Shlomo Vinker MD, Sasson Nakar MD, Michael A. Weingarten BM BCh, and members of the Israeli General Practice Research Network
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.
Michael A. Weingarten MA BM BCh, Irene Katzir MD, Elliot Sprecher PhD,Svetlana Kobzantsev MD, Cara Zelzer MD and Ernesto Kahan MD
Background: The pattern of diabetes and ischemic heart disease among emigrants from pre-industrialized societies to more developed countries may be explained by both genetic and environmental factors.
Objectives: To describe and interpret the pattern of diabetes and ischemic heart disease among Yemenite immigrants in Israel and their second-generation offspring.
Methods: Medical record charts of adult Yemenites were surveyed in a primary care health center, and the data were compared with prevalence rates derived from a non-Yemenite population.
Results: There was a marked excess of non-insulin dependent diabetes mellitus among Yemenite immigrants over 45 years of age, but not of hypertension or ischemic heart disease. Yemenites with diabetes were far less likely to develop ischemic heart disease than non-Yemenites with diabetes (odds ratio for non-Yemenites compared with Yemenites, 3.5; confidence interval 1.54<OR<7.77).
Conclusions: There was less of an association between diabetes and ischemic heart disease among Yemenites. This finding requires further investigation of the relative roles of genetic and environmental factors.
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OR= odds ratio
Menahem Fainaru MD and Zehava Schafer MsC
Background: Dyslipidemia and obesity serve as risk factors for the development of atherosclerotic cardiovascular disease. Fasting is sometimes recommended for treating these conditions. This study was undertaken to try to resolve conflicting results reported in the literature.
Objectives: To study the effect of fasting (0 calories, with free intake of fluids) for 3-5 days on plasma concentration of triglyceride, cholesterol and apolipoprotein B.
Methods: Physicians, about to begin a hunger strike, were divided into four groups: normolipidemic non-obese men (group 1), two moderately obese men and two men with type IV hyperlipidemia (group 2), healthy non-obese women (group 3), and healthy non-obese women on oral contraceptives (group 4). Adherence to fasting was monitored daily by detailed interviews, loss of weight, drop in plasma glucose, presence of ketonuria, progressive rise in serum creatinine and uric acid, and decrease in plasma pH. We monitored their serum glucose, electrolytes, liver function, lipids, lipoproteins and apolipoprotein B on days 0, 3, and 5.
Results: Physicians who adhered to complete fasting lost more than 1.5% of their body weight after 3 days of fasting (n=12), and more than 3.2% at 5 days (n=5). All non-obese normolipidemic males and females (groups 1 and 3) showed an increase in plasma triglyceride (by 28-162%) and very low density lipoprotein cholesterol (by 22-316%) after 3 days of fasting. The obese and hyperlipidemic men (group 2) showed a decrease of 17-63% in their VLDL cholesterol, and the women on oral contraceptives (group 4) showed a 20% decrease in their plasma triglyceride on day 3. Low density lipoprotein cholesterol increased by 13% in group 2, decreased by 7.3% in group 4, and remained unchanged in group 1 and 3. Apolipoprotein B level correlated well with LDL cholesterol in all groups. High density lipoprotein cholesterol changes were inconsistent.
Conclusions: These results help to explain and reconcile previous published reports. The metabolic background of the individual together with the amount of energy consumed affect the behavior of plasma lipids and lipoproteins levels during fasting.
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VLDL= very low density lipoprotein
LDL= low density lipoprotein
Ronen Rub, MD, David Margel, MD, Dror Soffer MD and Yoram Kluger, MD
Background: The course and outcome of appendicitis in the elderly differs from that of the general population. The rates of perforated appendices, error in diagnosis, postoperative complications and mortality may be related to the time lapse between onset of symptoms and admission, and hence delay in surgery.
Objectives: To evaluate if these factors have improved in recent years.
Methods: A retrospective study was carried out of all 61 patients over age 60 who underwent appendectomies in a major metropolitan hospital during 1988-98.
Results: We found that most patients had appendectomies within the first 24 hours of admission and within 3 days of symptoms. Rate of perforation was 43%, error 5.6%, morbidity 41%, and mortality 3.2%.
Conclusions: The high rate of appendix perforation in the elderly is not due to delay. The literature reveals little improvement in the statistics of the disease over the last five decades, despite advances in imaging and surgical technique. This may be explained by the increasing inclusion of octogenarian patients.
Anabel Aharon-Maor, MD and Yehuda Shoenfeld, MD
Rolando Cimaz, MD, Luca Catelli, MD, Cristina Luzzana, MD, Paola Panzerei, PhD and Pierluigi Meroni, MD
Michael David, MD, Dov Efron, PhD, Emmilia Hodak, MD and Zvi Even-Paz
by Zaher S. Azzam, MD and Jacob I. Sznajder, MD
Orna Geyer, MD, Meira Neufelder, MD, Adi Michaeli-Cohen, MD, Moshe Lazar, MD, Sigal Sadetzki, MD and Baruch Modan, MD
Elias Toubi, MD, Johana E. Naschitz, MD, Aharon Kessel, MD and Milo Fradis, MD
Michael Heim, MB CHB, Elinor Goshen, MD, Aharon Chechick, MD, Ilan Cohen, MD and Morris Azaria, MD