Corneal Infection in Wearers of Contact Lenses

Y. Domniz, R. Avisar, H. Savir

Assaf Harofeh Medical Center, Zerifin; and Hasharon Hospital, Petah Tikva

This is a 5-year retrospective survey of corneal infection in wearers of optical contact lenses (OCL). 23 of the 61 patients (38%; Hasharon Hospital) with positive cultures wore OCL. Visual acuity improved in 15 (65%), no change was noted in 4 (17.5%) and there was deterioration in 4 (17.5%), as compare with status on admission.

Pseudomonas aeruginosa was the most common cause of infections among OCL wearers. The improvement in visual acuity expected due to wearing OCL was affected by infections. After Staphylococcus albus infections had the highest rate (100%) of improvement in visual acuity and after Ps. aeruginosa the lowest rate (57.2%) of improvement, as well as the highest rate of deterioration (42.8%) found following recovery.

OCL wearers are at higher risk for damage to visual acuity following corneal infection, and highly virulent infections in OCL wearers are responsible for a high risk of damage to visual acuity.

Thrombocytopenic Purpura as Sole Manifestation of Brucellosis in a Child

Ronen Marom, Dan Miron, Herzel Gabriel, Yosef Horowitz

Pediatric Dept. A, Pediatric Infectious Disease Service, and Pediatric Hemato-Oncology Unit, HaEmek Medical Center, Afula and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Thrombocytopenic purpura associated with brucellosis has rarely been described in children. The thrombocytopenic purpura is usually part of the array of manifestations of brucellosis, such as fever, malaise, arthralgia, arthritis, hepatosplenomegaly and lymphadenopathy.

We describe a 4-year-old girl in whom severe thrombocytopenic purpura was the only manifestation of brucellosis which resolved after appropriate antibiotic therapy. We conclude that brucellosis should be included in the differential diagnosis of thrombocytopenic purpura in areas endemic for brucellosis, and when there is a history of exposure to infected food products.

Breaking Bad News - A Structured Course for Primary Care Physicians 

Lea Ungar, Mordechai Alperin, Gilad Amiel, Zvi Behrier, Shmuel Reiss

Family Medicine Dept., Kupat Holim Klalit Health Services, Western Galilee District; Medical Education Unit, Bruce Rappaport Faculty of Medicine, Technion Institute of Technology; and Urology, Dept., Bnei-Zion Medical Center, Haifa

Physicians are frequently required to break bad news to their patients. Previous research has shown that inconvenience, incompetence, and difficulty in dealing with patients' feelings are the main complaints expressed by physicians after such an encounter. Current educational programs dealing with breaking bad news are usually short, given in lecture format, and are inadequate in addressing essential issues such as knowledge, personal beliefs and attitudes, and previous personal experiences of physicians in such situations.

In the past 8 years our Dept. of Family Medicine has implemented a course in breaking bad news that addresses these issues. A senior family practitioner and a medical social worker conduct 14 sessions of discussions and role-playing for small groups of residents and primary care physicians. The program is based on: theory dealing with methods of managing stress and crisis intervention, clarifying personal attitudes, discussions of previous personal encounters of the participants, various modalities of communication, methods of addressing patients' feelings and emotions, and coping with the emotions of the one breaking the bad news.

On a 1-5 Likert scale questionnaire the course received an overall score of 4.47 (SD 0.51). Participants noted that they gained relevant communication skills for future patient encounters. A reliable examination of practitioners' competence in breaking bad news is mandatory in order to assess the efficiency of such courses.

What Primary Care Physicians Think of Israel's Health Policy Reform

Revital Gross, Hava Tabenkin, Shuli Brammli-Greenberg

JDC Brookdale Institute, Jerusalem, HaEmek Hospital, Afula; and Ben-Gurion University of the Negev, Beer Sheba

Opinions of the National Health Insurance (NHI) Law held by primary care physicians were surveyed. A questionnaire was submitted (April-July 1997) to 930 primary care physicians employed by sick funds, including general practitioners, family physicians, pediatricians and internists. Response rate was 86%.

They supported the main components of the NHI law. It was considered desirable "to a great" or "very great extent" to allocate funds to sick funds based on age and number of members (76%), to require them to accept all applicants (72%), to designate a uniform basket of services (65%), to allow members to transfer freely between funds (63%), and to allow sick funds to sell supplemental insurance (59%). However, only 41% were satisfied with the implementation of the law.

Multivariate analysis showed that employment by Maccabi, Meuhedet, or Leumit sick funds had an independent effect on low satisfaction with the law as implemented, and on negative opinions about the uniform basket of services, the accepting of all applicants, and allocation of funding based on age and number of members. Those employed by the Maccabi and Meuhedet funds were in favor of allowing sick funds to sell supplemental insurance.

The findings of the study have implications for policy-makers interested in increasing support for national health reform by physicians. It is important to examine possibilities of developing direct channels of communication between national policy-makers and physicians, as well as institutionalizing mechanisms that involve physicians directly in formulation of national policy.

Relationship between Occupation and Clinical Characteristics during Pregnancy and Recommendation to Stop Working

S. Gazit-Nissim, E. Sheiner, M. Mazor, I. Shoham-Vardi

Depts. of Epidemiology and Health Services Evaluation, and of Obstetrics and Gynecology, Soroka University Medical Center and Ben-Gurion University of the Negev, Beer Sheba

We examined the relationship between occupation and clinical characteristics during pregnancy and medical recommendations to stop working. Using a case-control design, we compared 58 working women who had preterm births, with 126 who had delivered at term. All women were interviewed postpartum while still in hospital.

There were no differences between the groups with regard to physical activity outside the home, weekly work hours, nor duration of work. Only a small proportion had been exposed to unusually difficult working conditions, to hazardous agents or to a very uncomfortable working environment. Women who had had preterm births were advised more often to leave their jobs or modify their working patterns. Multivariate analysis revealed that the physician's decision to recommend cessation of work was influenced primarily by complications during the current pregnancy.

It appears that our patients at risk for preterm birth are probably correctly identified, and receive appropriate guidelines as to working patterns. It is possible that a poor obstetric history or previous abortions may paradoxically have a protective effect, as they influence the physician to recommend cessation of work.

Multiresistant Escherichia Coli from Elderly Patients

Ilana Slucky-Shraga, Moshe Wolk, Sofia Volis, Israel Vulikh, David Sompolinsky

Dept. of Medicine and Microbiology Laboratory, Mayanei Hayeshua Hospital, Bnei Brak; Central Laboratories, Ministry of Health, Jerusalem; and Faculty of Life Sciences, Bar Ilan University, Ramat Gan

We examined all ceftriaxone-resistant Escherichia coli isolates obtained from clinical samples during 16 months (1 Dec. '97 - 31 Mar. '99). A total of 97 resistant isolates from 36 patients were obtained, mostly from urine specimens. Of these patients, 35/36 were over 75 years old, most lived in nursing homes, were dependent on nursing in their daily lives, and were incontinent and/or had indwelling catheters.

All 97 isolates had similar susceptibility profiles: resistant to ciprofloxacin, gentamicin, ampicillin, amoxycillin/clavulanate, tricarcillin/clavulanate, aztreonam, and cefuroxime; decreased susceptibility to ceftazidime and cefepime; and susceptible to imipenem and meropenem. Double-disc tests indicated that all strains produced extended spectrum beta-lactamase(s). All the isolates belonged to 1 of 3 E. coli serotypes: 79 were 0153:H31, 13 were 0142:H10, and 5 were 0102:H6.

Familiarizing Medical Students with Hospital Social Worker's Role 

Barbara Rabin (Rabinowitz), Dafna Manor

Dept. of Social Work, Meir Hospital, Kfar Saba

Patient care in a general hospital is usually provided by a multi-professional team. Treatment is most effective when each professional understands the functions of the various other members of the team. Professional literature and research have highlighted differences in perception by social workers and physicians of the proper function of the medical social worker.

Our social work department has developed a teaching program for medical students to enhance their knowledge with regard to this issue. It is presented at a single-session group meeting of an hour and a half, with structured content and goals.

Current Trends in Surgery for Female Urinary Stress Incontinence 

M. Neuman, A. Musaiev, Y.Z. Diamant

Dept. of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem

Quality of life of 5% of the female population is impaired by urinary stress incontinence. Its cause is pelvic floor relaxation and the cure is surgical. The most widely performed operations are retropubic colposuspensions and sling operations, which have relatively high, well-proven cure rates. Yet because of the long rehabilitation required, gyneco-urologists seek minimally invasive ways to solve the problem.

Vaginal colporrhaphy and laparoscopic operations are not common, but the recently reported TVT might become popular if proven effective.

Physicians' Reminders Promote Annual Fecal Occult Bloodtesting Compliance

Shlomo Vinker, Vardina Shumla, Eliezer Kitai

Family Medicine Dept., Sackler Faculty of Medicine, Tel Aviv University

Screening for the early detection of colorectal cancer using the fecal occult blood test has been shown to be effective in reducing mortality. In Israel family physicians recommend that their patients, aged 50-75, have the test performed annually. But compliance with testing in the general population has been poor.

We therefore studied this issue in 3 primary care facilities, in 384 patients, average age 62.7‏6.9 years; 81 (21.1%) performed the fecal occult blood test. Performance rates were significantly lower (13.9%) in those aged 50-59 (p = 0.0003), as compared wh those aged 60-69 and 70-75 (24.3% and 24.7%, respectively). Compliance rates of the patients of different physicians varied as well.

Recommendation of family physicians led to overall compliance of 21.1%. Additional efforts are needed to increase compliance in order to decrease colorectal cancer morbidity and mortality in Israel.

Pre-Induction Sport Activity in Prevention of Stress Fractures 

Aharon S. Finestone, Arieh Eldad, Charles Milgrom

Medical Corps, Israel Defense Forces, and Dept. of Orthopedics, Rabin Medical Center, Beilinson Campus, Petah Tikva and Hadassah University Hospital, Ein Kerem, Jerusalem

Pre-induction sports participation of 392 elite infantry recruits was evaluated for correlation with incidence of stress fractures (SF) during 14 weeks of basic training. 23.7% developed lower extremity stress fractures. 72% of the recruits had participated in sports on a regular basis during the 2 years prior to induction. Their fitness as examined by the Bar-Or induction fitness test, was significantly better than that of those who had not trained. 14.9% of the soldiers who had previously participated in ball games (primarily basketball) as an only sport suffered stress fractures, compared to 31.0% of those whose only sport was running (p<0.005).

Training for only 6 months prior to induction had no effect on the incidence of SF. The reason for the difference between ball games and running is probably related to the higher strains and strain rates developed during ball games and to their multidirectional nature, as compared to running.

These findings suggest that participation in a pre-induction program that includes activities that create strains, such as basketball, can reduce incidence of SF in infantry recruits. The training period has to last at least 2 years.

Israel Naval Medical Institute: 20 Years of Applied Research, and Future Goals 

Ran Arieli, Avi Shupak

Israel Naval Medical Institute, Medical Corps, Israel Defense Forces

The Israel Naval Medical Institute (INMI) is unique as a research center located in a naval base and having close inter-relations with naval underwater units. It is ideal for applied research, and for mutual exchange of needs and of ideas and instructions.

Factors making this institute so suitable for applied research include: direct personal communication with combat divers, professional naval divers, submariners, civilian recreational divers and professional civilian divers, as well as naval vessel crews prone to seasickness; hyperbaric oxygen therapy is administered in cooperation with a large neighboring hospital.

Close spatial and personal relations with an academic institution (the Technion, with its Faculties of Medicine, Biology and Biophysics) provide a basis for cooperative research which expands research capabilities, and allows access to extensive expertise, instrumentation and equipment. Close ties with physicians who served at the INMI in the past also bring them into this research community.

During their specialization, physicians may spend up to 6 months working with us on a research project. Undergraduate, graduate and post-graduate students may complete their research at our institute with the agreement of their parent academic institutions.

Much of the research can be released to the international community. However, some is classified, serves only internal needs or is not of public interest. The number of published papers has stabilized since 1991 at about 16 a year.

Studies of gas exchange and oxygen toxicity originate mainly in the Hyperbaric Research Unit, research on motion sickness in the Motion Sickness and Human Performance Laboratory, and work on hyperbaric and diving medicine in the Clinical Section of the INMI.
 

Decompression Sickness in Divers Treated at the Israel Naval Medical Institute 

A. Gil, A. Shupak, H. Lavon, Y. Adir

Israel Naval Medical Institute, Israel Defense Forces, Haifa

Clinical characteristics of 125 divers treated for decompression sickness (DCS) in the hyperbaric multiplace chambers of this Institute during 1992-1997 were analyzed retrospectively. In 62 (51%) the diagnosis was DCS Type I (joint pain or skin involvement) and in 60 (49%) DCS Type II (neurological, inner ear or pulmonary disease). Risk factors for the evolution of DCS were depth and duration of the dives involving accidents, violation of recommendations of the decompression tables, and repeated dives.

Results were available for 112 of the 125 patients. 54 of them (48%) recovered completely, and another 54 recovered partially; 4 did not respond to treatment. Inner ear DCS was less responsive to hyperbaric oxygen treatment (p=0.0001). There was significant improvement of neurological function in those with severe neurological injury (p=0.0001). Rapid diagnosis and transportation of divers with DCS to a hyperbaric chamber is of crucial importance.

Use of Civilian Emergency Departments by Israel Defense Force Soldiers 

A.D. Cohen, A. Porath, R. Bessorai, A. Shulman, Y. Snir

Medical Corps, Israel Defense Forces; Depts. of Medicine F and Orthopedics and Emergency Dept., Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Many physicians, civilian as well as in military, feel that some referrals of soldiers to civilian emergency departments are inappropriate and that soldiers should receive medical attention within their military units. We therefore evaluated referrals of soldiers to our emergency department.

707 referral letters from military physicians and the corresponding emergency room discharge letters were evaluated. Most soldiers were referred for mild trauma (45.0%) or miscellaneous diseases (52.9%); 22 (3.1%) were hospitalized.

It appears that some military physicians use the civilian hospital emergency department as a surrogate for an out-patient specialty clinic and for x-ray and laboratory services. This is in contrast to the designated functions of the emergency department which are to provide emergency and trauma services and to evaluate the need for hospitalization of referred patients.

Breast Cancer after Mantle Field Irradiation for Hodgkin's Disease 

A. Katz, B. Brenner, A. Sulkes, H. Luria, G. Marshak, E. Fenig

Oncology Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University

Effective use of modern therapeutic modalities results in the cure of 75%-80% of Hodgkin's disease patients, regardless of stage. The major threat to continued survival is, therefore, not recurrent disease but development of second malignancies. Recent reports have firmly established the increased risk of breast cancer developing in women treated with mantle field irradiation.

We describe 3 women who developed breast carcinoma following mantle field irradiation for Hodgkin's disease. Their clinical course was consistent with that reported in larger series. They were relatively young when irradiated and there was a long interval between radiation therapy and the diagnosis of breast cancer.

Review of the literature shows that there may be a role for prophylactic mastectomy after irradiation for Hodkgin's disease.

Placenta Accreta with Placenta Previa after Previouscesarean Sections 

Eylon Lachman, Alexander Mali, Gabriel Gino, Michael Burstein, Michael Stark

Depts. of Obstetrics and Gynecology and of Pathology, Misgav Ladach Hospital, Jerusalem

The increased rate of cesarean sections in recent decades has brought with it an increase in the frequency of placenta accreta. There are direct correlations between previous cesarean deliveries and also maternal age, with the risk of placenta accreta. There is also a direct correlation between placenta accreta and placenta previa.

The risk of placenta accreta in women who have had placenta previa is 2% for those younger than 35 years and with no history of uterine surgery. The risk increases to 39% for those over 35 who have had 2 or more cesarean sections.

We present 3 cases of placenta accreta admitted in 15 months, all of whom had a history of cesarean sections. The frequency of placenta accreta in our hospital is 1:1,579 deliveries, in line with the 1:1,420 in the literature. We consider hysterectomy the treatment of choice for this serious complication. When performing a cesarean in cases of placenta previa with a history of cesarean sections, the possibility of placenta accreta should be considered.