Israel Medical Association Journal

Objectives: To examine whether a military medic, using a structured questionnaire and an algorithm, can appropriately triage patients to receive over-the-counter medications and refer more complicated cases to a physician.

Methods: The study group comprised 190 consecutive soldiers who presented to a military primary care clinic with symptoms of ARVI. Using a questionnaire, a medic recorded the patient's history and measured oral temperature, pulse rate and blood pressure. All patients were referred to a doctor. Physicians were “blind” to the medic’s anamnesis and to the algorithm diagnosis. We compared the medic’s anamnesis and therapeutic decisions to those of the doctors.

Results: Patients were young (21.1 ± 3.7 years) and generally healthy (93% without background illness). They usually had a minor disease (64% without fever), which was mostly diagnosed as viral ARVI (83% of cases). Ninety-nine percent were also examined by a physician. According to the patients' data, the medics showed high overall agreement with the doctors (83–97.9%). The proposed algorithm could have saved 37% of referrals to physicians, with a sensitivity of 95.2%. Had the medics been allowed to examine the pharynx for an exudate, the sensitivity might have been 97.6%.

Conclusions: Medics, equipped with a questionnaire and algorithm but without special training and without performing a physical examination, can appropriately triage patients and thereby reduce the number of referrals to physicians.

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[1] ARVI = acute respiratory viral infection

Objectives: To assess user satisfaction and clinical short-term effectiveness of a computerized store and forward teledermatology service in urban and rural units.

Methods: A multi-center, prospective, uncontrolled, cohort pilot trial was conducted for a period of 6 months. Primary care physicians referred patients to a board-certified dermatologist using text email accompanied by digital photographs. Diagnosis, therapy and management were sent back to the referring PCP[1]. Patients were asked to evaluate the level of the CSAFTD[2] service, effect of the service on accessibility to dermatologists, respect for privacy, availability of drugs, health improvement and overall satisfaction. PCPs assessed the quality of the teledermatology consultations they received, the contribution to their knowledge, and their overall satisfaction.

Results: Tele-diagnosis alone was possible for 95% (n=413) of 435 CSAFTD referrals; 22% (n=95) of referrals also required face-to-face consultation. Satisfaction with CSAFTD was high among patients in both rural and urban clinics, with significantly higher scores in rural units. Rural patients rated the level of service, accessibility and overall satisfaction higher than did urban patients. PCPs were satisfied with the quality of the service and its contribution to their knowledge. Rural physicians rated level of service and overall satisfaction higher than the urban physicians. Tele-referrals were completed more efficiently than referral for face-to-face appointments.

Conclusions: CSAFTD provided efficient, high quality medical service to rural and urban military clinics in the IDF[3].

Objectives: To compare the subjective visibility of normal anatomic landmarks in the chest on storage phosphor-based digital radiographs versus conventional screen-film radiographs.

Methods: Digital phosphor-based and screen-film posteroanterior chest radiographs were obtained during 1 year in 140 asymptomatic patients without any known pulmonary disease (119 men, 21 women; mean age 52.1 years, range 23–86). Both sets of films were independently compared by two experienced radiologists in different sessions. The visibility of each of the following anatomic landmarks was graded from 1 to 3: pulmonary fissures, carina, bronchi to left upper lobe, right upper lobe and left lower lobe, bronchus intermedius, anterior and posterior junctional lines, and vessels behind the heart and diaphragm. Additionally, subjective general quality impression of each radiograph was graded similarly. Statistical analyses were performed using the chi-square test. A P value less than 0.05 was considered significant.

Results: Visibility with the digital images was statistically significantly higher for the carina, left lower lobe bronchus, bronchus intermedius, and vessels behind the heart and diaphragm. Subjective general quality impression of digital radiographs was also higher (P < 0.001). No significant visibility differences were found for pulmonary fissures or junctional lines.

Conclusion: Subjective visibility of anatomic structures behind the heart and diaphragm and at the hilae is significantly improved with phosphor-based digital radiography compared with conventional screen-film radiography. This suggests that pathologic processes such as pulmonary nodules, masses or consolidations projected over those structures may be more easily and reliably depicted on digital than conventional chest X-rays.

Objectives: To determine the prevalence of abnormal coagulation studies in ED[1] patients evaluated for suspected ACS[2], and to investigate whether abnormal international normalized ratio/partial thromboplastin time testing resulted in changes in patient management and whether abnormal results could be predicted by history and physical examination.

Methods: In this retrospective observational study, hospital and ED records were obtained for all patients with a diagnosis of ACS seen in the ED during a 3 month period. ED records were reviewed to identify all patients in whom the cardiac laboratory panel was performed. Other data included demographics, diagnosis and disposition, historical risk factors for abnormalities of coagulation, ED and inpatient management, INR[3]/PTT[4], platelet count and cardiac enzymes. Descriptive statistical analyses were performed.

Results: Complete data were available for 223 of the 227 patients (98.7%). Of these, 175 (78.5%) patients were admitted. The mean age was 64.2 years. Thirteen patients (5.8%) were diagnosed with acute myocardial infarction. Of the 223 patients, 29 (13%) and 23 (10%) had INR and PTT results respectively beyond the reference range. Seventy percent of patients with abnormal coagulation test results had risk factors for coagulation disorders. The abnormal results of the remaining patients included only a mild elevation and therefore no change in management was initiated.

Conclusions: Abnormal coagulation test results in patients presenting with suspected ACS are rare, they can usually be predicted by history, and they rarely affect management. Routine coagulation studies are not indicated in these patients.

Objectives: To describe an alternative de-loading method using a fiberglass removable walking cast.

Methods: This prospective uncontrolled study comprised 24 diabetic and non-diabetic patients with a single planter neuropathic ulcer. Exclusion criteria included the presence of osteomyelitis or cellulites, peripheral vascular disease, severe foot or leg edema, more than one ulcer on the treated foot, ulcers on the other foot, visual problems, gait instability, and personality or psychiatric problems. All patients were treated with the removable fiberglass de-loading cast. At each weekly follow-up visit the cast was removed. Data were collected using a clinical report form.

Results: The ulcer healed completely in 21 of the 24 patients treated (87.5%). The mean time for healing was 6.8 weeks (range 3–20 weeks, SD = 4.2). New ulcers developed in six patients (25% of the group).

Conclusions: The effectiveness and safety of the method is comparable to that of the total contact cast, but is less labor intensive because the cast is manufactured only once and serves for the whole length of treatment. Improving the technique is expected to lower the complication rate.

Objective: To determine breast-feeding patterns and the association between sociodemographic characteristics and breast-feeding in the Tel Aviv district.

Methods: The mothers of infants aged 2, 4, 6 and 12 months, attending 59 well-baby clinics in the Tel Aviv district, were interviewed by telephone. Singleton infants who weighed less than 2,000 g and multiple-gestation infants were excluded from the study. The questions covered background data, sociodemographic characteristics of the family, and breast-feeding practices. Stepwise logistic regression was used to analyze the association between breast-feeding and various sociodemographic characteristics.

Results: Altogether, 78.5% of the mothers (1,307/1,665) initiated breast-feeding. The rate of breast-feeding at 2, 4, 6 and 12 months was 55.8, 36.8, 29.9 and 11.8%, respectively. Only 35.8% of the infants at 2 months and 11.2% at 6 months were exclusively breast-fed. The mean duration of breast-feeding was 5.2 ± 0.2 months. Grand multiparas (≥5 children) had a significantly higher rate of breast-feeding than women with one to four children (P < 0.001). More likely to breast-feed for 2 weeks or longer were women married to Yeshiva students (odds ratio = 5.3), women with ≥13 years education (OR[1] = 2.1), and women on maternity leave (OR = 1.6). The predictors for breast-feeding for 6 months or longer were similar.

Conclusions: Although the rate of breast-feeding initiation in central Israel was 78.5%, only 29.9% of the mothers continue to breast-feed for 6 months. Already at a young age, an appreciable number of breast-fed infants receive infant formula. Breast-feeding promotion should focus on less educated women, homemakers, and families with one to four children.