תוצאת חיפוש

Characteristics of Israeli Primary Health Care Physicians who Treat Depression

Jonathan Rabinowitz, Dina Feldman, Revital Gross, Wienka Boerma

Bar Ilan University, Ramat Gan; Israel Ministry of Health; JDC-Brookdale Institute, Jerusalem; and Netherlands Institute of Primary Health Care (NIVEL)

Primary health care physicians have a pivotal role in treating mental health problems. We determined the proportion of primary care physicians in Israel who treat depression and their characteristics. The study was based on a stratified national random sample of primary care physicians (n677, response rate 78%). From these physicians' reports 22% always treat depression, 36.6% usually, 28.6% sometimes, and 12.6% never. Based on a logistic regression model the physicians who always or usually treated depression were distinguished from the other physicians by their treating more medical conditions on their own, seeing themselves as having more first contact for psychosocial problems, having frequent contact with social workers and specializing in family medicine. Primary health care physicians play a major role in treating depression on their own. This raises new questions about how they treat depression themselves, and under what circumstances they treat or refer to a specialist.

Trisomy 18 Anomalies on Sonography and Calculated Risk of Chromosomal Abnormalities During First Trimester

Ron Maymon, Arie Herman, Eli Dreazen, Mati Glasner, Zvi Weinraub

Ultrasound Unit, Dept. of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zrifin, and Sackler School of Medicine, Tel Aviv University; and Women's Health Center, Kupat Holim, Holon Branch, Tel Aviv-Jaffa District

Trisomy 18 is a chromosomal disorder giving multiple anomalies. Its frequency depends on maternal age. We report a 28-year-old woman in her first pregnancy, who underwent first trimester scanning for screening. Due to increased nuchal translucency and exomphalos, chorionic villous sampling was performed. Cytogenetic diagnosis was trisomy 18 and termination of pregnancy was carried out immediately.

Epidemiology of Invasive Hemophilus Influenzae B Infections in Bedouins and Jews; Conjugate Hib Vaccines

Limor Gortzak-Uzan*, Drora Fraser, Ron Dagan

Pediatric Infectious Disease Unit and Dept. of Epidemiology, Soroka Medical Center and Ben-Gurion University of the Negev, Beer Sheba

From 1989 to 1996, 139 cases of invasive Hemophilus influenzae B (Hib) infections were identified in children in the Negev, 110 of which occurred before introduction of the conjugate vaccine (1989-92). At that time there were 60.5 cases of Hib per 100,000 in the Negev among children under 5 years of age. During 1995-1996, when Hib conjugate vaccine was part of the regular immunization program, Hib decreased to 6.5 cases per 100,000 in that age group. The effectiveness of PRP-OMP vaccine was 96.5% among Jews and 89% among Bedouins, and the efficacy of the immunization program was 99.99%. This degree of success exceeded all expectations based on the literature. During the whole study period, Hib infections were more frequent among Bedouins than Jews. There was no significant difference in the occurrence of Hib among Jews in the Negev before and after the vaccine was introduced. Hib among Bedouins in the Negev was significantly more frequent than in the Israeli population as a whole before the vaccine was introduced. That gap narrowed after the vaccine was introduced because of the decrease in morbidity among the 2 groups.

* Medical student.

Follicle-Stimulating Hormone in Azoospermia in Prediction of Spermatogenic Patterns

David B. Weiss, Shoshana Gottschalk-Sabag, Zvi Zukerman, Elchanan Bar-On, Zvi Kahana

Kupat Holim Me'uhedet; and Dept. of Pathology and Cytology and Male Infertility Unit, Shaare Zedek Medical Center, Jerusalem; Andrology Unit, Rabin Medical Center (Beilinson Campus), Petah Tikva; and Paper Research Consultant Institute, Jerusalem

Follicle-stimulating hormone (FSH) is considered to be the most important plasma hormone correlated with spermatogenesis. Elevated FSH plasma levels were shown to be associated with complete damage to testicular seminiferous tubule germinal epithelium. Recently, there have been conflicting reports with regard to the value of FSH plasma levels in predicting seminiferous tubule histology in the azoospermic patient and hence, as a guide for therapy in assisted reproduction using testicular sperm retrieval. The aim of this study was to evaluate whether FSH plasma levels can predict spermatogenic pattern in the testes of the azoospermic infertile patient. 69 infertile men with non-obstructive azoospermia and 18 with very severe oligospermia were studied. In all, plasma levels of testosterone, free testosterone, prolactin, luteinizing hormone and follicle-stimulating hormone were measured by enzyme immunoassay. In the azoospermic patients the seminiferous tubule spermatogenic pattern was determined in testicular aspirates obtained by multiple fine needle aspiration and categorized according to the most mature spermatogenic cell type in the aspirates: Sertoli cells only, spermatogenic maturation arrest or full spermatogenesis. There were no significant differences in plasma levels of any hormone measured except in very severely oligospermic and azoospermic patients. Both normal and elevated levels were detected in all, regardless of seminiferous tubule cytological pattern or plasma FSH in azoospermic patients. It is concluded that plasma levels of FSH can not be used as a predictive parameter, neither for the presence of spermatozoa nor for any other seminiferous tubule cytological pattern in azoospermic infertile men. They cannot serve as guides for selection of azoospermic men for trials of testicular sperm retrieval in assisted reproduction.

Vacuum Phenomenon in the Hip Joint: Diagnostic Value

S. Iordache, E. Rath, D. Atar, A. Vindzberg

Orthopedics Dept., Soroka Medical Center, Beer Sheba

Vacuum phenomenon is well known in degenerative spinal disease in the elderly, but is seldom seen in other joints, especially in children. The phenomenon does not represent a pathological finding, and can be used for imaging of the articular facets, mainly in the hip and knee joints. We report a patient with this phenomenon in the hip joint.

Botulinum Toxin Injection Effective for Post-Peripheral Facial Nerve Palsy Synkinesis

Samih Badarny, Nir Giladi, Silvia Honigman

Dept. of Neurology, Carmel Medical Center, Haifa; and Movement Disorders Unit, Dept. of Neurology, Tel Aviv Medical Center

Facial synkinesis is an involuntary activation of muscles innervated by the zygomatic or mandibular branche of the facial nerve in conjunction with voluntary activation of the other branch. It appears frequently after recovery from peripheral facial nerve paralysis. We report 10 patients with facial synkinesis following Bell's palsy with a mean duration of synkinesis of 7±4 years before treatment with periorbital injections of Botulinum toxin type A. 9 had marked subjective and objective improvement starting a few days after injection andlasting 4-9 months. The results suggest a useful treatment option for post-Bell's palsy facsynkinesis with Botulinum toxin type A.

Attitudes of Family Physicians to Alternative Medicine

Amiram Sarel, Jef Borkan, Ralph L. Carasso, Judith Bernstein, Uri Rozovsky

Brull-Tel Aviv Community Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba; and Dept. of Neurology, Hillel Yaffe Medical Center, Hadera

80 Israeli family physicians (51.25% men and 48.75% women) participated in a telephone survey concerning attitudes, practices and experience with alternative medicine. 23.75% reported practicing 1 or more alternative techniques, most commonly acupuncture28%) and hypnotherapy (24%). 55% had referred at least 1 patient to an alternative practitioner during the preceding month. Physicians who studied in Israel or Western countries referred more patients than graduates of medical schools of Eastern Europe. Specialists referred patients more often than residents. The most common reason for referral was back pain.

Urgent, Unscheduled Self-Referrals by Ambulatory Patients

S. Vinker, S. Nakar, Z. Alon, H. Abu-Amar, G. Sadovsky, E. Hyam

General Sick Fund, Central District and Dept. of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University

Direct self-referral to a consultant is common in the Israeli health system. Yet patients' reasons for their urgent, unscheduled self-referrals for ambulatory consultations (UUSR) have not been explored. We studied such consultations in an urban multi-disciplinary consultation center serving a population of approximately 100,000. Over a 3-month period such consultations in ophthalmology, ear-nose-and-throat and dermatology clinics were treated by a duty family physician (FP). The FP was instructed to focus on the urgent complaint and either to give definitive treatment and schedule a consultation when needed, or refer the patient for immediate specialist consultation. Patients treated by the FP were asked to fill an anonymous questionnaire, which 347/645 (55.4%) did.

Among the reasons for UUSR were that the patient thought that his/her complaints should be treated by a consultant (29%), the patient was sent by the FP without a consultation note (13.9%), the FP was not available (10.4%), or the patient wished to see the consultant for a second opinion (8.2%). In only 7.8% had the patient noted that his complaint needed urgent consultation. Duration of complaints, but not prior efforts to schedule a consultation, were associated with different reasons for asking for an UUSR. For various reasons patients preferred an UUSR rather than seeing their own FP. Patients' opinions regarding self-referrals are important in planning primary care facilities and FP training.

Abnormal Liver Function Tests in the Primary Care Setting

Shlomo Vinker, Sasson Nakar, Emanuel Nir, Eitan Hyam, Michael A. Weingarten

Dept. of Family Medicine, Rabin Medical Center, Sackler Faculty of Medicine; Tel Aviv University; and General Sick Fund, Central District

Results of laboratory tests ordered during a primary care encounter may reveal findings of abnormal liver function tests, including elevated liver enzymes, hyperbilirubinemia, hypoalbuminemia or abnormal coagulation tests. The object of this study was to describe the spectrum of these liver function test (LFT) abnormalities in primary care.

Results of all laboratory tests ordered during 10 months in an urban primary care clinic were retrospectively reviewed and the medical charts of patients with abnormal LFTs were studied. In 217/1088 (20%) of the tests at least 1 LFT abnormality was found in 156 patients. New diagnoses were made in 104 patients. The main diagnostic groups were: non-alcoholic fatty liver changes, Gilbert's disease, acute infectious hepatitis, alcoholic liver disease and cirrhosis and hepatotoxic drug injury. In 60 patients the physician classified the abnormality as negligible and not associated with significant disease. However, an abnormal test that had been ordered for evaluation of a specific complaint, was indeed likely to represent significant disease (X²=29.5, p<0.001). We conclude that finding abnormalities in liver function tests is common in the primary care clinic but does not often indicate significant liver disease.

Professional Assessment of Senior Immigrant Physicians

N. Notzer, M.I. Zibziner, J. Shemer, M. Ravid

Sackler Faculty of Medicine, Tel Aviv University

Israel has absorbed many immigrant physicians and has utilized their skills without compromising local professional standards. In accordance with this policy a special law for the assessment of the licensing of senior immigrant physicians, mainly from the former Soviet Union, who had practiced medicine for at least 14 years was implemented in 1994.

Considering their considerable medical experience on the one hand and their lack of experience in speaking Hebrew or undergoing testing techniques, they were exempted from the written national licensing examination. Instead they were obliged to undergo a 6-month clinical observation period in a local hospital or clinic.

At the end of this period a letter of confirmation was issued which was followed by an oral assessment of their clinical ability. In the assessment session, each candidate was presented with written presentations of 4 typical clinical cases which practitioners encounter on a daily basis, in family medicine, emergency medicine, surgery, and pediatrics or gerontology. Of 114 cases prepared, 4 were selected for each candidate by the committee of 13 trained, experienced Israeli physicians.

3 members of the committee assessed each candidate using specified criteria. The assessment, which lasted about an hour, focused on the candidates' professional knowledge involved in differential diagnosis and case management.

Of 497 candidates examined between 1994 and 1996, approximately 80% passed in their first attempt. However, about 30% of the invited candidates did not appear for the exam. Characteristics of successful candidates were being young and being among the seniors with the least clinical experience. Most had specialized in internal medicine and had completed their observation period in a non-academic hospital. There they had received somewhat more attention than those who had been in academic hospitals. Significantly, the successful candidates were more proficient in Hebrew than the unsuccessful candidates, and reported no special problems during the observation period.

Leiomyosarcoma of the Stomach

I. Roisman, I. Lifshitz, O. Papo, Z. Kovach, A.Z. Reznick, A.L. Durst

Surgical Dept. A, Rambam Medical Center, Haifa; Depts. of Surgery and Pathology, Hadassah University Hospital, Jerusalem; and Surgical Dept. B, Carmel Medical Center, Haifa

Gastric leiomyosarcoma (GLMS) is a malignant, smooth muscle neoplasm accounting for not more than 0.45%-3.5% of primary gastric malignancies and 17%-20% of all smooth muscle tumors of the stomach. A well-chavariant has been variously referred to as leiomyoblastoma and epithelioid leiomyosarcoma. Because of the rarity of GLMS, few authors have tried to correlate clinical presentation, pathological findings, and treatment. There is no uniform therapeutic approach for leiomyosarcoma of the stomach and reported survival rates vary widely. We present a 56-year-old man whom we treated for this condition.

Incarcerated Diaphragmatic Hernia presenting as Colonic Obstruction

Yoram Moses, Simon Sapoznicov, Yuri Manoskin, Boris Yoffe

Dept. of General and Vascular Surgery, Barzilai Medical Center, Ashkelon (Affiliated with the Faculty of Health Sciences, Ben-Gurion University of the Negev)

Diaphragmatic hernias in adults that are not categorized as hiatal hernias are rare. Hernias of the diaphragm itself appear in the perinatal age group and are defined as congenital hernias, presenting with severe respiratory distress and requiring immediate repair. There are a few asymptomatic postpartum cases in young children or adults.

We present 3 cases of diaphragmatic hernia in men, aged 19, 20 and 74, respectively. 2 were admitted because of colonic incarceration with strangulation in the hernial sac. In the other case there was an incidental finding of incarcerated colon in a diaphragmatic hernia discovered in a patient who initially presented with unrelated thoraco-abdominal trauma. Contrary to the dominant clinical presentation as infant-respiratory distress, the predominant findings in adults are gastrointestinal complications.

We believe successful treatment is more likely when there is a high level of awareness of the possibility of this kind of hernia in the adult, which can be a recurrence after perinatal hernia repair. It is essential to recognize that this is a combined thoraco-abdominal problem since it is often necessary to perform simultaneous laparotomy, thoracotomy and stoma formation.

The Electroencephalogram in Psychiatric Patients

Mark Weiser, Raya Lapidus, Yehuda Abramowitch, Michael Davidson

Psychiatric Division, Sheba Medical Center and Beer Yaakov Mental Health Center

270 consecutive electroencephalograms (EEGs) performed in a psychiatric hospital were reviewed. 194 (75%) were within normal limits but 66 (25%) showed diffuse generalized slowing. The contribution of the abnormal EEGs to diagnosis and treatment was evaluated by retrospective file review. In none of the cases with abnormal EEGs was there a relationship to diagnosis or treatment.

Brucellosis in Pregnancy

Rinat Hackmon, Juri Bar-David, Asher Bashiri, Moshe Mazor

Dept. of Obstetrics and Gynecology, Soroka Medical Center, Beer Sheba

Brucellosis is rare in pregnancy. Recently, an increase in the incidence of this disease has been observed in our area. We present 7 cases of brucellosis in pregnancy and review the literature on the effects of brucellosis on the outcome of pregnancy. Brucellosis is rare in the Middle East and Africa and the most common source of infection is unpasteurized milk products. Brucella is a coccobacillus, gram-negative bacterium, whose hosts are mostly animals.

There is controversy about the relationship between brucellosis and the outcome of pregnancy. There is some evidence that there is a higher rate of complications such as abortion, premature rupture of membranes and preterm delivery in infected animals. Reasons for this difference in the impact of brucella in animals and man include the absence of the carbohydrate erythritol in the human placenta, which appears to be a preferential medium and growth factor for brucella in the placentas of animals.

There is uncertainty regarding effects of brucella in early pregnancy and no evidence of its transplacental passage in later pregnancy, causing adverse obstetrical outcome, although recently there has been a single report of Brucella abortus (biotype 2). 
We present 7 cases of brucellosis in pregnant women found between 1977-1988. Its incidence among the women who delivered here is 0.007% (7/92,768 deliveries). Our first case was complicated by preterm premature rupture of membranes and preterm delivery in the 20th week of gestation. In 2 other cases there was preterm delivery with 1 developing clinical chorioamnionitis. The 4 remaining women delivered at term, although 1 had preterm premature rupture of membranes and intra-uterine growth retardation, and 2 had postpartum endometritis.

Viagra, the First Oral Treatment for Impotence

Y. Assouline-Dayan, Y. Levi, Y. Shoenfeld

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

Impotence, a common problem especially among older men, can now be treated with Viagra, This oral pill, unlike previous approved treatments mostly involving local injections, does not directly cause penile erection, but increases response to sexual stimulation. It acts by enhancing the relaxant effects of nitric acid on smooth muscle, and thus increases blood flow to certain areas of the penis, leading to erection. It has been evaluated in many randomized trials and in all was more successful in inducing erection than placebos. The most common side-effects include headache, flushing and indigestion, but there have also been reports of fatalities.

We describe a 75-year-old man who had an acute myocardial infraction in the past and who had maturity-onset diabetes and hypertension. In the week prior to admission he had a cardiac scan following a few weeks of exacerbation of anginal pain for which he had been taking nitrites. He took a Viagra pill without prescription or medical advice and 2 hours later, during intercourse with his wife, developed audible respiratory distress and lost consciousness. His wife started cardiac massage but not mouth-to-mouth breathing. The emergency team found ventricular fibrillation and gave 5 electrical shocks and amines and atropine. He remained unconscious, but his pulse returned and he was hospitalized. He then had several generalized convulsions treated with IV valium. 20 minutes after admission there was asystole and all attempts at resuscitation failed.

Cardiovascular status must be considered prior to prescribing Viagra, and the associated risk evaluated.