A simplified severity score for acute asthma exacerbation.

BACKGROUND: To evaluate a simplified severity score designed to facilitate decision making in the Emergency Department (ED) regarding hospital admission of young adult patients with acute asthma exacerbation (AAE). METHODS: All AAE-related ED encounters during two calendar years of patients aged 17-35 years were retrospectively classified as "mild", "moderate" or "severe", according to vital and readily available signs and symptoms, including pulse rate, presence of respiratory wheezes, rales or prolonged expirium, oxygen saturation, and the use of accessory muscles, measured upon arrival to the ED. All medical records of ED and hospital admissions were reviewed for treatment and outcomes. RESULTS: During the study period, 723 AAE-related ED encounters were recorded among 551 asthma patients. Of them, 35.0% were classified as "mild", 37.9% "moderate" and 27.1% "severe". For increasing levels of AAE severity, hospital admission rate increased (11.5%, 42.0%, 61.2%, respectively, p < 0.001). Adjusting for age and sex, odds ratios for hospitalization were 12.2 (95% CI: 7.5-19.9) and 5.6 (95% CI: 3.5-8.9) for the "severe" and "moderate" categories, respectively, compared to the "mild" category. "Mild" asthma patients also had shorter length of hospital stay and none required mechanical ventilation or died during hospitalization. CONCLUSION: The simplified asthma severity score requires no additional tests or costs in the ED, and could facilitate the decision of whether to hospitalize or discharge adult AAE patients. Prospective validation of this tool is needed.

Testing manual dexterity using a virtual reality simulator: reliability and validity.

Virtual reality dental training simulators, unlike traditional human-based assessment, have the potential to enable consistent and reliable assessment. The purpose of this study was to determine whether a haptic simulator (IDEA Dental(®) ) could provide a reliable and valid assessment of manual dexterity. A total of 106 participants were divided into three groups differing in dental manual dexterity experience: (i) 63 dental students, (ii) 28 dentists, (iii) 14 non-dentists. The groups, which were expected to display various performance levels, were required to perform virtual drilling tasks in different geometric shapes. The following task parameters were registered: (i) Time to completion (ii) accuracy (iii) number of trials to successful completion and (iv) score provided by the simulator. The reliability of the tasks was calculated for each parameter. The simulator and its scoring algorithm showed high reliability in all the parameters measured. The simulator was able to differentiate between non-professionals and dental students or non-professionals and dentists. Our study suggests that for improved construct validity, shorter working times and more difficult tasks should be introduced. The device should also be designed to provide greater sensitivity in measuring the accuracy of the task.

Adult-onset diabetes among Arabs and Jews in Israel: a population-based study.

AIMS: To study the age at presentation and factors associated with adult-onset diabetes (≥ 20 years) among Arabs and Jews in Israel. METHODS: Participants (n = 1100) were randomly selected from the urban population of the Hadera District in Israel. The study sample was stratified into equal groups according to sex, ethnicity (Arabs and Jews) and age. Information on age at diabetes presentation, family history of diabetes, history of gestational diabetes, socio-demographic and lifestyle characteristics was obtained through personal interviews. Self reports of diabetes were compared with medical records and were found reliable (κ = 0.87). The risk for diabetes was calculated using Kaplan-Meier survival analysis. Factors associated with diabetes in both ethnic groups were studied using Cox proportional hazard model. RESULTS: The prevalence of adult-onset diabetes was 21% among Arabs and 12% among Jews. Arab participants were younger than Jews at diabetes presentation. By the age of 57 years, 25% of Arabs had diagnosed diabetes; the corresponding age among Jews was 68 years, a difference of 11 years (P < 0.001). The greater risk for diabetes among Arabs was independent of lifestyle factors, family history of diabetes and, among women, history of gestational diabetes; adjusted hazard ratio 1.70; 95% confidence interval 1.19-2.43. CONCLUSIONS: Arabs in Israel are at greater risk for adult-onset diabetes than Jews and are younger at diabetes presentation. Culturally sensitive interventions aimed at maintaining normal body weight and active lifestyle should be targeted at this population. Possible genetic factors and gene-environmental interactions underlying the high risk for diabetes among Arabs should be investigated.

Bone strength in children with growing pains: long-term follow-up.

OBJECTIVES: To examine the changes in bone strength in a cohort of children with 'growing pains' (GP) after 5 years follow-up and the correlation with pain outcome. METHODS: Bone strength was measured by quantitative ultrasound. Subjects were 39 children with GP previously studied. Controls were normograms based on the measurement of bone speed of sound in 1085 healthy children. Current GP status was assessed by parental questionnaires. Bone strength was compared with pain outcome. RESULTS: We examined 30/39 (77%) patients after 5 years. Bone strength was significantly increased when compared to the first study (Z score 0.65±1.77 vs. -0.62±0.90, p<0.001). While overall there was no significant difference in the bone strength between the 16 (53%) patients whose GP resolved and the 14 (47%) who continued to have GP episodes (p=0.71), all 6 (20%) patients with a speed of sound Z-score <-1 continued to have GP (p=0.003). CONCLUSIONS: Our findings that pain improves in most patients parallel to the increase in bone strength may support the hypothesis of GP representing in some patients a local overuse syndrome.

Minding the gap: training in adolescent medicine when formal training programmes are not available.

There is a growing need for healthcare professionals to extend their knowledge in adolescent health care. Formal training curricula in adolescent medicine have been developed in only the United States, Canada and Australia. The Israeli experience in building an infrastructure that allows physicians to train in adolescent medicine is described. It includes the development of hospital-based and community-based multidisciplinary adolescent health services, a 3-year diploma course in adolescent medicine and a simulated patient-based programme regarding communication with adolescents. In the course of one decade an infrastructure has been developed to create a cadre of physicians who are able to operate adolescent clinics and to teach adolescent medicine. Consequently a formal fellowship training programme in adolescent medicine has been recently approved by the Scientific Council of the Israel Medical Association. This model can be applied in countries where formal training programmes in adolescent health care are not yet available.

Simulated-patient-based programs for teaching communication with adolescents: the link between guidelines and practice.

Adolescents frequently tend not to share personal issues with their health care providers, thus communication with the adolescent patient and frequently also with his or her parents requires unique skills on behalf of the physician. Guidelines for obtaining information regarding adolescents' risk behaviors and other psychosocial issues that have been developed, do not provide the necessary tools for optimal communication with adolescents. Communication skills are best obtained in role-play models where either colleagues or actors simulate the patients' roles. Simulation-based medical education offers a safe and "mistake forgiving" environment that enables consideration of the trainees' needs, without the use of real patients that is associated with traditional bedside teaching. Training programs to improve physicians' communication skills with adolescents have been developed at the Israel Center for Medical Simulation (MSR). Between 2003 and 2007, 470 physicians were trained at MSR in 40 one-day courses. These courses dealt with common adolescent health issues that require unique communication skills on behalf of the clinician, utilizing the simulated-patient-based programs. At each training day up to 12 physicians were exposed to 8 typical adolescent health related scenarios simulated by professional actors in rooms equipped with video facilities and one-way mirrors. Following the encounters with the simulated patients, the different scenarios were discussed in debriefing group sessions with experienced facilitators utilizing the encounters' video recording. Feedbacks from participants in the programs were excellent, emphasizing the need to include simulation-based programs in physicians' training curricula.

Psychometric properties of the Hebrew version of the Oswestry Disability Index.

BACKGROUND: Low back pain (LBP) is one of the most common health complaints, with lifetime prevalence rates as high as 84%. The Oswestry Disability Index (ODI) is often the measure of choice for LBP in both research and clinical settings and, as such, has been translated into 29 languages and dialects. Currently, however, there is no validated version of Hebrew-translated ODI (ODI-H). OBJECTIVE: To examine the psychometric properties of the ODI-H. METHODS: Cross-culturally appropriate translation into Hebrew was conducted. A convenience sample of 115 participants (Case Group) with LBP and 68 without LBP (Control Group) completed the ODI-H, SF-36 Health Survey, and two Visual Analog Scales (VAS). RESULTS: Internal consistency was α = 0.94 and test-retest reliability for 18 participants repeating the ODI-H was 0.97. No floor or ceiling effects were noted for Cases, although there was a floor effect for the Control Group. Scores were significantly different for the two groups, indicating discriminant validity. Concurrent validity was reflected by significant correlations with SF-36 scores, particularly the Physical Functioning and Bodily Pain subscales (-0.83 and -0.79, respectively) and with the VAS (0.84 and 0.79). CONCLUSIONS: The ODI-H is a valid and reliable measure of low back pain-related disability for the Hebrew-speaking public.

Utilization of physician offices by adolescents in the United States.

UNLABELLED: Recent guidelines for adolescent primary care call for the specification of clinical services by three adolescent age subgroups. Yet analyses of office visits have either merged adolescence into one stage or divided it at age 15 years. OBJECTIVE: To explore the utilization of physician offices in the United States by early (11-14 years), middle (15-17 years), and late (18-21 years) adolescents. DESIGN: Secondary analysis of the 1994 National Ambulatory Medical Care Survey, focusing on visits made by the three adolescent age groups. SETTING: Nationally representative sample of 2426 physicians in nonfederal, nonhospital offices. SUBJECTS: A total of 33 598 visits by patients of all ages, representing 681.5 million visits in 1994. MAIN OUTCOME MEASURES: Number of visits, health insurance, providers seen, duration of visits, reasons for visits, resulting diagnoses, and counseling provided. RESULTS: Adolescents aged 11 to 21 years made 9.1% (61.8 million) of the total office visits and represented 15.4% of the total US population in 1994. This underrepresentation in visits held across all three adolescent age subgroups. Within the adolescent cohort, whites were overrepresented relative to their population proportion (78.5% of visits, 67.6% of population) and blacks and Hispanic adolescents were underrepresented (8.3% and 9.3% of visits, 15.5% and 13.1% of population). Middle adolescence signaled a life turning point from male to female predominance in office visits. Peak lifetime uninsurance rates occurred at middle adolescence for females (18.7%) and late adolescence for males (24.0%). Between childhood and early adolescence, public insurance decreased from 24.7% to 15.7% and uninsurance increased from 12.7% to 19.7%. Pediatricians accounted for the highest proportion of early adolescent visits (41.2%), family physicians for middle adolescent visits (35.3%), obstetrician-gynecologists for late adolescent female visits (37.3%), and family physicians for late adolescent male visits (34.8%). Mean visit duration during adolescence was 16 minutes, did not differ by age subgroup or sex, exceeded that of children (14.6 minutes), and was shorter than that of adults (19.3 minutes). Obstetrician-gynecologists spent more time with adolescents than did other physicians. Education or counseling was included in 50.4% of adolescent visits, ranging from 65.1% for obstetrician-gynecologists to 34.8% for internists. During early adolescence, the leading reasons for both male and female visits were respiratory (19.4%), dermatological (10.0%), and musculoskeletal (9.7%). A similar profile was found for middle and late adolescent males. For middle and late adolescent females, the leading reason for visits was special obstetrical-gynecological examination (12.8% and 21.1%), and the leading diagnosis resulting from visits was pregnancy (9.5% and 20.4%). CONCLUSIONS: Adolescents underutilize physician offices and are more likely to be uninsured than any other age group. Visits are short, and counseling is not a uniform component of care. As adolescents mature, their providers, presenting problems, and resulting diagnoses change. The data from the National Ambulatory Medical Care Survey support a staged approach to adolescent preventive services, targeted to the needs of three age subgroups.

Increased incidence and severity of Streptococcus pyogenes bacteremia in young children.

An increase in the incidence and severity of bacteremia caused by group A streptococci was noted in 1993 and 1994 in the Hadassah University Medical Center, Jerusalem. During the 6-year period 1987 to 1992, 12 children with group A streptococcal bacteremia were hospitalized, whereas in 1993 and 1994 there were 17 patients, 5 of them with 1 each of the following severe clinical manifestations: meningitis and septic shock; streptococcal toxic shock syndrome; septic shock; pleural empyema; and fatal outcome. Our 29 patients with group A streptococcal bacteremia were younger than those reported in the literature: 10 (35%) were < 3 months of age; 17 (59%) were < 1 year old. Most children were previously healthy and only 3 had an underlying immunodeficiency predisposing to infection (1 case each): leukemia; Di George syndrome; and congenital nephrotic syndrome. Two children were recovering from varicella. The skin was the most common site of primary infection (16 of 29). The average white blood cell (WBC) count was 18 150 cells/mm3 (range, 2200 to 34,200). The cases were not related epidemiologically and were caused by a variety of M-protein types. Polymerase chain reaction amplification of the genes encoding exotoxins A (speA) and C (speC) was done on 19 isolates and disclosed 2 strains positive for speA and 5 positive for speC. One of the speA-positive isolates was from the single patient with toxic shock syndrome.

A pediatric clinical skills assessment using children as standardized patients.

OBJECTIVES: To develop and implement a pediatric clinical skills assessment (PCSA) for residents, using children as standardized patients (SPs); to assess the psychometric adequacy of the PCSA and use it to evaluate the performance of residents; and to evaluate the feasibility of using child SPs and the response of the residents and the child SPs to participation in the PCSA. METHODS: Ten 22-minute complete patient encounters were developed, 7 with child SPs. Fifty-six residents (10 second-year pediatric residents, 29 first-year pediatric residents, and 17 first-year family practice residents) were evaluated on the following clinical skills: history taking, physical examination, interpersonal skills, and documentation and interpretation of clinical data/patient note. MAIN OUTCOME MEASURES: Patient encounter checklists, focus groups, and questionnaires. RESULTS: Average skill scores for the 56 residents were 68% (SD, 12%) for history taking, 56% (SD, 26%) for physical examination, 46% (SD, 12%) for patient note, and 68% (SD, 16%) for interpersonal skills. Second-year pediatric residents scored significantly higher on history taking than first-year pediatric and first-year family practice residents; first-year pediatric residents scored significantly higher on interpersonal skills than second-year pediatric and first-year family practice residents; and first- and second-year pediatric residents scored significantly higher on the patient note component than first-year family practice residents. All differences noted were significant at P<.05. There were no significant differences on physical examination between the groups. Reliabilities were 0.69 for history taking, 0.64 for physical examination, 0.76 for interpersonal skills, and 0.81 for the patient note component. On a Likert scale (5 indicates high; 1, low), residents rated the PCSA 3.9 for realism, 4.1 for challenge, 3.1 for enjoyment, and 2.9 for fairness. Child SPs found the experience positive. No negative effects on the children were identified by their real parents or their SP parents. CONCLUSIONS: Our development method gives content validity to our PCSA, and resident scores give indication of PCSA construct validity. Reliabilities are in the acceptable range. Residents found the PCSA challenging and realistic but less than enjoyable and fair. Use of child SPs is feasible. Resident performance scores were low relative to the performance criteria of the PCSA development group. The adequacy of clinical skills teaching and assessment in residency programs needs to be reviewed. Deficits in specific skills and overall performance of residents identified by a PCSA could be used to guide individual remediation and curricular change.

Lessons learned from six years of international administrations of the ECFMG's SP-based clinical skills assessment.

PURPOSE: The Educational Commission on Foreign Medical Graduates (ECFMG) conducted international clinical skills assessments (CSAs) to evaluate the readiness of foreign medical graduates to enter U.S. residency programs, to validate national medical examinations in other countries, and to introduce other countries to new methods of evaluating medical students. METHOD: The ECFMG conducted CSA studies in the United States, Israel, Spain (Madrid and Barcelona), Ukraine, and Brazil between 1989 and 1995. ECFMG staff worked with local teams in following a seven-phase implementation process. The CSAs were conducted in each country's native language, and clinical cases were translated from English and culturally adapted. A total of 636 examinees took a ten-station standardized patient-based examination. RESULTS: A comparison of test results indicated stable psychometric properties and similar patterns of relationships among test components across all six countries. In every country, physical-examination and patient-note mean scores were lower than were history-taking scores, indicating the possibility of common skill deficiencies. CONCLUSION: The successful completion of international CSA projects in six countries suggests that high-quality standardized CSA projects are feasible and can be implemented from long distances.

Postpartum depression in an Israeli cohort: demographic, psychosocial and medical risk factors.

Demographic, psychosocial and medical risk factors for postpartum depression (PPD) were studied prospectively in a community cohort of 288 Israeli women. An Edinburgh Postnatal Depression Scale score of > or = 10 at 6 weeks postpartum was the criterion for PPD. Psychosocial risk factors were found to be the most potent. Lack of social support, marital disharmony, depressive symptoms during pregnancy, history of emotional problems and prolonged infant health problems were most predictive of PPD. The major role of psychosocial factors in PPD was similar to that found in other countries. The results were somewhat different for new Russian immigrants. These findings indicate that early identification of women at risk for PPD is feasible, and that consideration should be taken of subgroups that may be at heightened risk, or for whom risk factors play different roles.

Prospective study of postpartum depression in an Israeli cohort: prevalence, incidence and demographic risk factors.

This study aimed to assess the prevalence and incidence of postpartum depression (PPD) and to identify risk factors in a community cohort of Israeli-born, as well as new and veteran immigrant women. A random sample of 288 registrants at a community clinic was assessed for depressive symptoms at 26 weeks' pregnancy using the Beck Depression Inventory (BDI) and at 6 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Information regarding risk factors was gathered through interviews and medical record abstracting. The prevalence of PPD was 22.6%. Two-thirds of the women had scored 'depressed' during pregnancy, and one-third (6.9%) were new incident cases. Immigrant status was the only significant demographic predictor of PPD identified by either univariate or multivariate analysis, with Russian new immigrants having over twice the risk for PPD as Israeli-born subjects. The rate of PPD in this Israeli cohort was comparable to that found in other countries. The finding that immigrant status was the most potent demographic predictor may support the role of stressful life events in the etiology of PPD. The use of the EPDS for PPD screening was found acceptable and feasible in the primary health setting.

Actual car fleet emissions estimated from urban air quality measurements and street pollution models.

A method to determine emissions from the actual car fleet under realistic driving conditions has been developed. The method is based on air quality measurements, traffic counts and inverse application of street air quality models. Many pollutants are of importance for assessing the adverse impact of the air pollution, e.g. NO2, CO, lead, VOCs and particulate matter. Aromatic VOCs are of special great concern due to their adverse health effects. Measurements of benzene, toluene and xylenes were carried out in central Copenhagen since 1994. Significant correlation was observed between VOCs and CO concentrations, indicating that the petrol engine vehicles are the major sources of VOC air pollution in central Copenhagen. Hourly mean concentrations of benezene were observed to reach values of up to 20 ppb, what is critically high according to the WHOs recommendations. Based on inverse model calculation of dispersion of pollutants in street canyons, an average emission factor of benzene for the fleet of petrol fuelled vehicles was estimated to be 0.38 g/km in 1994 and 0.11 in 1997. This decrease was caused by the reduction of benzene content in Danish petrol since summer 1995 and increasing percentage of cars equipped with three-way catalysts. The emission factors for benzene for diesel-fuelled vehicles were low.

Parental perception and self-concept of gifted and average underachievers.

Self-concept and parental evaluation of their child's self-concept were investigated in fifth to eighth grade gifted and average achievers and underachievers (n = 134). In the average sample achievers had higher self-concepts than underachievers. In the gifted sample, the reverse was true; underachievers had higher self-concepts than achievers. In general, the parental evaluations of their children were unaffected by the child's performance in school. In the average sample only the mothers evaluated their underachieving children lower, whereas in the gifted sample there was no significant difference between parents' evaluations. A tentative explanation is offered for the relationship among giftedness, achievement, and self-concept.

The effect of humor on aggression catharsis in the classroom.

Two studies were designed to measure the cathartic effects of humor on aggressive responses. In the first study, two versions (easy and difficult) of Raven's intelligence test were administered to two groups of high school students. Only the easy version could be solved in the alloted time. Rosenzweig's (1951) Picture Frustration test was then administered and the students' aggressive responses were scored. Results showed that those who did not solve the problems had significantly higher scores on aggressivity than did the others. The second study, using four different groups, was planned according to a modified Solomon design. Two of the four groups of students completed the difficult part of the Raven test, and then two video-tapes were presented: a humorous one to two groups and a neutral one to the others. Finally, the Rosenzweig Picture Frustration test was administered to all four groups. An analysis of variance computed on the aggressivity scores showed one significant difference: frustrated students who viewed the humorous videotape had lower scores than those viewing the neutral one.

[Traumatic brain injury--the National Trauma Registry].

BACKGROUND: Traumatic Brain Injury (TBI) has been established as a category in reporting systems. Uniform data systems case definition has been suggested for hospital discharge data surveillance systems cases based on ICD-9-CM diagnostic codes. These include fractures and specific mention of intracranial injuries such as contusion, laceration, hemorrhage, and concussion. Inspection of data from the Israel National Trauma Registry suggested that two diagnostic groups of very different severity and outcome were being unjustifiably combined. AIM: To evaluate the validity of categorizing TBI into two discrete groups, using the presence of specific mention of intracranial injury and/or loss of consciousness for more than one hour as the definition of definite TBI. Possible TBI includes skull fractures with no mention of intracranial injury and/or concussion with no loss of consciousness. METHODS: The study population includes all traumatic injuries admitted to hospital, dying in the ER or transferred to other hospitals and recorded in the 1998 Trauma Registry in all 6 level I trauma centers in Israel and two level II centers. RESULTS: The significant difference in severity between groups supports the validity of sub-dividing the TBI classification into definite and possible subcategories. As a result, we obtain two different severity groups without measuring specific severity scores which are limited in the reporting system. CONCLUSION: The groups were significantly different in severity, hospital resource use, immediate outcome, demographic and injury circumstances.

Comprehensive Approach to Lower Blood Pressure (CALM-BP): a randomized controlled trial of a multifactorial lifestyle intervention.

Complementary medicine advocates the use of a multifactorial approach to address the varied aspects of hypertension. The aim of this study was to compare the blood pressure (BP) effect and medication use of a novel Comprehensive Approach to Lowering Measured Blood Pressure (CALM-BP), based on complementary medicine principles, with the standard recommended Dietary Approach to Stop Hypertension (DASH). A total of 113 patients treated with antihypertensive drugs were randomly assigned to either CALM-BP treatment (consisting of rice diet, walks, yoga, relaxation and stress management) or to a DASH+exercise control group (consisting of DASH and walks). Ambulatory 24-h and home BP were monitored over a 16-week programme, followed by 6 months of maintenance period. Medications were reduced if systolic BP dropped below 110 mm Hg accompanied by symptoms. In addition to BP reduction, medications were reduced because of symptomatic hypotension in 70.7% of the CALM-BP group compared with 32.7% in the DASH group, P<0.0001. After 6 months, medication status was not altered in the majority of individuals. Significant reductions in body mass index, cholesterol and improved quality-of-life scores were observed only in the CALM-BP group. Lifestyle and diet modifications based on complementary medicine principles are highly effective with respect to BP control, medication use and cardiovascular risk factors.