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: Spinal dural arteriovenous fistulae comprise the majority of spinal vascular malformations. The most common clinical presentation is that of progressive myelor­adicuiopathy, probably related to venous hypertension, which may lead to permanent disability and even death.

Objective: To report our clinical experience with spinal dural arteriovenous fistulae.

Methods: Nine patients with spinal dural AVF were managed at our center during a one year period (1998-1999). The patients, eight men and one woman ranging in age from 46 to 75 years, presented with initially fluctuating and eventually permanent and progressive paraparesis, sensory disturbances and sphincter dysfunction. The neurological signs generally began symmetrically and progressed from the distal to proximal limb regions. The duration of symptoms before diagnosis ranged from 6 to 36 months during which the patients underwent an extensive but fruitless work-up and even unnecessary operations due to misdiagnosis. All patients finally underwent magnetic resonance imaging and spinal angiography, which demonstrated the pathological vascular fistula. Interruption of the AVF was achieved by embolization or by surgical resection.

Results: Following treatment, six patients experienced improvement of gait and sphincter control, and the severe neurological deficits stabilized in the other three patients with long duration of illness. There was no further deterioration in any of the treated patients.

Conclusions: The history, neurological findings and radiological changes on MRI scan should alert clinicians to the possibility of spinal dural AVF, leading to diagnostic spinal angiography. Early diagnosis and treatment may significantly improve outcome and prevent permanent disability and even mortality.

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.

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.
 

Background: Knowledge of the prevalence of chronic disease in the population is essential for health planners and providers.

Objectives:To present the results of a concentrated effort by the largest health maintenance organization in Israel (Clalit Health Services) in order to develop a comprehensive register of chronic diseases.

Methods: In 1998, all 2,704 primary care physicians in Israel’s largest health provider were requested to report on all patients with selected chronic diseases. In addition, all the filled prescriptions for medications relevant to the investigated diseases and all relevant hospitalization events were added to the database. Prevalence rates were calculated based on the reporting practices only (1,653 physicians responsible for a total of 1,409,725 adults).

Results: Hypertension (10.2/100), diabetes (6.1/100), hyperlipidemia (5.7/100), peptic ulcer (4.7/100) and ischemic heart disease (4.3/100) were the most prevalent. Females had significantly higher rates of hypothyroidism, psychoses, neu­roses and malignancies, and lower rates of ischemic heart disease, chronic obstructive pulmonary disease, heart failure and asthma. Arabs had higher rates of diabetes mellitus and lower rates of ischemic heart disease, hypertension and hyperlipidemia than Jews. About 20% of the adult population had one or more of the selected chronic diseases.

Conclusions: Differences in rates noted between physi­cians, not explainable by population characteristics, may reflect differences in the quality and delivery of health services. Rate differences between demographic subgroups call for further studies on the etiology, susceptibility and natural history of these diseases.
 

Background: On 1 January 1995 a new mandatory National Health Insurance Law was enacted in Israel, The new law fostered competition among the four major Israeli healthcare providers (HMO5 or sick funds) already operating in the market due to the possibility that an unlimited number of patients and the relative budget share would shift among the HMOs. This led them to launch advertising campaigns to attract new members.

Objectives: To examine newspaper advertising activities during the early stages of healthcare market reform in Israel.

Methods: Advertising efforts were reviewed during a study period of 24 months (July 1994 to June 1996). Advertisements were analyzed in terms of marketing strategy, costs and quality of information.

Results: During the study period 412 newspaper adver­tisements were collected. The total advertising costs by all HMOs was approximately US$4 million in 1996 prices. Differences were found in marketing strategy, relative adver­tising costs, contents and priorities among the HMOs.

Conclusions: The content of HMO5 newspaper advertis­ing was consistent with their marketing strategy. The mes­sages met the criteria of persuasive advertising in that they cultivated interest in the HMOs but did not provide meaningful information about them. Future developments in this area should include consensus guidelines for advertising activities of HMOs in Israel, instruction concerning the content of messages, and standardization of criteria to report on HMO performance.

Sex steroid hormones (estrogens, progestagens and androgens) have been associated with healthy and neoplastic pancreatic biology, although the precise significance of the findings has not been well established. Receptors for the three different types of SSH are expressed in normal and tumoral pancreatic tissue with varying profiles related to cell origin (exocrine or endocrine), to type of neoplasm. and probably even to tumoral behavior. The activity of specific enzymes involved in the synthesis and transformation of SSH are increased in some neoplastic pancreatic tissues, which may influence the circulating concentrations of these hormones, such as the low serum testosterone: dihydrotestosterone ratio described in male patients with pancreatic carcinoma. Different patterns of age and gender-related incidence and growth of neoplasms have been identified. Experimental studies have shown that pancreatic carcinogenesis is promoted or inhibited by SSH. At present, the data supporting hormonal manipula­tion for the treatment of these tumors are non-conclusive. Normal and tumoral pancreatic tissues may be regarded as a target for SSH and an additional site of biosynthesis. The influence of these hormones on physiological activities is not well known but should be further explored. The study of SSH in pancreatic neoplasms will provide clues about its origin, development, tumoral behavior, prognosis and more specific hormonal therapy. We review here the evidence favoring the role of SSH and their possible clinical implications in pancreatic function.

Background: High dose interleukin-2 therapy, adminis­tered in bolus, is considered to be a reasonable treatment option in a selected group of patients with metastatic malignant melanoma.

Objectives: To present our experience using this mode of therapy in 21 patients with metastatic melanoma.

Materials and Methods: The 21 patients in our study group comprised 13 men and 8 women with a mean age of 46 years (range 29-63). Their metastatic disease was present in all extracranial sites, dermal and sub-dermal metastases being the most common (15 patients had at least one site, in addition to other locations of metastases). Patients with intracranial disease were excluded due to the poor effectivity of IL-2 at this site. Treatment comprised a course of 2 weeks of therapy with a 1 week rest interval between. Radiological and physical evaluation was performed 6-8 weeks after the first course. If a response was achieved a second course of therapy was given. Patients received up to 14 planned doses of IL-2 in each week, 720,000 lU/kg of IL-2 per dose iv. in 15 minutes. All treatments were given in the surgical ward, and only one patient was hospitalized in the intensive care unit.

Results: Of the 21 patients, one had a complete response that has lasted for 17 months and 5 patients had a partial response (range 3 months to 3 years). One patient died during treatment, and one patient who refused further treatment because of no response died a few days after completion of treatment. Prior to therapy three of the responders had received autologous vaccines with good immunological response (P=0.115). Toxic side effects were significant, but they were treated successfully with no residual damage.

Conclusions: High dose IL-2 can be administered safely in a surgical department. The response rates achieved in this series justify the use of high dose IL-2 in a selected group of patients. To improve response rates, a combination of auto­logous vaccines prior to high dose IL-2 may be recommended.

Background: Parental knowledge of their child’s heart disease, while often overlooked, contributes to compliance and reduces anxiety. Prior studies have shown that 36% of parental diagnostic descriptions are incorrect.

Objectives: To assess parental knowledge and attitudes among outpatients at a hospital pediatric cardiology clinic.

Methods: Seventy-four families completed a questionnaire in which they described their child’s condition and stated their attitude towards dental hygiene and future prenatal diagnosis.

Results: Eighteen percent of the parents failed to describe their child’s malformation correctly. We found that parental understanding of the heart defect correlated with parental education. Future prenatal diagnosis was considered by 88% of families, and termination of pregnancy by 40%. Only 40% of children were aware of their heart problem. Children of parents who were ignorant about the condition tended to lack knowl­edge themselves. An additional finding was that 68% of Jewish families turn to non-medical personnel for medical advice - an interesting finding not hitherto addressed.

Conclusions: Ignorance of their child’s problem did not correlate with its severity or complexity but rather with parental background: the less educated the parent, the more likely was the problem perceived incorrectly.