The role of a radiopaque peri-rectal hydrogel spacer in aiding accurate daily image-guidance for prostate stereotactic radiotherapy.

Introduction: Precise patient positioning with image guidance (IGRT) is essential for safe prostate radiotherapy. We present the first report of utilizing a CT-visible hydrogel spacer, used to decrease rectal radiation dose, as a surrogate fiducial marker to aid in daily IGRT with cone-beam CT (CBCT) in stereotactic radiotherapy (SABR) for prostate cancer. Materials and methods: Prior to CT simulation, patients underwent placement of three intraprostatic gold fiducial markers and radiopaque hydrogel spacer per standard practice. At treatment, after initial setup, a CBCT was acquired and fused to the planning CT based on 3-dimensional matching of the spacer. A second alignment was then performed based on the fiducial markers. The six directional shifts (three linear and three rotational) were recorded, and the differences compared. Results: 140 individual fractions across 41 consecutive patients were evaluated. Mean/median differences between hydrogel spacer-based and fiducial-based alignment in linear (vertical, longitudinal, lateral) and rotational (rotation, pitch, roll) shifts were 0.9/0.6mm, 0.8/0.5mm, and 0.6/0.4mm, and 0.38/0, 0.62/0, and 0.35/0 degrees, respectively. No difference was observed in 9.9%, 22.9%, and 22.14% of linear shifts, and 65.7%, 65%, and 66.4% rotational shifts, respectively. Significantly smaller differences were observed in the latter 70 fractions vs. the former, and results were consistent across evaluators. Conclusions: For precise daily IGRT with CBCT for prostate SABR, alignment using a radiopaque hydrogel spacer was highly comparable to intraprostatic fiducial markers. This represents the first report supporting an additional indication of IGRT for a CT-visible hydrogel spacer, to further enhance treatment accuracy and potentially obviate the need for the additional fiducial marker procedure.

Changes in triglyceride levels over time and risk of type 2 diabetes in young men.

OBJECTIVE: The association between changes in triglyceride concentrations over time and diabetes is unknown. We assessed whether two triglyceride determinations obtained 5 years apart can predict incident type 2 diabetes. RESEARCH DESIGN AND METHODS: Triglyceride levels at baseline (time 1) and 5 years later (time 2), followed by subsequent follow-up of 5.5 years, were measured in 13,953 apparently healthy men (age 26-45 years) with triglycerides <300 mg/dl (<3.39 mmol/l). RESULTS: During 76,742 person-years, 322 cases of diabetes occurred. A multivariate model adjusted for age, BMI, total cholesterol-to-HDL cholesterol ratio, family history of diabetes, fasting glucose, blood pressure, physical activity, and smoking status revealed a continuous independent rise in incident diabetes with increasing time 1 triglyceride levels (P(trend) < 0.001). Men in the lowest tertile of time 1 triglyceride levels who progressed to the highest tertile over follow-up (low-high) exhibited a hazard ratio (HR) of 12.62 (95% CI 3.52-31.34) compared with those remaining in the lowest tertile at both time points (reference group: low-low). Whereas men who were at the top triglyceride level tertile throughout follow-up (high-high) had a HR for diabetes of 7.08 (2.52-14.45), those whose triglyceride level decreased to the lowest tertile (high-low) exhibited a HR of 1.97 (0.67-6.13). Alterations in triglyceride levels during follow-up were associated with changes in BMI, physical activity, and eating breakfast habit (P < 0.05), but remained an independent modifier of diabetes risk even after adjustment for such changes. CONCLUSIONS: Two measurements of fasting triglyceride levels obtained 5 years apart can assist in identifying apparently healthy young men at increased risk for diabetes, independent of traditional risk factors and of associated changes in BMI and lifestyle parameters.

Family history of cardiovascular disease does not predict risk-reducing behavior.

BACKGROUND: Family history is one of the main risk factors for cardiovascular disease, especially in the younger population. These individuals, being closely related to young symptomatic patients, are anticipated to have a high rate of risk factors but also to control them aggressively. The aim of the study was to evaluate the association between family history of cardiovascular disease and risk factors that control as well as reduce risk-reducing behavior among young, healthy adults. DESIGN AND METHODS: Demographic, clinical and lifestyle parameters of career service personnel of the Israeli Defense Forces, who were checked at the staff periodic examination center, were evaluated. Behavioral and clinical parameters of participants, with and without cardiovascular family history, were compared. RESULTS: The study cohort comprised 41,099 patients (36,236 men and 4863 women). Of those, 3802 men and 628 women with a family history of cardiovascular disease were identified. Male individuals had a higher rate of treatable risk factors like, obesity (P<0.0005), high blood pressure (P<0.0005), high plasma glucose (P<0.0005) and dyslipidemia (P<0.0005) than individuals without a family history. Among the women, the rate of these risk factors was higher than in the control groups but was statistically significant only for obesity, high blood pressure and high glucose levels. Risk-reducing behavior like regular physical activity and nonsmoking status in both the sexes did not differ between the groups. CONCLUSION: Members of the young population with a family history of cardiovascular disease is easily identified but remains largely uncontrolled. Special attention and continued education are required to modify their behavioral and medical parameters.

Association between acute lead exposure in indoor firing ranges and iron metabolism.

BACKGROUND: Iron deficiency and lead poisoning are common and are often associated. This association has been suggested previously, mainly by retrospective cross-sectional studies. OBJECTIVE: To assess the impact of short-term lead exposure at indoor firing ranges, and its relationship to iron, ferritin, lead, zinc protoporphyrin, and hemoglobin concentrations in young adults. METHODS: We conducted a clinical study in 30 young healthy soldiers serving in the Israel Defense Forces. Blood samples were drawn for lead, zinc protoporphyrin, iron, hemoglobin and ferritin prior to and after a 6 week period of intensive target practice in indoor firing ranges. RESULTS: After a 6 week period of exposure to lead dust, a mean blood lead level increase (P < 0.0001) and a mean iron (P < 0.0005) and mean ferritin (P < 0.0625) decrease occurred simultaneously. We found a trend for inverse correlation between pre-exposure low ferritin levels and post-exposure high blood lead levels. CONCLUSIONS: The decrease in iron and ferritin levels after short-term lead exposure can be attributed to competition between iron and lead absorption via divalent metal transport-1, suggesting that lead poisoning can cause iron depletion and that iron depletion can aggravate lead poisoning. This synergistic effect should come readily to every physician's mind when treating patients with a potential risk for each problem separately.

Refractive surgery in Israel Defense Forces recruits.

PURPOSE: To determine the prevalence of refractive surgery history in recruits for military service in the Israel Defense Forces (IDF) between 1998 to 2005 and to evaluate the effect of surgery on the recruits' fitness to serve in combat units. SETTING: Surgeon General's HQ, Medical Corps, Israel Defense Forces. METHODS: The computerized medical records of all ametropic Israeli army inductees were reviewed. They included spectacle-wearing, contact lens-wearing, and post refractive-surgery individuals who were examined in the recruitment office before their compulsory military service. The extracted data from the personal files consisted of the assignment to combat units of those who had refractive surgery and those who wore corrective eyewear and the first and last military position of all ametropic recruits who were assigned to combat units. RESULTS: Five hundred ninety-seven inductees (513 men, 84 women) had refractive surgery before their military service during the study period. The prevalence of recruits who had refractive surgery increased from 0.8/1000 ametropes in 1998 to 4.9/1000 ametropes in 2005. Significantly more recruits who had surgery (73.5%) than recruits who wore corrective eyewear were assigned to combat units (P<.001). The dropout rate from combat units of the former was significantly lower than that of the latter (13.1% versus 29.2%) (P<.001). CONCLUSIONS: More corrective eyewear users had refractive surgery before their IDF military service, and relatively more of them applied for combat duty. The high percentage of recruits who had refractive surgery who serve uninterruptedly in combat units indicates that the procedure has no deleterious effect on the recruits' fitness.

Mild renal dysfunction associated with incident coronary artery disease in young males.

AIMS: Although impaired renal function is associated with adverse cardiovascular outcomes, it is unknown whether this association exists in young, healthy adults with normal or mildly impaired renal dysfunction. METHODS AND RESULTS We calculated the baseline creatinine clearance of young males without antecedent diabetes mellitus, coronary artery disease (CAD), or renal dysfunction, and examined their subsequent diagnosis of CAD, defined as coronary artery diameter stenosis of at least 50% and/or myocardial infarction. The 23 964 males, 32.5 +/- 5.9 years old, had a baseline estimated creatinine clearance of 107.9 +/- 0.6 mL min(-1) per 1.73 m(2) (60-150 mL min(-1) per 1.73 m(2)). During a mean follow-up of 3.5 +/- 1.9 years, 77 subjects were diagnosed with CAD. After age adjustment, there was a progressive increase in the risk for CAD as the estimated creatinine clearance decreased [hazard ratio (HR) 4.77, 95% confidence interval 3.22-7.06, P < 0.001 for comparison between the fifth and first quintiles]. This association also persisted after further adjustments for conventional and ancillary risk factors for CAD (HR 2.10, 95% confidence interval 1.40-3.14, P < 0.001). Conclusion Reduced renal function in the normal to mildly impaired range is independently associated with increased risk for CAD among young, healthy males.

Changes in triglyceride levels and risk for coronary heart disease in young men.

BACKGROUND: Current triglyceride levels might be only a weak predictor of risk for coronary heart disease (CHD). OBJECTIVE: To assess the association between changes over time in fasting triglyceride levels and CHD risk in young adults. DESIGN: Follow-up study over 5.5 years after 2 measurements of fasting triglycerides 5 years apart. SETTING: The Staff Periodic Examination Center of the Israel Defense Forces, Zrifin, Israel. PATIENTS: 13,953 apparently healthy, untreated, young men (age 26 to 45 years) with triglyceride levels less than 3.39 mmol/L (<300 mg/dL). MEASUREMENTS: Two triglyceride measurements (at enrollment [time 1] and 5 years later [time 2]), lifestyle variables, and incident cases of angiography-proven CHD. RESULTS: Within 5.5 years, 158 new cases of CHD were identified. The multivariate model was adjusted for age; family history; fasting glucose; high-density lipoprotein cholesterol; blood pressure; body mass index; and changes between time 1 and time 2 in body mass index, physical activity, smoking status, and habit of eating breakfast. Investigators categorized triglyceride levels according to low, intermediate, and high tertiles (as measured at time 1 and time 2 [expressed as tertile at time 1/tertile at time 2]). The risk for CHD in men with high-tertile triglyceride levels at time 1 changed depending on the tertile at time 2 (hazard ratios, 8.23 [95% CI, 2.50 to 27.13] for high/high, 6.84 [CI, 1.95 to 23.98] for high/intermediate, and 4.90 [CI, 1.01 to 24.55] for high/low, compared with the stable low/low group). The risk for CHD in men with low-tertile levels at time 1 also changed depending on the tertile at time 2 (hazard ratios, 3.81 [CI, 0.96 to 15.31] for low/intermediate and 6.76 [CI, 1.34 to 33.92] for low/high, compared with the stable low/low group). LIMITATIONS: Participants were healthy and had a low incidence rate of CHD. The study was observational. CONCLUSIONS: Two triglyceride measurements obtained 5 years apart may assist in assessing CHD risk in young men. A decrease in initially elevated triglyceride levels is associated with a decrease in CHD risk compared with stable high triglyceride levels. However, this risk remains higher than in those with persistently low triglyceride levels.

Asthma prevalence, family size, and birth order.

BACKGROUND: Asthma prevalence may be reduced in large families. The hygiene hypothesis suggests that older siblings protect their younger siblings from asthma through a modulating effect on the still-maturing immune system. If the hygiene hypothesis is correct, asthma prevalence should be inversely related to birth order. The objective of this study was to examine the relationship between asthma prevalence, and family size and birth order. METHODS: The medical records of 531,116 Israeli military conscripts were reviewed. The association between number of children in the family and the prevalence of asthma, and between birth order and the prevalence of asthma was assessed. Odds ratios for asthma by birth order and family size, adjusted for each other, were calculated. RESULTS: Asthma was diagnosed in 26,833 male subjects (8.6%) and 15,079 female subjects (6.9%). Asthma prevalence was inversely related to the number of children in the family (p < 0.001). Among subjects who were the only child in the family, the prevalence of asthma was 7.3%. The prevalence increased to 8.95% among subjects from families with three siblings, and then progressively decreased as the number of siblings increased, and reached a trough of 0.58% in conscripts from families of 15 to 20 siblings. Asthma prevalence was similar for all birth orders. CONCLUSIONS: In families with four or more children, asthma prevalence is inversely related to the number of children in the family. Asthma prevalence is similar for all birth orders. The similar asthma prevalence for all birth orders challenges the hygiene hypothesis as the mechanism for the decreased asthma prevalence in large families.

Autoimmune diseases in asthma.

BACKGROUND: Previous research has suggested an inverse relationship between T-helper 2-related atopic disorders, such as asthma, and T-helper 1-related autoimmune diseases. One controversial hypothesis postulates that asthma provides a protective effect for the development of autoimmune-related disorders. OBJECTIVE: To assess the rate of newly diagnosed autoimmune disorders in a large cohort of young adults. DESIGN: Using cross-sectional data from the Israeli Defense Force database, the authors analyzed the prevalence of autoimmune disorders in asthmatic and nonasthmatic military personnel between 1980 and 2003. A follow-up study traced newly diagnosed autoimmune disorders among asthmatic and nonasthmatic individuals from the time of enrollment in military service until discharge (22 and 36 months for women and men, respectively). SETTING: General community. PATIENTS: 307,367 male and 181,474 female soldiers in compulsory military service who were between 18 and 21 years of age. MEASUREMENTS: Cases of type 1 diabetes mellitus, vasculitis, immune thrombocytopenic purpura, inflammatory bowel disease, rheumatoid arthritis, and the antiphospholipid syndrome. RESULTS: Of 488,841 participants at enrollment, significantly more women than men had autoimmune disorders. Compared with asthmatic women, nonasthmatic women had a significantly higher prevalence of all autoimmune disorders except for the antiphospholipid syndrome. Type 1 diabetes mellitus, vasculitis, and rheumatoid arthritis were less prevalent in men with asthma than in those without. During the follow-up period, vasculitis and rheumatoid arthritis were more frequently diagnosed in nonasthmatic persons of both sexes. There was a significantly higher incidence of immune thrombocytopenic purpura, inflammatory bowel disease, and the antiphospholipid syndrome in nonasthmatic women and a statistically significantly higher incidence of type 1 diabetes mellitus in nonasthmatic men. LIMITATIONS: The study was limited to a population of young military recruits; therefore, its findings are not necessarily applicable to the general population. Because of the noninterventional nature of the study, it describes associations but cannot prove causality. CONCLUSIONS: Asthma status may affect the prevalence of major autoimmune disorders. Preexisting asthma seems to protect against the development of autoimmune disorders to varying degrees in men and women.

CNS toxicity in closed-circuit oxygen diving: symptoms reported from 2527 dives.

INTRODUCTION: Oxygen toxicity is a problem in diving and can have fatal consequences in the water. Various aspects of oxygen diving have been studied in dry hyperbaric chambers, but there is a lack of information on in-water diving using closed-circuit oxygen apparatus. METHOD: We collected 2527 dive reports from 473 closed-circuit oxygen divers (a mean of 5.2 reports per diver), and analyzed the relationships between various symptoms and their dependence on depth and diving time. RESULTS: No CNS oxygen toxicity-related symptoms were reported at a depth of 2 m seawater (msw), but their proportion increased at depths from 3 to 6 msw. We found that CNS oxygen toxicity-related symptoms appeared in 2.5% of dives conducted at a Po2 of 119 kPa. The main symptoms and signs reported were headache: 4.5%; nausea: 2.6%; hyperventilation: 2.6%; heavy breathing: 2.4%; dizziness: 1.6%; hiccups: 1.5%; bloody sputum: 1.4%; cold shivering: 1.1%; tinnitus: 0.9%; difficulty maintaining a steady depth: 0.9%; disorientation: 0.6%; tiredness: 0.5%; tingling in the limbs: 0.4%; hearing disturbances: 0.4%; a choking sensation: 0.4%; extreme effort: 0.4%; and loss of consciousness: 0.3%. DISCUSSION: Environmental factors, light vs. dark and temperature, had no effect on symptoms. The number of symptoms increased with diving time. Divers who experienced amnesia, facial twitching, hearing disturbances (p < 0.001), and disorientation (p < 0.014) were prone to suffer loss of consciousness. It was found that some divers are more sensitive to oxygen than others (p < 0.0001).

Proteinuria on dipstick urine analysis after sexual intercourse.

OBJECTIVE: To examine the role of sexual intercourse as a cause of proteinuria, and establishes its duration, as a knowledge of benign causes of proteinuria is required to avoid unnecessary testing. SUBJECTS AND METHODS: Twenty-four married couples were instructed to produce a urine sample before and after sexual intercourse; their urine was tested for proteinuria by dipstick analysis. RESULTS: Samples were assayed from 22 men and 11 women. Whereas none of the 24 men originally assessed for the study had proteinuria before sexual intercourse, six of the 22 who were eventually enrolled had proteinuria after intercourse (27.3%, 95% confidence interval, 10-50%; P = 0.008). None of the women had proteinuria after sexual intercourse (95% confidence interval, 70-100%). The time to disappearance of proteinuria was <12 h. CONCLUSION: Sexual intercourse is confirmed as a benign cause of proteinuria in men. Whenever possible, it is wise to avoid sexual intercourse at least 12 h before urinary dipstick testing.

Normal fasting plasma glucose levels and type 2 diabetes in young men.

BACKGROUND: The normal fasting plasma glucose level was recently defined as less than 100 mg per deciliter (5.55 mmol per liter). Whether higher fasting plasma glucose levels within this range independently predict type 2 diabetes in young adults is unclear. METHODS: We obtained blood measurements, data from physical examinations, and medical and lifestyle information from men in the Israel Defense Forces who were 26 to 45 years of age. RESULTS: A total of 208 incident cases of type 2 diabetes occurred during 74,309 person-years of follow-up (from 1992 through 2004) among 13,163 subjects who had baseline fasting plasma glucose levels of less than 100 mg per deciliter. A multivariate model, adjusted for age, family history of diabetes, body-mass index, physical-activity level, smoking status, and serum triglyceride levels, revealed a progressively increased risk of type 2 diabetes in men with fasting plasma glucose levels of 87 mg per deciliter (4.83 mmol per liter) or more, as compared with those whose levels were in the bottom quintile (less than 81 mg per deciliter [4.5 mmol per liter], P for trend <0.001). In multivariate models, men with serum triglyceride levels of 150 mg per deciliter (1.69 mmol per liter) or more, combined with fasting plasma glucose levels of 91 to 99 mg per deciliter (5.05 to 5.50 mmol per liter), had a hazard ratio of 8.23 (95 percent confidence interval, 3.6 to 19.0) for diabetes, as compared with men with a combined triglyceride level of less than 150 mg per deciliter and fasting glucose levels of less than 86 mg per deciliter (4.77 mmol per liter). The joint effect of a body-mass index (the weight in kilograms divided by the square of the height in meters) of 30 or more and a fasting plasma glucose level of 91 to 99 mg per deciliter resulted in a hazard ratio of 8.29 (95 percent confidence interval, 3.8 to 17.8), as compared with a body-mass index of less than 25 and a fasting plasma glucose level of less than 86 mg per deciliter. CONCLUSIONS: Higher fasting plasma glucose levels within the normoglycemic range constitute an independent risk factor for type 2 diabetes among young men, and such levels may help, along with body-mass index and triglyceride levels, to identify apparently healthy men at increased risk for diabetes.

Smoking habits and obesity in young adults.

AIMS: The aim of this work was to study the association between obesity and smoking habits in young adults. Specifically, we tested the hypothesis that obesity does not prevent young adults from smoking and conversely smoking does not protect against obesity. DESIGN AND SETTING: Trained nurses interviewed participants concerning demographic data and health behaviors such as smoking. At the time of the interview, weight and height were measured. Data were analyzed retrospectively. PARTICIPANTS: A representative sample of Israel Defense Force (IDF) personnel upon discharge from compulsory service, usually at the age of 20-21 years. FINDINGS: Overall, 29 745 participants were included during the 13-year study (16,363 males and 13,382 females). Smoking rates were higher among obese participants than among overweight and non-obese participants (34.9%, 37.1%, 43.6% for non-obese, overweight and obese, respectively; P < 0.001). Mean number of cigarettes smoked per day were also higher among smokers that were obese and overweight compared to the non-obese (15.2 +/- 9.2, 15.6 +/- 10.7, 18.0 +/- 9.8, respectively; P < 0.001). Overweight and obesity were associated with the father's lower academic educational level. In logistic regression analysis, obesity, year of study and parental academic education were correlated independently with smoking (P < 0.001). CONCLUSION: The positive association between obesity and smoking suggests that obesity is not a deterrent to smoking and also that smoking does not help to prevent obesity.

Evaluation of intravenous cannula and administration set fixation methods.

Intravenous cannula and administration set fixation is crucial for fluid resuscitation and intravenous administration of medications. Because conventional hospital fixations are insufficient for the military field scenario, two consecutive, prospective, randomized, clinical trials were performed in the Israel Defense Forces Medical School, to determine the most effective fixation method in the military arena. Gauze bandage, adhesive bandage, Coban wrap, and plastic wrap fixation methods were tested for field conditions and intravenous fluid flow. The results showed that plastic wrap is the fastest fixation method, withstands field conditions with minimal negative effects on the intravenous fluid flow, and is the most cost-effective.

Smoking habits in adolescents with mild to moderate asthma.

To study the impact of mild to moderate asthma on smoking habits in adolescents. Specifically, we tested the hypothesis that asthma does not prevent adolescents from smoking. A research questionnaire, filled by a systematic sample of military personnel upon enrollment to service in the Israeli Defense Force (IDF), was analyzed. Conscripts were asked to voluntarily fill (after obtaining a signed informed consent) a research questionnaire about their medical history, and several health related topics including smoking. This database was matched with the military medical profile of the soldier, which includes the patient asthma status. Overall, 38,047 young adults were included in this study. There was a significant increase in the rate of mild to moderate asthma, from the mid-1980's to date. During the 1980's and early 1990's, asthmatics smoked significantly less frequently (20-22%) than non-asthmatics (25-27%). In the mid- to late-1990's, the smoking rates increased relatively more in asthmatics, to the point that in the last 8 years of this study, they were found to be almost identical in both groups, at a rate of approximately 30%. The presence of asthma is not a powerful motivating agent to prevent from smoking. It is likely that smoking asthmatic teenagers are at risk for suboptimal lung growth, and as young adults, they will become at greater risk of lung function deterioration. We suggest that primary care physicians, caring for asthma in children, adolescents, and young adults, should explain the particular risks generated by tobacco smoking.

Army personnel satisfaction in different settings of primary health care clinics.

PURPOSE: To analyze patient satisfaction in Israeli Defense Forces primary care clinics (PCCs), and to compare different satisfaction indices that best correlate with general satisfaction index. METHODS: Large-scale patient satisfaction survey throughout all PCCs, classified as active front clinics, training schools clinics, and home front clinics. RESULTS: Participants (5,103) filled out standardized questionnaires. Patients in active front clinics were more satisfied with their PCCs than in the other two settings. Patients showed the highest satisfaction level in the environment questions and the lowest satisfaction level in the accessibility questions. In training school clinics and home front clinics, accessibility questions were most important, whereas in active front clinics, health outcome questions prevailed. CONCLUSIONS: Overall patient satisfaction is the highest in active front clinics, lower in training school clinics, and lowest in home front clinics. Accessibility is the most important factor in patient satisfaction in training school and home front units, and is less important in active front units.

Quality assessment program in primary care clinics: a tool for quality improvement.

BACKGROUND: Assessment of quality of health care is a major ongoing project of the Israeli Defense Forces (IDF) medical corps. OBJECTIVE: (i) To describe mechanisms of quality assessment (QA) in IDF primary care clinics; (ii) to compare quality of care in different types of primary care clinics; and (iii) to test the hypothesis that implementation of the QA program results in improved quality of care. RESEARCH DESIGN: A prospective, single-blinded, uncontrolled, non-randomized study. MEASURES: Teams of two physicians carry out the QA process once or twice a year according to clinic size. Five areas were evaluated: (i) physician-patient interaction; (ii) medical chart evaluation; (iii) high-risk patients management; (iv) medical care provided by specialists; and (v) medical staff guidance. Clinics were classified in two groups: single-physician clinics (battalion troop clinics) and multi-physician clinics (home-front base clinics). General Linear Models were used for analysis. A P-value <0.05 was considered significant. RESULTS: In 2000 and 2001, 99 primary clinics and 162 primary care physicians were assessed. Seventy-four (45%) physicians were evaluated twice. Single-physician clinics scored higher than multi-physician clinics on most QA parameters. Physicians had significantly better QA results at the second encounter, regardless of the type of clinic. CONCLUSIONS: A primary care medicine QA system is feasible in the IDF. It allows for standardized, reliable, and comprehensive assessment of primary care across the military clinics. We postulate that the increase in QA assessment scores from one examination to the next one indicates an improvement in quality due to the QA program.