A 74-year-old man with an enlarging pleural-based mass that was not a mesothelioma.

Soft tissue sarcomas of the chest wall, also known as primary malignant mesenchymal tumors, may be mistaken for a malignant mesothelioma because of their histologic similarities. Reports of primary pleural sarcomas are exceedingly uncommon. We present an unusual case of a primary pleural sarcoma with unique clinical and histological features not previously seen in any other subtype of pulmonary sarcoma.

A controlled trial of desmopressin and behavioral therapy for nocturnal enuresis.

The combination of desmopressin (DDAVP) and behavioral therapy for treatment of nocturnal enuresis was compared with use of each of these modes alone. We randomly assigned 226 enuretic children being treated in primary care clinics of a major medical center in the largest health maintenance organization in Israel into 3 groups: Group A) DDAVP plus behavioral therapy (double-blind); Group B) behavioral therapy plus placebo (double-blind); and Group C) DDAVP alone (open group). DDAVP (20 micrograms/naris) and placebo were administered by intranasal spray. Both pharmacologic and behavioral therapy were initiated after a 2-week observation period and continued for 8 weeks. All patients were followed for 2 months after completion of treatment. A significant reduction in the number of wet nights/week was registered for all 3 groups: 49% in Group A, 45% in Group B, and 19% in Group C. After controlling for confounding factors, no significant difference in effect was noted among the 3 types of treatment during the trial period. However, on follow-up the results for the DDAVP patients were significantly less stable compared with the other 2 groups (p = 0.015). Minor side effects were registered, but none of the participants withdrew from the trial. To our knowledge, this is the largest randomized trial of nocturnal enuresis conducted to date. Our findings suggest that simply discussing the problem with the patient and family leads to improvement, and that behavioral therapy is also beneficial. DDAVP can help, but the relapse rate on discontinuation is high.

Pharmacologic, nonhormonal treatment of impotence. Evaluation of associated factors.

A group of impotent patients previously treated with Strychiomel was evaluated. Strychiomel is a compound of three drugs, yohimbine, thioridazine (Mellaril), and strychnine sulfate, each of which has a specific effect. The results suggest that the compound drug may be beneficial in the majority of patients (66.7%) when impotence occurs without hormonal or severe vascular or psychologic problems. Other factors such as age or presence of other simultaneous diseases do not appear to be significant when treatment with this multiaction drug (Strychiomel) is utilized.

Factors associated with family physicians' involvement in research in Israel.

OBJECTIVES: To identify the factors that encourage or deter family medicine physicians and residents in Israel from participating in research. METHOD: In October 1995, a questionnaire containing items on demographic variables, research attitudes, and academic and research activities in primary care settings was mailed to a random sample of 200 family medicine physicians and residents (out of approximately 600) employed by the General Sick Fund, the largest health maintenance organization in Israel. The questionnaire also contained items regarding difficulties in participating in research and asked for opinions about several general statements about research in family practice. RESULTS: In all, 190 physicians responded, for a response rate of 95%. Based on their responses, the respondents were divided into four groups by amount of research involvement. Univariate analysis using the chi-square test was used for the comparison of variables among the four groups. The respondents reporting greater knowledge of and involvement in research were, by and large, men (p = .01) who were qualified specialists with academic status (p < .00001). They also taught students (p = .0005) and residents (p < .0005), participated in more conferences (p < .0005), and while in residency training had had a mentor who encouraged involvement in research (p = .0001). CONCLUSION: Research is essential to family medicine with regard to both primary care practice and academic activities, its development, however, has been inhibited. Given the results of this preliminary study, family medicine residency programs would be well advised to assign a research mentor to every resident; also, time and resources should be devoted to research in postgraduate training programs. Perhaps more important, women physicians in Israel should be encouraged to participate more actively in research, and support for them in their special needs should be made available.

Serum lipoproteins in Israeli "Bnei Israel" Indians.

Serum lipoprotein concentrations differ markedly in the various ethnic groups which compose Israel's immigrant population. A group of subjects belonging to a community of "Bnei Israel" Indians, consisting of 21 women and 16 men between the ages of 30 and 60 years, was studied 10 years after immigration. The women had lipoprotein levels comparable with the Israeli-born population. The men had significantly lower mean cholesterol levels and significantly higher HDL/total cholesterol ratios and a tendency for lower triglycerides than an age-matched Israeli-born group, and a higher HDL/LDL cholesterol ratio than the women of the same origin. These results are consistent with the observed low incidence of coronary heart disease in Israeli Bnei Israel men who appear to have a "healthier" lipoprotein profile than the women in this community.

Thyroid cancer in patients 70 years of age or older. Retrospective study of 50 patients.

This report presents our experience with 50 thyroid cancer patients 70 years of age or older, out of 606 patients of all ages. Comparing this series to those describing thyroid cancer patients of all ages, we found that thyroid carcinoma in the 70+ age group presents at a more advanced clinical stage, behaves more aggressively, and has a higher death rate. These findings are attributed mainly to the higher incidence of undifferentiated carcinoma and the more aggressive course of the differentiated types of carcinoma in the older age group. If suspected thyroid nodules are managed by initial radical treatment, carcinoma can be diagnosed earlier and patients will survive longer.

A survey of primary care physicians' perceptions of their patients' use of complementary medicine.

PURPOSE: To study the perceptions and attitudes of primary care physicians concerning their patients' use of complementary medicine. METHODS: A questionnaire was distributed to all 165 primary care physicians attending a routine continuing-medicine education program. Items included physicians' estimated rates of patient utilization of complementary medicine or herbal remedies and of patient reportage of such use; physicians' knowledge about side effects and interactions of herbal remedies; and frequency with which physicians questioned their patients on the use of complementary medicine and herbal remedies. RESULTS: The compliance rate was 90.0% (n=150). Sixty-eight percent of physicians estimated that up to 15% of their patients use complementary medicine; 58% always or often asked their patients about it; 50% estimated that 10% of patients report use of complementary medicine, and 60% estimated the same rate for herbal remedies; 51% believed that herbal remedies have no or only mild side effects; more than 70% claimed that they had little or no knowledge about what herbal remedies are; 24% never referred patients for complementary medicine, and 69% did so occasionally. Twenty-five percent had some training in complementary medicine, and 31% practiced some kind of complementary medicine. Most of the physicians believed that people turn to alternative methods when they are dissatisfied with conventional medicine. CONCLUSIONS: Physicians underestimate the rate of complementary medicine use by patients, suggesting that many patients do not report such use to their physician. Since alternative treatments are potentially harmful and may interact with conventional medications, physicians should be encouraged to communicate with patients about complementary medicine in general and herbal remedies in particular, and they should regularly include questions about their use when taking histories. They should also inform themselves about risks of alternative treatments particularly with herbal remedies, and have access to appropriate information systems.

Medical investigations requested by patients: how do primary care physicians react?

BACKGROUND AND OBJECTIVES: We investigated the characteristics of patients who request medical investigations and the type of tests requested to study the manner in which primary care physicians react to these requests. METHODS: The study was conducted within the framework of a national health insurance system. Twelve primary care practices from three randomly chosen clinics with different population characteristics participated in the study. The attending physicians were instructed to ask all patients who presented to the clinics within a 7-month period and requested a medical test to complete a questionnaire, indicating the type of test(s) requested and the reason. The physicians were asked to rate the manner in which the patient made the request, their own reaction to the request, and whether they ordered the tests that were requested. RESULTS: During the survey period, 12,322 patients visited the clinics, of whom 295 (2.4%) were reported by a physician to have requested a medical investigation. More-educated patients were more likely to request tests for disease prevention. The types of tests requested were imaging scans, laboratory (blood) tests, and others. The main reason for the request was symptoms (60%), followed by disease prevention (25%). More than 30% of the requests generated self-reported negative feelings in the physician. Physician compliance with patient requests was not significantly correlated with the reason for the request. Laboratory tests were ordered significantly more often than other types. There was a strong correlation between physicians' compliance with the request and physicians' feelings about the request. CONCLUSION: Our findings raise questions about the frequency with which physicians order tests solely in response to patients' requests and provide information about circumstances in which patients make requests for medical investigations.

The influence of litter size and favourable conditions on mortality and weaning weights in rats.

Litters of 12 pups produced the optimum results for survival (P less than 0.005) and for weaning weights (P less than 0.05) when compared with litters of 8 and 10 pups. This number is similar to the normal litter size and normal number of teats in rats. In our study, the normal litter size was means = 12.5. Our results were obtained under favourable conditions without disturbing the animals and facilitating access to food and water for the mothers and pups.

The influence of the first-mating age of rats on the number of pups born, their weights and their mortality.

Widely differing ranges for the preferred first-mating age for rats have been reported by different investigators. As well as being of physiological interest this information is important for optimum utilization of animal resources. Previously published results, however, do not provide sufficient information on mortality and the numbers of pups born and weaned. We studied 1623 pups born to 36 female Wistar rats. Dams were first mated at the age of 35 days or 70 days or 105 days. The results show that reproduction and weaning weights increase with an increased first-mating age of dams, although the pup mortality rate also increases. This study can be used when a programme for the production and supply of Wistar rats is planned.

Methylphenidate use for attention deficit hyperactivity disorder in northern Israel--a controversial issue.

BACKGROUND: The prevalence of attention deficit hyperactivity disorder and its pharmacologic treatment have increased dramatically in the past decade in the United States and Britain. We examined the use of methylphenidate hydrochloride for the treatment of ADHD in children in northern Israel. METHODS: We evaluated all prescriptions for methylphenidate filled in 1999 for children aged 5-18 years residing in northern Israel who were insured by Clalit Health Services, a health maintenance organization that covers approximately 70% of the population. RESULTS: Methylphenidate was prescribed to 1.45% of the children in northern Israel in 1999, an increase of 20% in the overall prevalence of methylphenidate use since 1992. Eighty-two percent were boys. The rate of prescription varied widely by type of settlement, from 0.2% in Arab cities and towns to 5.7% in kibbutzim. Primary care physicians wrote 78% of all the prescriptions. CONCLUSIONS: The increase in methylphenidate use was much smaller in northern Israel than in most other developed regions and countries. More efforts at diagnosis and treatment of attention deficit disorders may need to be directed at Arab populations and those with inadequate medical services.

Evaluation of the approach of primary care physicians to the management of streptococcal pharyngotonsillitis. IPROS Network.

BACKGROUND: Streptococcal pharyngotonsillitis remains a common illness in children and can lead to serious complications if left untreated. OBJECTIVE: To evaluate the diagnostic and management approach of a sample of primary care physicians in the largest sick fund in Israel to streptococcal pharyngotonsillitis in children. METHODS: A questionnaire was mailed to all physicians who treat children and are employed by the General Health Services (Kupat Holim Klalit) in the Jerusalem District. The questionnaire included data on demographics, practice type and size, and availability of throat culture and rapid strep test; as well as a description of three hypothetical cases followed by questions relating to their diagnosis and treatment. RESULTS: Of the 188 eligible physicians, 118 (62.5%) responded, including 65 of 89 pediatricians (73%) and 53 of 99 family and general practitioners (53.5%). Fifty-six physicians (47.4%) had more than 18 years experience, and 82 (70%) completed specialization in Israel. Mean practice size was 950 patients. Fifty-three physicians (43%) worked in Kupat Holim community clinics, 25 (21%) worked independently in private clinics, and 40 (34%) did both. A total of 91 (77%) had access to laboratory facilities for daily throat culture. The time it took for the results to arrive was 48 to 72 hours. For the three clinical scenarios, 90% of the physicians accurately evaluated case A, a 1-year-old with viral pharyngotonsillitis, and 100 (85%) correctly diagnosed case C, a 7-year-old with streptococcal infection. As expected, opinions were divided on case B, a 3-year-old child with uncertain diagnosis. Accordingly, 75 (65.3%) physicians did not recommend treatment for case A, compared to 109 (92.5%) for case C. For case B, 22 (19%) said they would always treat, 43 (36%) would sometimes treat, and 35 (30%) would await the result of the throat culture. For 104 (88%) physicians the antibiotic of choice for case C was penicillin, while only 9 (7.5%) chose amoxicillin. However, the recommended dosage regimens varied from 250 to 500 mg per dose, and from two to four doses daily. For case C, 110 physicians (93%) chose a 10 day duration of treatment. CONCLUSIONS: The primary care physicians in the sample (pediatricians, general practitioners and family physicians) accurately diagnosed viral and streptococcal pharyngotonsillitis. However, there was a lack of uniformity regarding its management in general, and the dosage regimen for penicillin in particular.

Behavior of patients with flu-like symptoms: consultation with physician versus self-treatment.

BACKGROUND: The reasons that patients consult the clinic physician for common minor symptoms are not clearly defined. For seasonal epidemic events such as flu-like symptoms this characterization is relevant. OBJECTIVES: To identify the factors that prompt patients to seek medical attention, and correlate patient behavior with different demographic and disease variables. METHODS: A random sample of 2,000 enrolled people aged 18-65 years and registered with eight primary care clinics located throughout Israel were asked to report whether they had had flu-like symptoms within the previous 3 months. Those who responded affirmatively (n = 346) were requested to complete an ad hoc questionnaire evaluating their treatment-seeking behavior. RESULTS: A total of 318 patients completed the questionnaire (92% response rate), of whom 271 (85%) consulted a physician and 47 (15%) did not. Those who sought medical assistance had more serious symptoms as perceived by them (cough, headache and arthralgia) (P < 0.05), and their main reason for visiting the doctor was "to rule out serious disease." Self-employed patients were more likely than salaried workers to visit the clinic to rule out serious disease (rather than to obtain a prescription or sick note or to reassure family). They also delayed longer before seeking treatment (P = 0.01). CONCLUSION: In our study the majority of individuals with flu symptoms tended to consult a physician, though there were significant variations in the reasons for doing so, based on a combination of sociodemographic variables. We believe these findings will help primary care physicians to characterize their practices and to program the expected demand of flu-like symptoms.

Primary care physicians' attitudes to battered women and feelings of self-competence regarding their care.

BACKGROUND: Previous descriptive studies have demonstrated the problematic nature of physicians' attitudes toward battered women. However, little empirical research has been done in the field, especially among the various medical specialties. OBJECTIVES: To compare the approach and feelings of competence regarding the care of battered women between primary care and non-primary care physicians. The non-primary care physicians who are likely to encounter battered women in the ambulatory setting are gynecologists and orthopedists. METHODS: A self-report questionnaire formulated for this study was mailed to a random sample of 400 physicians working in ambulatory clinics of the two main health maintenance organizations in Israel (300 primary care physicians, 50 gynecologists and 50 orthopedists). RESULTS: In both physician groups, treating battered women tended to evoke more negative emotional states than treating patients with infectious disease. The most prevalent mood state related to the management of battered women was anger at her situation. Primary care physicians experienced more states of tension and confusion than non-primary care physicians and had lower perceived self-efficacy and self-competence in dealing with battered women. CONCLUSIONS: Though both physician groups exhibited negative feelings when confronting battered women, the stronger emotion of the primary care physicians may indicate greater sensitivity and personal awareness. We believe that more in-service training should be introduced to help physicians at the undergraduate and postgraduate levels to cope both emotionally and professionally with these patients.

Diabetes and ischemic heart disease among Yemenite immigrants in Israel.

BACKGROUND: The pattern of diabetes and ischemic heart disease among emigrants from pre-industrialized societies to more developed countries may be explained by both genetic and environmental factors. OBJECTIVES: To describe and interpret the pattern of diabetes and ischemic heart disease among Yemenite immigrants in Israel and their second-generation offspring. METHODS: Medical record charts of adult Yemenites were surveyed in a primary care health center, and the data were compared with prevalence rates derived from a non-Yemenite population. RESULTS: There was a marked excess of non-insulin dependent diabetes mellitus among Yemenite immigrants over 45 years of age, but not of hypertension or ischemic heart disease. Yemenites with diabetes were far less likely to develop ischemic heart disease than non-Yemenites with diabetes (odds ratio for non-Yemenites compared with Yemenites, 3.5; confidence interval 1.54 < OR < 7.77). CONCLUSIONS: There was less of an association between diabetes and ischemic heart disease among Yemenites. This finding requires further investigation of the relative roles of genetic and environmental factors.

Breast-feeding and smoking habits among Israeli women.

BACKGROUND: Many women stop smoking before or during pregnancy, or while breast-feeding (nursing). OBJECTIVES: To assess the relation between breast-feeding and smoking habits. METHODS: A survey was conducted among 920 women attending family health clinics (group 1) and a maternity department (group 2) on their breast-feeding and smoking habits. RESULTS: A total of 156 women (16.95%) smoked during pregnancy. A significant correlation was found between breast-feeding and not smoking after delivery (P = 0.009 in group 1, P = 0.03 in group 2). A higher tendency to nurse was found among women with an uneventful pregnancy, who vaginally delivered a singleton at term weighing 2,500-4000 g, and who received guidance on breast-feeding. CONCLUSION: Professional guidance in favor of breast-feeding is crucial to increase the rate of nursing. Encouraging breast-feeding will probably decrease the rate of cigarette smoking.

Influenza surveillance during winter 1997-1998 in Israel.

BACKGROUND: Each winter influenza activity is a major cause of morbidity and mortality both in Israel and worldwide. OBJECTIVES: To identify the influenza viruses active in Israel during the winter season and to assess the extent of influenza morbidity. METHODS: Information was collected on a population of 18,684 individuals enrolled in two community clinics in central Israel. It included the total number of visits for acute respiratory infection--including influenza and influenza-like illness (ARI/flu-like)--during a 20 week surveillance period (23 November 1997 to 27 March 1998) and the percent of influenza virus isolates in nasopharyngeal specimens from a sample of patients with ARI/flu-like collected on a weekly basis during the same period. RESULTS: A total of 5,947 visits for ARI/flu-like were recorded among 18,684 enrolled patients in two community clinics (18.1%). The progressive increase in the number of visits for ARI/flu-like reached a peak on week 2/98 with 597 visits and a rate of 31.95 visits per 1,000 population. After this, a decrease to the initial values was evident by week 12/98. Most affected patients were in the age groups 5-14 and 65 years and over, with a rate of 733.5 and 605.3 visits per 1,000 population, respectively. Influenza virus was isolated from 92 of the 426 nasopharyngeal specimens (21.6%). The most commonly detected strain was A/Sydney/5/97 (H3N2) like (77.2%). The peak rate of isolates was recorded at the beginning of January (01/98). CONCLUSIONS: A/Sydney/5/97 (H3N2) like-strain was the dominant influenza virus. Its presence did not prevent the simultaneous activity of influenza A/H1N1 virus. The dynamic of the clinical disease as expressed by the weekly visit rate for ARI/flu-like was similar to the temporal pattern of the virological findings. The extent of morbidity suggests moderate epidemic activity.

The influence of SCUD missile attacks on the utilization of ambulatory services in a family practice.

The consulting load in a family practice exposed to SCUD missile attacks during the 1991 Gulf War was compared with the equivalent period in 1990. The rate of visits was cut by half, with a relative and absolute increase in psychological consultations, and a decrease in consultations for infectious and respiratory conditions. There were more urgent consultations and fewer planned appointments. It is suggested that the stress of the SCUD missile attacks led to a reduction in consultations for trivial disorders, but an increase in the anxiety level of the population.

[Pediatric research in an office-setting network--a new dimension in pediatric research in Israel].

Pediatric care in the community is gradually replacing traditional care in hospitals. Despite that, research activity in the community setting is minimal due to objective difficulties. These are mainly constraints of time, office work and lack of research-supporting logistics. In the past decade, throughout the world, primary physicians interested in research have grouped together and formed research networks. The aim of such networks is to support and promote research in the community. An Israel Pediatric Research in Office-Setting network (IPROS) was established 2 years ago by the Israel Ambulatory Pediatric Association (IAPA). Today, there are over 140 pediatricians listed in IPROS, representing the heterogeneous composition of pediatricians in Israel. The network's policy is defined by a joint steering committee. The committee is composed of IAPA representatives, senior network members and Schneider Hospital senior investigators. The research subjects are diverse, and represent common practical issues. Effective intra-net communication is vital to the existence of the network, and is accomplished by 3 modalities: 1) semiannual updates by mail, 2) e-mail, using an electronic mailing list to facilitate connection between members, 3) semi-annual meetings. Research budgets are derived from public sources like the Ministry of Health and IAPA, and private sources such as pharmaceutical companies. The administration of the network is supported by Schneider Children's Medical Center, and financed by IAPA.