Clinical trial: evaluation of a clinical decision-support model for upper abdominal complaints in primary-care practice.

BACKGROUND: Gastro-oesophageal reflux disease (GERD) and dyspepsia affect 25-40% of the general population. In the absence of alarm symptoms, the current recommended policy in young dyspeptic patients is a 'test and treat' strategy for Helicobacter pylori; in GERD patients, a therapeutic trial with proton pump inhibitors is the treatment of choice. AIM: To create a short and simple clinical algorithm, for the diagnosis and treatment of patients with upper gastrointestinal complaints. METHODS: The clinical usefulness and cost-effectiveness of the new algorithm were evaluated in a controlled clinical trial, held in primary-care clinics in Israel. Clinical and economical treatment outcomes were evaluated after 1, 3 and 6 months comparing doctors who used the algorithm (cases) vs. those who did not (controls). RESULTS: 78 cases and 54 controls completed the 6 months of follow up. The improvement in symptom severity and quality of life was greater in the cases than in the controls (P < 0.05). General practitioner clinics visits (P = 0.04), gastroenterology clinics visits (P = 0.02) and medication costs (P = 0.004) were all significantly reduced among cases. Controls underwent also more imaging tests (computerized tomography, ultrasound and X-ray) and endoscopies. The average cost for 6 months' treatment and follow-up was $US 199 for cases compared with an average of $US 336 in the control group. CONCLUSION: The use of a clinical decision-support tool can facilitate and promote the implementation of management guidelines by general practitioners. The short algorithm presented in the study was found to be useful and easy to apply in clinical practice. Its effectiveness can be further increased by implementing it in computerized medical systems.

Association of calcitriol and blood pressure in normotensive men.

The purpose of this study was to clarify the possible associations between the serum 1,25-dihydroxyvitamin D (calcitriol) level and blood pressure. Cross-sectional analysis of data was performed. Data collected included levels of serum calcitriol, parathyroid hormone, serum calcium, and blood lead; blood pressure; dietary history; and demographic and anthropometric variables. One hundred normotensive male industrial employees made up the study population. Systolic blood pressure and diastolic blood pressure were main outcome measures. After possible confounders were controlled for, multivariate analyses yielded an inverse, independent, and statistically significant association between calcitriol level and systolic blood pressure (standardized beta= -0.2704, P=.0051). A similar trend of borderline significance was found for the association between calcitriol and diastolic blood pressure (standardized beta= -0.1814, P=.0611). Parathyroid hormone, serum calcium, and blood lead levels were not associated with blood pressure. When subjects were divided into four groups by calcitriol level, those in the lowest quartile showed significantly higher systolic and diastolic blood pressures than those in the upper quartile (difference=11 mmHg, P=.007, and difference=4 mmHg, P=.071, respectively). There is an inverse association between serum calcitriol level and blood pressure. This suggests that in addition to its role in calcium homeostasis, the active metabolite of vitamin D may play a role in determining blood pressure. The differences in both systolic and diastolic blood pressures between the upper and lower quartiles of serum calcitriol were substantial and may be of clinical significance.

Usefulness of echocardiographically determined mitral leaflet motion for diagnosis of mitral valve prolapse in 17- and 18-year-old men.

Mitral leaflet motion during systole was studied by echocardiography in 102 healthy young men. Mean posterior maximal leaflet motion was 2 +/- 1 mm behind the CD line on 2-dimensionally (2-D) directed M-mode examination. On the apical 4-chamber cross-sectional view a mean area of 0.34 +/- 0.24 mm2 was contained by the mitral leaflets above the plane of the mitral anulus. Elevated values on the M-mode view (greater than or equal to 4 mm) compared with the 2-D 4-chamber view (greater than or equal to 0.70 mm2) were discordant, with 90% (18 of 20) of the elevated values found in 1 view only. Thus, there is a wide spectrum of mitral leaflet motion in asymptomatic young men. The value of the echocardiogram in diagnosis of mitral valve prolapse is questionable because any cutoff point between normal and abnormal is arbitrary and the degree of motion has not been shown to correlate with morbidity or mortality.

Clinical, radiologic, demographic, and occupational aspects of hand osteoarthritis in the elderly.

OBJECTIVE: Osteoarthritis (OA) of the hand is common in elderly patients. The aim of this study was to characterize OA frequency, severity, and distribution and to trace interrelationships between these findings and the demographic, occupational, and medical data from elderly Jewish nonrheumatologic patients. METHODS: Study participants were 253 consecutive patients admitted to a geriatric center for a variety of nonrheumatic medical conditions. Excluded patients were those with rheumatoid arthritis; neurologic, orthopedic, or other conditions that would interfere with symmetric hand function; and mental or medical states that would interfere with history taking and radiographic studies. Patient occupations were graded as workload degree (on a scale of 1 to 3) and as the total occupational score (workload degree multiplied by the duration of each job). Clinical findings of Heberden nodes, Bouchard nodes, and malignment, graded on a scale of 0 to 3, were summed as the clinical OA score. Hand radiographs were independently read (modified Altman method), grading 5 parameters in each joint on a scale of 0 to 3, summed as a radiologic OA score. Statistical analyses included the Student t test, chi(2) test, ANOVA, Pearson correlation, and partial correlation coefficients. RESULTS: Among 253 elderly patients (171 women, 82 men; mean age, 79 years) OA was frequent (occurring in about 80% of patients), involving most severely the second and third distal interphalangeal, right first interphalangeal, and both first carpometacarpal joints. The prevalence of OA was similar in women and men, with higher scores in women, and reached significance only in the distal interphalangeal joints. Metacarpophalangeal joints were more involved in men. Age had a clear influence on OA scores. Ethnicity affected OA severity, with Ashkenazi Jews having significantly higher scores than Sepharadi Jews. Dominant hands had significantly higher global OA scores as well as isolated joint scores (except for the first carpometacarpal joint). Occupational load, housekeeping tasks, and the number of children did not influence the total or specific joint OA scores. Associated conditions such as obesity, diabetes, hypothyroidism, and chondro calcinosis were not associated with more pronounced OA. CONCLUSIONS: Hand OA was prevalent in our elderly cohort, and its severity was influenced by inherent traits such as age, female gender, ethnicity, and handedness. In contrast, acquired factors such as workload, number of children, and associated diseases did not appear to influence OA expression.

Asymptomatic microscopic hematuria--is investigation necessary?

Microscopic hematuria is common in asymptomatic adults, but the benefit of screening the general population for blood in the urine has not been established. On the other hand, most studies of referred patients with putatively asymptomatic microscopic hematuria have reported a 2-11% prevalence of urothelial malignancies, leading to the recommendation that all patients with microscopic hematuria be thoroughly investigated. Urinalysis is inexpensive and highly acceptable to the general population, but is neither a sensitive, nor specific test, and has poor predictive value for urothelial malignancies, and nephrological diseases. Furthermore the benefits of early detection of such diseases has not been established. We conclude that screening urinalysis cannot be recommended. Studies are needed to determine which constellation of findings primary physicians use to select patients for referral to centers with urological and nephrological expertise.

Healthy volunteer effect in industrial workers.

Volunteers for epidemiological research, have lower mortality rates than non-volunteers, thereby producing a bias referred to as the "healthy volunteer effect" (HVE). Occupationally active persons have been similarly shown to have a reduced mortality relatively to the general population (the "healthy worker effect"). To determine whether a HVE exists in occupationally active persons, we followed for 8 years a cohort of Israeli male industrial employees, of whom 71.6% agreed to participate in 1985 in screening examinations for cardiovascular disease. We calculated standardized mortality ratios (SMRs) of the entire cohort relative to the general population, and compared the mortality among participants with that of the non-participants. Over 8 years follow up, SMRs were 78% for the entire cohort, 71% for participants and 99% for non-participants. Participants were older than non-participants and worked more commonly in smaller factories. A proportional hazard model indicated that after adjusting for these variables, the all cause mortality hazard ratio among participants and non-participants was 0.69 (95% CI = 0.51-0.94). During the first and last two years of the 8-year follow-up there were 39.6 and 30.0 age-adjusted deaths per 10,000 person-years among participants, and 58.6 and 51.5 respectively among non-participants. We conclude that the HVE occurs in occupationally active persons, and that it may persist for up to 8 years follow-up.

Body mass index is associated with differential seasonal change in ambulatory blood pressure levels.

Seasonal changes in blood pressure may be partially explained in thermoregulatory terms. We hypothesized that the seasonal variation in blood pressure is related to body mass index, due to the increased thermoregulatory requirements of leaner individuals. Ambulatory systolic and diastolic blood pressure were monitored once each in summer and winter in 101 healthy normotensive men aged 28 to 63 years. Environmental conditions and body mass index were measured. The population was divided according to quartiles of body mass index. The percentage of subjects with systolic blood pressure increases of more than 10 mm Hg from summer to winter was highest among subjects in the lowest body mass index category, and lowest among those in the highest body mass index category (35% and 8%, respectively, P < .0001). After adjusting for possible confounders, the change in mean systolic blood pressure from summer to winter was inversely associated with body mass index (beta = -0.26, P = .0149). There was no association between diastolic blood pressure change and body mass index. The increase in systolic blood pressure from summer to winter is inversely and independently associated with body mass index. Hypertension research and epidemiological blood pressure studies should take into account the interaction between season, body mass index, and blood pressure. It may also be important to assess hypertension and response to antihypertensive treatment in relation to season, particularly in lean hypertensives.

The effect of age on the prevalence of asymptomatic microscopic hematuria.

The medical files of a sample of men who had been followed by annual examinations from 1968 through 1978 were selected, using a random number sequence from the records of the Israel Air Force. One group of 430 men, ages 21-23 at entry, and a second group of 264 men, ages 25-28 at entry, were studied. The results of the urinalysis at entry and after ten years of follow-up were recorded. The point prevalence of all degrees of microhematuria increased significantly with age in both groups. One to three or more red blood cells (RBCs) per high-power field (HPF) were found in 3.5% of the subjects ages 21-23 at entry and in 14.2% in the same subjects ten years later (P = 0.001). Similarly, one to three or more RBCs per HPF were found in 4.9% of men ages 25-28 at entry and in 11.7% of the same subjects ten years later (P = 0.001). The authors conclude that age needs to be taken into consideration in drawing the line between physiologic and pathologic microhematuria.

Usefulness of the protection motivation theory in explaining hearing protection device use among male industrial workers.

The present study examined the usefulness of personal variables: noise annoyance, and components of the protection motivation theory (R. W. Rogers, 1983) along with social-organizational factors in explaining hearing protection device (HPD) use among Israeli manufacturing workers. Participants were 281 men exposed to harmful noise levels for which routine HPD use is required by regulation. In practice, 3 HPD user groups were identified: nonusers (n = 38), occasional users (n = 125), and regular users (n = 118). HPD use was objectively verified. HPD use was primarily related to the personal variables but not to management pressure, coworker pressure, or family support. The most powerful predictors of HPD use were perceived self-efficacy (for long-term HPD use), perceived susceptibility (to hearing loss), and noise annoyance, together explaining 48% of the outcome variance. These findings have implications for interventions aimed at motivating workers to use HPDs regularly.

Pressure response to successive clinic readings predicts an elevated blood pressure at 2.6 years' follow-up: the Israeli CORDIS Study. Cardiovascular Occupational Risk Factor Determination in Israeli Industries.

BACKGROUND: Many persons exhibit an elevation in blood pressure (BP) when examined in a medical setting. We examined whether individuals exhibiting an exaggerated pressure response (high responders) to BP determination would have an elevated baseline BP on follow-up, independent of the initial BP level. METHODS AND RESULTS: A total of 1217 employed men not on hypertensive medication, aged 20-64 years were examined over 2-4 years (mean 2.6 years) following the baseline measurements at entry. Pressure response was assessed at entry and defined as the difference between the first and fourth values in successive readings. Such a response was apparent for systolic BP (SBP) but was negligible for diastolic BP (DBP) and the former was negatively related to the baseline BP value. High responders were defined as persons showing a pressure response greater than the average for the respective subgroup with an initially similar baseline BP value. Logistic regression results indicated that those with high SBP responsivity had a 2.7 times greater chance of having an elevated SBP (> or = 140 mm Hg) on follow-up (95% CI 1.8-4.1, P < 0.001), independently of initial SBP, age, or body mass index. Other significant predictors were the initial baseline SBP value and age. In those with an initial SBP of 130-139 mm Hg, the baseline SBP was not predictive of future readings whereas high responders had a four times higher risk of having an elevated SBP on follow-up (OR = 4.0, 95% CI 2.0-8.0, P < 0.001). CONCLUSIONS: These findings suggest that SBP hyperresponsivity, to BP determination at the clinic independently predicts elevated SBP 2.6 years later. Further studies are warranted to determine the predictive value over a longer follow-up period.

Occupational physicians in Israel: work structure, job and personal characteristics, and job satisfaction.

This study concerns psychosocial factors among Israeli occupational physicians. Eighty-one participants (specialists, residents, and general practitioners) responded anonymously to questionnaires assessing activities demanded by the job, satisfaction from these activities, negative and positive job characteristics, job involvement, and global job satisfaction. There was little overlap between the most frequent activities (fitness for work assessments, statutory health surveillance examinations, and administrative tasks) and the activities the physicians enjoyed most (professional consultations and participation in continuing medical education (CME) activities, fitness for work assessments, and scheduled workplace visits). The most powerful predictors of job satisfaction were job involvement and satisfaction with job activities. Job involvement was related to job characteristics. The findings provide various insights for promoting job involvement and satisfaction, such as improving communication, social support, and feedback within the occupational health system and finding ways to increase quality.

Needlesticks in medical students in university hospitals.

The incidence of needlesticks and the effect of experience and other personal characteristics on the risk of needlesticks in medical students are unknown. Eighty-nine medical students were given a self-administered questionnaire. The questionnaire was completed by 86 students, and there were 91 sticks in 43 students. The incidence of needlesticks was 5.8/1000 procedures on the first rotation and 0.1/1000 during the second 4-month period (relative risk, 6.5, with 95% confidence interval (CI) of 3.4-125; P < 0.001). Personal characteristics were not associated with needlesticks except for tension felt while drawing blood and accident proneness. Those who were stuck during the first rotation were more likely to be stuck subsequently (odds ratio, 9.0, with 95% CI of 1-422; P < 0.05). We conclude that experience decreases the risk for needlesticks and therefore effective instructional intervention may have the biggest impact during the first medical student ward experience. Emphasis may have to be placed on those students who are accident prone or have been stuck in the past. Further studies are warranted to substantiate our findings and to test the effectiveness of various interventional approaches.

Biological monitoring of exposure to cadmium, a human carcinogen, as a result of active and passive smoking.

Cadmium (Cd), a known human carcinogen, is one of the components of tobacco and also has many industrial uses. Smoking Cd-contaminated cigarettes at work may cause an increase in blood levels and toxicity of Cd. For a population of nonexposed workers, we compared blood Cd and urine cotinine (Cot) levels as biological markers of exposure to cigarette smoke of active smokers (AS) and passive smokers (PS) with those of unexposed nonsmokers (UNS) in 158 workers. The mean Cd in AS (0.097 microgram%; ie, 0.097 microgram/100 mL whole blood) was significantly higher than in UNS (0.085 microgram%), and was very close to the mean Cd levels in PS (0.093 microgram%). Mean Cd levels in exposed past smokers (0.105 microgram% was higher than in nonexposed past smokers (P < 0.05) and in AS. The mean Cot level was significantly higher in AS than in PS or in UNS. Increased smoking was associated directly with increased blood Cd and urine Cot. Our results supported and proved quantitatively that exposure to cigarette smoke is harmful to both AS and PS, as we show that in both cases there is an increase in blood Cd. According to our results, exposure to cigarette smoke via active and passive smoking increases blood Cd by an average of 0.01 micrograms% over the background (UNS). We conclude that exposure to cigarette smoke is a confounder to be taken into account when carrying out epidemiological studies and surveillance programs on workers exposed to Cd at work.

A graduate course in work site health promotion for occupational health practitioners.

This paper describes the rationale, teaching strategies, outcomes, and a 6-month follow-up of an academic course in work site health promotion, in which 35 occupational health practitioners participated. The one-semester course was part of the Masters in Science program in occupational health at the Tel-Aviv University Medical School. The primary goals of the study were to teach the theoretical bases of work site health promotion and their application to specific health needs, and to train better role models for employees. The primary teaching strategies were: (1) facilitation of experiential learning, by encouraging students to undergo health screening and then engage in a personal health promotion plan; (2) use of health promotion experts as guest teachers; and (3) an increase in formal knowledge through formal lectures and background reading. At the time of follow-up, most of the students were still adhering to their plans and maintaining much of their health promotion achievements. Additional outcomes included increased awareness of health risks and health promotion issues, and positions as role models in the private and professional domains. The primary barrier to adherence was low frustration tolerance, which can be regarded as the major challenge to health promotion programs and courses. It is suggested that the course format is an effective means of educating health promoters.

Fatigue among Israeli industrial employees.

We examined the prevalence of fatigue and its association with occupational conditions and health-related habits in 3785 industrial employees of six industrial sectors to define modifiable factors. The factors examined included complaints of fatigue during and after work, an ergonomic evaluation of employees' workstations, demographic characteristics, and health-related habits. Eighteen percent of the subjects complained of severe fatigue frequently or very frequently. We were able to identify two major modifiable variables that were independently associated with the presence of fatigue. Logistic regression showed that those workers who did not participate in physical activity at least once a week had a 1.7-fold increase in prevalence of severe fatigue (95% confidence interval = 1.3 to 2.3, P < 0.001). The other major modifiable factor was temperature control, with those workers who worked at non-temperature-controlled workstations having a 50% increase in the prevalence of fatigue (odds ratio = 1.5, 95% CI = 1.1 to 2.1; P = 0.01). Accidents were significantly more frequent in those workers with fatigue. Further studies should focus on intervention programs to modify the factors identified by this study.

Hematological changes in hospital workers due to chronic exposure to low levels of ethylene oxide.

We conducted a cross-sectional study to determine whether occupational exposure to low levels of ethylene oxide can cause hematological abnormalities. Blood samples were collected from a group of 47 hospital workers who were exposed to ethylene oxide during a mean period of 6.6 years (standard error, 1.1). Ethylene oxide range levels measured were < 0.01 to 0.06 ppm. The control group, individually matched by age, sex, and smoking habits, consisted of 88 workers from the administrative sector. We found significant differences between the exposed and the control group in the frequency of workers with white blood cells lower than the normal range. Although there was no significant difference in the absolute mean number of the total white blood cells, we found an elevation in the absolute mean number of monocytes and eosinophils (P < 0.01) and a decrease (P < 0.01) in the absolute mean number of lymphocytes in the exposed group compared with the control group. We also found an elevation (P < 0.01) in the percentage of hematocrit and the mean absolute number of the red blood cells, and a decrease (P < 0.01) in the mean absolute number of platelets, in the exposed group compared with the control group. The mean absolute number of eosinophils, red blood cells, and percentage of hematocrit was significantly higher, and the mean absolute number of lymphocytes and platelets was significantly lower, in the subgroups with a higher cumulative dose of exposure. A positive dose-response was found between cumulative dose exposure and the absolute mean number of eosinophils. In view of our findings, we suggest that the use of complete blood cells with differential in routine medical surveillance and for early detection of hygiene problems should be reexamined with special attention to the eosinophils count.

Lead exposure in battery-factory workers is not associated with anemia.

Anemia is a manifestation of lead toxicity. However, there are conflicting reports of its prevalence among lead-exposed workers, and it is uncertain whether they should be monitored by periodic hemoglobin (Hb) examinations. To explore the relationship between Hb and lead exposure, we examined the correlation between Hb, blood lead (PbB), and zinc protoporphyrin (ZPP) levels in 961 blood samples obtained from 94 workers in a lead-acid battery plant in Israel between 1980 and 1993. Blood lead levels exceeded 60 micrograms/dL (2.90 mumol/L) in 105 (14%) of the blood samples. The correlation between PbB and logZPP was 0.594. Hb levels did not correlate with PbB or ZPP. We conclude that (a) periodic Hb determinations are not a useful indicator of lead exposure in Israeli industrial workers; (b) the discrepancies between the reported correlation between PbB and Hb levels remain unexplained and in need of further study; and (c) a finding of anemia in a person with PbB levels of up to 80 micrograms/dL should be considered to be due to lead toxicity only after other causes for anemia have been excluded.

Accelerated silicosis with mixed-dust pneumoconiosis in a hard-metal grinder.

We describe a fatal case of accelerated silicosis with a component of mixed-dust pneumoconiosis in a young hard-metal grinder that we believe is the first case of its kind in Israel and one of the rare cases reported worldwide. The patient's diagnosis was based on typical features: restrictive lung function, abnormal chest roentgenogram suggesting lung fibrosis, a history of exposure to silica and hard metals, bronchoalveolar lavage (BAL) fluid findings, and mineralogical studies. BAL cells showed an abundance of giant multinucleated macrophages. The CD4/CD8 ratio of T lymphocytes was 1.1, with a high percentage of CD8 and CD8/38 positive cells (37% suppressor/cytotoxic and 12% cytotoxic T lymphocytes, respectively). mRNA transcripts isolated from BAL cells were positive for interleukin-1 (IL-1) and transforming growth factor (TGF) Il-5, IL-2, and IL-10 but not for IL-6, IL-4, and interferon. Polarizing light microscopic studies of BAL and induced sputum cells showed polarizing particles, which are typical for silica. Mineralogical studies of electron microscopy performed on BAL fluid and on dust collected at the patient's workstation revealed silica particles as well as aluminum-titanium and other particles. The latter might have contributed to the patient's lung disease.

Circulating natural killer cells in retired asbestos cement workers.

The effect of past exposure to asbestos on natural killer (NK) cell number and activity is uncertain. We measured NK cell number and activity in 1052 retired asbestos workers without symptomatic lung disease, lung cancer, or mesothelioma and with a long latency period from exposure; results were compared with those for 100 healthy age-matched controls. The exposed workers showed a decreased NK cell activity and increased NK cell number, yielding a 10.8 higher odds ratio for low NK activity per cell compared with controls (95% confidence interval 6.4 to 18.4), which was due to both a decrease in NK cell activity and an increase in NK cell number. Asbestos exposure of 10 years or more increased the risk of low NK activity per cell. We conclude that exposure to asbestos is associated with diminished effectiveness of NK cells and a concomitant increase in the number of NK circulating cells.

Referral to occupational medicine clinics and resumption of employment after myocardial infarction.

Rehabilitation after acute myocardial infarction (AMI) consists of education, exercise, and an encouragement to return to work (RTW). This study attempts to (1) determine whether the time interval between AMI and the visit at occupational medicine (OM) clinics predicts resumption of full employment, and (2) estimate the incidence of work-related recurrent AMI after RTW. We followed 216 consecutive AMI patients at a single OM clinic. The independent variables were clinical and personal data, physical workload and time between AMI, and first visit to the OM clinic. The outcome variables were full employment 24 months after the acute event and recurrent AMI during this period. Of all patients, 168 attempted RTW. Of these, 18 stopped working subsequently. Of the remaining 150 patients, 54 returned to part-time work and 96 were employed full-time after 2 years. Logistic regression indicated that a failure to resume full employment was independently associated with diabetes, older age, Q wave AMI, angina before AMI, heavy work, and a late visit to the OM clinic. For each month's delay in referral to the OM clinic, there was a 30% decrease in the chance for full employment 24 months after AMI. Six (4%) of the 150 patients who resumed employment sustained a recurrent AMI, two of them while at work. A delayed referral to the OM clinic was associated with work disability after AMI. Late referrals to OM clinics should receive a more intensive and sustained rehabilitation than early referrals. Whether an earlier referral to OM clinics will result in increased RTW rates is unknown. Patients who attempted to resume employment had a 1.2% risk of a recurrent ischemic event at their workplace.