity of sports injuries described.

Objective: To conduct a survey on previous sports injuries among a sample of Israeli athletes.

Methods: A convenience sample of Israeli amateur athletes participating in the 1997 15th Maccabiah Games was randomly selected. The study group answered an anonymous self-administered questionnaire that included sociodemographic data, and information regarding their sports activity and sports-related injuries that had occurred during the previous 2 years.

Results: The study group, aged 12-3 years (median age 21), comprised 301 consenting athletes in 28 different sports. Of these athletes 56.1% reported having had at least one injury. Most injuries (75.6%) involved the upper and lower extremities, and 37.8% of the injured sportsmen had received medical attention from a physician. Half of the athletes participated in contact sports - both collision and limited impact. This group had a much greater proportion of reported injuries in all age groups.

Conclusion: Surveillance of sports injuries should be expanded in order to develop appropriate prevention programs in Israel.

Objective: To explore the putative effect of cardiac rehabilitation programs on the health-related quality of life’ and ‘return to work’ in pre-retirement patients one year after coronary artery bypass grafting.

Methods: Of the 2085 patients aged 45-4 who survived one year after CABG and were Israeli residents, 145 (6.9%) had participated in rehabilitation programs. Of these, 124 (83%) who answered QOL questionnaires were individually matched with 248 controls by gender, age within 5 years. and the time the questionnaire was answered. All patients had full clinical follow-up including a pre-operative interview. The Short Form-36 QOL questionnaire as well  as a specific questionnaire were mailed to surviving patients one year after surgery. Study outcomes included the scores on eight scales and two summary components of the SF-36, as well as return to work’ and ‘satisfaction with medical services’ from the specific questionnaire. Analysis was done for matched samples.

Results: Cardiac rehabilitation participants had signifi­cantly higher SF-36 scores in general health, physical functioning, and social functioning. They had borderline significant higher scores in the physical summary component of the SF-36. The specific questionnaire revealed significantly better overall functioning, higher satisfaction with medical care. and higher rate of return to work. While participants in cardiac rehabilitation and their controls were similar in their socio­-demographic and clinical profiles, participating patients tended to be more physically active and more fully employed than their controls.

Conclusions: Rehabilitation participants had a self-per­ception of better HRQOL, most significantly in social function­ing. Our findings of more frequent return to work and higher satisfaction with medical care should induce a policy to encourage participation in cardiac rehabilitation programs after CABG.