תוצאת חיפוש

Primary Care Physicians in Israel Compared with European Countries

P. Shvartzman, R. Gross, H. Tabenkin, D. Yuval, M. Grinshtein, B. Wienka

Dept. of Family Medicine, Ben-Gurion University of the Negev, Beer Sheba;

Brookdale Institute, Jerusalem; and Nivel Institute, Maastricht, the Netherlands

This study compares Israeli primary care physicians with those of European countries. In Israel a larger proportion of those in primary care are women. The Israeli physicians see many patients a day, but almost never make home visits. They also report for work the fewest hours a day, but spend 21 hours a month in continuous medical education. (more than Europeans?) The Israeli primary care physician scores high in screening for breast cancer and blood cholesterol level, but very low in the fields of minor surgery and alcohol and smoking prevention, contraception, nutrition counseling and normal pregnancy follow-up. Residency training and education may be inadequate, and more emphasis has to be put on the health system and recognizing environmental influences.

Clinical Characteristics of those who Leave the Emergency Room Against Advice

A. Carmel, H. Amital, Y. Shemer, A. Sahar

Emergency Dept. and Dept. of Medicine B, Gertner Institute for Medical Service Research, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

The object of this study was to characterize those who leave the emergency department agmedical advice and to examine the short-term consequences. The study was conducted retrospectively 1992 and prospectively during May-August 1993 by telephone interviews. About 0.5% of all the patients who applied to the emergency department left against medical advice. Their main characteristic was that they were mostly young, single men. A wide range of complaints had brought them to the emergency department, very similar to that of the control group, but with a higher tendency to abuse drugs and alcohol. Most of those who left against medical advice had less severe disease than the controls. However 10% of them had to be hospitalized within the subsequent 2 weeks, in comparison with 4% of the controls. This study suggests that improving the efficiency of the emergency department will decrease the number leaving against advice.

Fibrosarcoma after Silicone Breast Augmentation: Associated?

Anabel Aharon-Maor, Yair Levy, Yehuda Schoenfeld

Medical Dept. B, Chaim Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University

We describe a 42-year-old woman in whom bilateral fibrosarcoma of the breast was diagnosed 15 years after bilateral breast augmentation with silicone implants. 3 years prior to admission the implants were replaced and 2 years prior to admission mammography showed a nodule in the left breast which biopsy showed to be fibrosarcoma. The implants were removed from both breasts and she was given chemotherapy but later that year underwent bilateral mastectomy. Despite chemotherapy, as well as adjuvant radiotherapy, the disease progressed, with involvement of the lungs and the skin of the left hemithorax. She was admitted repeatedly for severe anemia caused by bleeding from the malignant skin lesions, and died less than 2 years after diagnosis of the disease.

Not all reports in the literature find a significant connection between silicone implants and subsequent development of breast cancer, but there are reports that do connect them. Breast fibrosarcoma is not significantly more frequent after silicone augmentation, but still there is controversy as to whether there is a connection between silicone implants and breast malignancy. In the patient we present, the prolonged exposure to silicone may have been a predisposing factor for the development of bilateral fibrosarcoma, since other known risk factors for breast cancer were denied.

Hepatocellular Damage after Using Ecstasy

E. Shiloach, E. Zecler, M. Horowiz, E. Scapa

Depts. of Medicine C and Gastroenterology, Assaf Harofeh Medical Center, Zerifin (Affiliated with Sackler Faculty of Medicine, Tel Aviv University)

Ecstasy is a stimulant used mainly by youngsters to get 'high.' There are few reports of acute injury of the liver due to ecstasy. We describe a 37-year-old woman who presented with the clinical picture of recurrent hepatitis following ingestion of the drug. After several months she developed liver cirrhosis shown by biopsy and CT scanning. This case emphasizes the potential danger of ecstasy. Every patient with hepatitis of unknown origin must be questioned about ingestion of the drug.

Recurrent Syncope as a Presenting Symptom of Systemic Mastocytosis

Iris Barshack, Ginette Schiby, Ofer Shpilberg, Yechezkel Sidi

Pathology Dept., Hematology Institute and Medical Dept. C, Chaim Sheba Medical Center, Tel Hashomer

A 48-year-old man presented with recurrent syncope which was preceded by facial edema and difficulty in breathing. Physical examination, laboratory tests, abdominal CT and bone scan were all within normal limits. Bone marrow biopsy was consistent with mastocytosis. Systemic mastocytosis consists of a spectrum of disorders characterized by aberrant proliferation of tissue mast cells, and are mainly related to mast cell mediator release.

Paroxysmal Nocturnal Hemoglobinuria

Haim Ben-Ami, Yehuda Edoute

Medical Dept. C, Rambam Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired disorder of blood cells which originate from an abnormal hematopoietic stem cell. The condition is characterized by nocturnal hemoglobinuria, chronic hemolytic anemia, and thrombosis. We describe a 60-year-old woman with PNH admitted with abdominal pain and jaundice, who had dark urine on arising after a night's sleep. The diagnosis was established by the typical clinical story and a positive Ham test. She was successfully treated with Halotestin and folic acid. Although PNH is rare, it should be considered in the differential diagnosis of hemolytic anemia. Early diagnosis and treatment are important.

Patients' Opinions of the Role of Primary Care Physicians and the Organization of Health Care Services

Revital Gross, Hava Tabenkin, Shuli Bramli, Pesach Schvartzman

JDC-Brookdale Institute, Jerusalem; Dept. of Family Medicine, HaEmek Hospital, Afula; Kupat Holim Clalit, Northern District; Institute for Specialization, Ben-Gurion University, Northern Branch; and Dept. of Family Medicine, Ben-Gurion University of the Negev and Kupat Holim Clalit, Beer Sheba

Patients' opinions of the role of the primary care physician were studied. The study population consisted of Hebrew-speaking members of the Clalit Sick Fund, aged 18+, who visited primary care and specialty clinics. Interviews took place during January-March 1995 in the Emek and Jerusalem, and during August-October 1995 in Beer Sheba. A total of 2,734 interviews were conducted, and the response rate was 88%. 64% of the respondents preferred the primary care physician as the first address for most problems occurring during the day. Multivariate analysis revealed that the variables predicting this preference were: being over age 45, having completed less than 12 years of schooling, being satisfied with the physician, and when a child's illness was involved. Whether the physician was a specialist had only a marginal effect. The findings also show that among those who did go directly to a specialist for the current visit, 49% would still prefer the primary care physician to be the first address for most problems. However, half of the respondents initiated the current visit to the specialty clinic themselves. The findings also showed that a preference for the primary care physician to be the first address had an independent and statistically significant effect on the following aspects of service consumption: taking the initiative to go to a specialist, the intention to return to the primary care physician or to the specialist for continuing care, and the patient's belief that referral to a specialist was needed. The findings of the study may be of assistance to policy-makers on the national level and to sick funds in planning the role of the primary care physician, so that it corresponds, on the one hand, to the needs of the sick funds and the economic constraints in the health system, and on the other, to the preferences of the patient.

Percutaneous Ablation of Malignant Kidney Tumors in Rabbits by Low Frequency Radio Energy

Boaz Moskovitz, Ofer Nativ, Edmond Sabo, Yousef Barbara, Daniel Mordohovich, Yoseph Kaftori, Arie Shalhav, Benad Goldwasser

Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Radio-frequency (RF) current has been used successfully to ablate normal human tissue. To investigate further the clinical application of this modality in tumors, we studied the potential of using RF percutaneously to destroy experimental kidney tumors. 35 outbred albino rabbits underwent direct-implantation of renal VX2 tumor during open surgery. After 21 days, ultrasonography was performed to show tumor presence and size. A shielded RF needle was designed to be inserted percutaneously through an introduction needle. An electrical insulation shield covering the RF needle was retractable, controlling the length of exposure of the RF needle inside the tissue. 22 days after tumor implantation, RF was applied via this special needle using a ZoMed International RF generator. In one group of rabbits the procedure was performed under direct vision during open surgery, while in another group treatment was percutaneous, the needle guided by palpation of the tumor. Rabbits were killed 3 days later and revealed 4-25 mm intra-tumoral RF-induced lesions. A direct relation was found between lesion size and the power and duration of RF applied (at 7.5 W, R=0.48, and P=0.32). Based on our preliminary results we can conclude that RF may have clinical applications in the near future for percutaneous local tumor control in parenchymal organs.

Fatal Multiple Organ System Dysfunction Associated with Germanium Metal

Micha Shamir, Charles L. Sprung

Dept. of Anesthesiology and Critical Care Medicine, Hadassah--University Hospital and Hebrew University-Hadassah Medical School, Jerusalem

The element germanium is widely distributed in nature. It is used in industry as a semiconductor and there have been a few attempts to use it in medicine. In the past few years 20 patients have been described in the literature as suffering from germanium overdosage. Like laboratory animals affected by the element, they suffer from renal failure and injury to other organs. We describe a 52-year old man given germanium to prevent recurrence of a brain tumor. He developed multiple organ dysfunction syndrome and died of intractable hyperdynamic shock. We call for caution regarding morbidity resulting from treatments believed safe.

Oral Anticoagulation Therapy in the Primary Care Setting

Shlomo Vinker, Sasson Nakar, Sergei Finkel, Emanuel Nir, Eitan Hyam

Family Medicine Dept., Sackler Faculty of Medicine, Tel Aviv University; and Shaaraim Clinic, General Sick Fund, Rehovot; Central Cinical Laboratories, and District Medical Director, Central District of the General Sick Fund

The use of oral anticoagulant therapy (OAT) to prevent thromboembolism has been widespread in recent years. The concept of high- and low-intensity regimens has facilitated treatment for many, and has lowered the hazards of overly intense anticoagulation. However, a significant proportion of patients suited to the low intensity regimen are not being treated. It is not clear whether its wider use is limited by continued debate, lack of resources, lack of expertise, or other causes. We retrospectively reviewed the medical records of 32 patients treated with OAT administered in the primary care setting. The average age was 66±11 years (range 34-84). 9 were treated with high-intensity OAT: 8 due to artificial heart valves, and 1 due to a hypercoagulable syndrome with recurrent thromboembolism. 23 were treated with low-intensity OAT, 17 of whom had atrial fibrillation. 11 were also being treated continuously with other medication which interacted with OAT or interfered with other coagulation pathways. Such medication included: aspirin, dipyridamole, amiodarone, bezafibrate and allopurinol. Of 414 coagulation tests, 57% and 65% were in the therapeutic range in the high- and low-intensity OAT groups, respectively. There was no major bleeding event, but in 2 of 8 who bled, gastrointestinal bleeding led to hospitalization. Treatment was discontinued in 1 patient because of difficulties in achieving target INR, and in the 2 hospitalized for bleeding. The percentages of test results in, above and below the therapeutic range were similar to those in other large series, for both intensity regimens. We found that a significant proportion of patients were under chronic treatment with other medication which interacted with OAT. To estimate the rate of complications in primary care OAT, larger series are needed. We conclude that OAT can be given and monitored by the family physician, and that awareness of long and short term drug interactions with OAT is mandatory.