Case report: clinical and serological evaluation of echinococcosis of the spine.

A 53-year-old male with a severe destructive lesion of the L4 vertebral body caused by an Echinococcus granulosus hydatid cyst was studied. He underwent surgery twice, and was treated continuously with albendazole, followed by albendazole combined with praziquantel. Specific anti-echinococcal immunoglobulin (Ig) G, IgG4, and IgE activities before and after surgery were further determined. In spite of long-term chemotherapeutic treatment combined with surgery, no eradication of the disease was achieved.

Neck circumference as a simple screening measure for identifying overweight and obese patients.

OBJECTIVE: There are numerous methods of assessing overweight and obesity. We undertook an observational study to test a method of identifying overweight or obese patients solely by measuring the circumference of the neck. RESEARCH METHODS AND PROCEDURES: A test sample and a second validation sample included 979 subjects (460 men and 519 women), who visited a family medicine clinic in a southern Israeli urban district for any reason between the randomly chosen months of January and September 1998. Main outcome included neck, waist, and hip circumferences; body mass index (BMI); and waist:hip ratio measures. RESULTS: Pearson's correlation coefficients indicated a significant association between neck circumference (NC) and: BMI (men, r = 0.83; women, r = 0.71; each, p < 0.0001), age (men, r = 0.33; women, r = 0.36; each, p < 0.0001), weight (men, r = 0.7; women, r = 0.81; each, p < 0.0001), waist circumference (men, r = 0.86; women, r = 0.85; each, p < 0.0001), hip circumference (men, r = 0.62; women, r = 0.56; each, p < 0.0001), and waist:hip ratio (men, r = 0.66; women, r = 0.87; each, p < 0.0001). NC > or=37 cm for men and > or =34 cm for women were the best cutoff levels for determining the subjects with BMI > or =25.0 kg/m(2) using the receiver output curve analysis. In the validation unrelated group, the test characteristics were excellent with 98% sensitivity, 89% specificity, and 94% accuracy for men, and 100% sensitivity, 98% specificity, and 99% accuracy for women. NC > or =39.5 cm for men and > or =36.5 cm for women were the best cutoff levels for determining the subjects with BMI > or =30 kg/m(2) using the receiver output curve analysis. In the validation unrelated group, the test characteristics were excellent with 93% sensitivity, 90% specificity, and 91% accuracy for men, and 93% sensitivity, 98% specificity, and 97% accuracy for women. DISCUSSION: NC measurement is a simple and time-saving screening measure that can be used to identify overweight and obese patients. Men with NC <37 cm and women with NC <34 cm are not to be considered overweight. Patients with NC > or =37 cm for men and > or =34 cm for women require additional evaluation of overweight or obesity status.

What was the disease of the legs that afflicted King Asa?

BACKGROUND/OBJECTIVE: The elderly have suffered from pain in their legs, which may be associated with various diseases, for thousands of years. This report analyzes the disease that afflicted the biblical King Asa (the third king of the house of Judah who reigned between 867 and 906 BCE). RESULTS: The sentence 'Nevertheless in the time of his old age he was diseased in his legs' indicates that King Asa suffered from disease in his legs. Among numerous diseases, peripheral vascular disease, gout, and degenerative osteoarthritis were most likely to affect the King's legs. And among these diseases, the diagnosis of peripheral vascular disease is the most acceptable. CONCLUSION: This report shows that the roots of contemporary modern gerontology can be traced back to biblical times.

Characteristics of comorbidity in adult asthma.

BACKGROUND: Although asthma in adult patients is responsible for a large proportion of the morbidity in primary care practice, there is minimal published information on comorbid conditions associated with asthma. The objective of this study was to compare the prevalence of common medical conditions in adult asthmatic and non-asthmatic subjects. METHODS: A case control study was conducted on a population of 4341 men and women aged 18 years or older. The prevalence of 17 medical conditions was measured in asthmatics (n = 141) and non-asthmatic subjects (n = 423) registered with a primary care practice. RESULTS: The most prevalent conditions among asthmatics were: hypertension (22.7%), diabetes (16.3%), and hiatal hernia with or without gastroesophageal reflux (13.5%), while cerebrovascular accident (1.0%) and depression (0.7%) had the lowest prevalence. The most common conditions among non-asthmatics were: hypertension (25.1%), obesity (13.9%), and diabetes (12.5%), while sinusitis, and glaucoma (1.4%) had the lowest prevalence. The odds ratios in asthmatics vs. non-asthmatics were for hiatal hernia 5.83 (95% confidence interval [CI] 2.56-13.5, p < 0.0001), chronic bronchitis 6.31 (95% CI 2.58-15.70, p < 0.001), gastric ulcer 2.55 (95% CI 0.95-6.81, p < 0.04), sinusitis 6.3 (95% CI 1.69-25.29, p < 0.001), and glaucoma 3.1 (95% CI 0.90-11.0, p < 0.04). CONCLUSIONS: A different pattern of comorbid conditions was observed. Recognition of these conditions is essential for the proper management of asthma and coexisting disorders.

Drug-induced respiratory disorders: incidence, prevention and management.

Various drugs are associated with adverse respiratory disorders (ARDs) ranging in severity from mild, moderate to severe and even fatal. Cardioselective and nonselective beta-blockers, calcium antagonists and dipyridamole can induce asthma. ACE inhibitors are mainly associated with cough. Amiodarone is related to a form of interstitial pneumonitis (IP) which can be fatal, tocainidine and flecainidine to a form of IP, and hydrochlorothiazide to a form of IP and pulmonary oedema. Antiasthmatic drugs can be associated with a paradoxical bronchospasm, while leukotriene antagonists are linked to the development of Churg-Strauss syndrome. Nonsteroidal anti-inflammatory drugs including aspirin (acetylsalicylic acid) may induce asthma. Gold is mainly related to IP, penicillamine to IP, systemic lupus erythematosus, bronchiolitis obliterans, and Goodpasture's syndrome. Acute respiratory reactions to nitrofurantoin include dyspnoea, cough, IP, and pleural effusion while IP and fibrosis are common in chronic reactions. Other antibacterials mainly evoke pneumonitis, pulmonary infiltrates and eosinophilia, and bronchiolitis obliterans. ARDs are similar for most categories of cytotoxic agents, with chronic pneumonitis and fibrosis being the most common. Noncardiogenic pulmonary oedema occurs as the most common respiratory complication in opioid agonist addiction. Psychotropic drugs such as phenothiazides, butyrophenones and tricyclic antidepressants can also induce pulmonary oedema. Oral contraceptives may produce asthma exacerbation, while long term use and/or high doses of postmenopausal hormone replacement therapy increase the risk of asthma. Bromocriptine is mainly associated with pleural effusion, while methysergide is usually associated with pleural effusion and fibrosis. Some anorectic agents have been linked to the development of primary pulmonary hypertension. The possibility of the occurrence of ARDs should be taken into account in each individual patient. Although in most cases the adverse effects are unpredictable, they can be reduced to a minimum or prevented if some drugs are avoided or stopped in time.

Patients' smoking status: the family practice physician's view.

BACKGROUND: Smoking rates have decreased in western countries as well as in Israel during the past 20 years. OBJECTIVES: To estimate current rates of smoking and smoking cessation, and to assess factors associated with smoking and smoking cessation in family practice. METHODS: Prospective face-to-face interviews were conducted with 1,094 subjects, aged 16 years or older, registered in a family practice. RESULTS: Of all subjects studied, 746 (68.2%) were nonsmokers, 237 (21.7%) were current smokers, and 111 (10.1%) had stopped smoking. Overall, 31.8% of the males and 13.8% of the females were current smokers, and 20.1% males and 2.4% females had stopped smoking. Current smoking and smoking cessation rates were significantly and inversely associated with age among males and females. Smoking rates were higher among males and females who were married, had 10-12 years of education, and among males of North African origin and females of Israeli origin. The number of cigarettes smoked per day was associated with smoking and smoking cessation in males, but not in females. The highest rate of quitting occurred among males who smoked > or = 25 cigarettes per day. In a multiple regression analysis, gender and the number of cigarettes smoked per day were the most significant factors that predicted smoking cessation. The most common reason for stopping was the appearance of new signs of illness or the development of a new chronic disease, followed by a physician's recommendation to quit smoking. CONCLUSIONS: Female smokers and male smokers who smoke less than 25 cigarettes per day are the least likely to quit smoking. Future programs should be designed for and targeted at these groups of patients.

Coronary artery bypass grafting: long-term psychological and social outcomes.

Long-term psychosocial outcomes were examined in 132 patients 7 to 22 years (M = 9.4 years) after coronary artery bypass grafting. The control group comprised 145 medically treated patients with coronary heart disease of 7 to 22 year duration (M = 9.2). Significantly more medically than surgically treated patients were scored in the clinically significant range for anxiety, and for depression on the hospital anxiety and depression scale. Significantly more medically than surgically treated patients reported a definite, considerable, or very severe impairment of family relationships, social activities, leisure activities, home management, and work on the social functioning scale. Work status did not significantly differ between surgical and medical patients. This study shows previously unreported long-term favorable psychosocial outcomes in patients who underwent coronary artery bypass grafting.

Is there a relationship between smoking and asthma in adults?

A case-control study was carried out to investigate the possibility of a relationship between smoking and asthma in adults. The study group of 141 asthmatic adults and 423 age- and sex-matched non-asthmatic controls were selected from 4341 men and women aged 18 years and over, who were registered with a family practice. Both groups were interviewed by telephone about past and present smoking habits. Current smokers constituted 22% of the asthmatic group and 15% of the controls (not significantly different). The prevalence of those who had given up smoking (quitters) was significantly higher in asthmatics than in controls (8.5% versus 3.6%). Asthma began at younger ages in smokers than in quitters and non-smokers. In smokers, the duration of smoking was associated with the duration of asthma. No other significant differences in or associations between smoking habits and asthma were found. No major relationship between smoking and asthma was demonstrated.

Pattern of primary care clinic visits of adult asthmatics.

BACKGROUND: Although asthma in adult patients is responsible for a large proportion of the morbidity in primary care, there has been little research on the pattern of visits among adult patients with asthma. The objective of this study was to compare the pattern of visits by adult patients with asthma with that by non-asthmatics over one year. METHODS: A case-control study was conduced on a population of 4341 men and women, aged 18 years or older, registered with a primary care clinic. The study group consisted of 141 asthmatics, and the control group, of 423 non-asthmatic subjects. The pattern of visits was examined for asthmatics and compared with non-asthmatic subjects. RESULTS: Respiratory, circulatory, musculoskeletal, and digestive disease categories were the most common reasons for visits for both asthmatics and non-asthmatics, with visits for pregnancy and family planning, trauma, and neoplasm being the least common. The rate of visits was significantly higher in asthmatics than non-asthmatics for respiratory diseases, including asthma, upper respiratory tract infections (URTI), and acute bronchitis, while non-asthmatics had a higher rate of visits for endocrine and metabolic disorders, including diabetes mellitus, low back pain, trauma, urogenital disorders, and pregnancy and family planning. The mean number of visits per patient per year was significantly higher for asthmatic than non-asthmatic subjects. CONCLUSIONS: A different pattern of consultations was observed. Asthmatics visited their doctors more frequently than patients without asthma, mainly consulting for various respiratory problems.

Generalized anxiety disorder in dysfunctional families.

The purpose of this study was to investigate the relation between persistent prolonged dysfunction in parents and the development of Generalized Anxiety disorder (GAD). Initially, 940 adult subjects from a general practice were studied. Thirty-two parents aged 24 to 61 yr diagnosed with GAD served as the experimental group, while 117 healthy normal parents aged 24-66 yr made up the control group. The rate of dysfunctional families with parents diagnosed with GAD was significantly higher than in families with parents not diagnosed with GAD. Family dysfunction was associated with parents' age both in men and in women. GAD was not connected with (1) parents' age, (2) education, (3) employment, (4) country of origin or (5) number of children in the family. There was no significant difference between men and women in onset and duration of GAD. Implications for diagnostic and treatment issues are discussed.

The capability to resist smoking relapse.

BACKGROUND: Remaining in the maintenance stage and preventing a relapse of smoking is the main problem in the smoking cessation process. The objectives of this study were to compare characteristics of successful quitters with those who relapsed, to examine characteristics of the maintenance stage, and reasons for not resuming smoking. METHODS: Prospective face-to-face interviews with 1094 subjects registered with a family practice. Those who had relapsed or stopped smoking permanently comprised the study group. RESULTS: Of all subjects studied, 10.1% stated that they had stopped smoking and 10.8%, that they had relapsed. Quitters were older than relapsers, less educated, smoked significantly more cigarettes per day, and made fewer attempts to quit smoking. No significant difference was found between quitters and relapsers in marital status, country of origin, age of starting to smoke, duration of smoking, and method used to stop smoking. Age and the number of cigarettes smoked per day were associated with the maintenance stage, which was longer when smoking > or = 25 cigarettes/day. No significant association was found between the maintenance stage and marital status, country of origin, education, age of starting to smoke, and duration of smoking. Eighty-three (74.8%) of the quitters stated that the reasons for remaining in the maintenance stage were having the capability to overcome smoking and a strong resistance to temptation for relapse, 16 (14.4%) noted that they had no interest in cigarettes, 8 (7.2%) reported that cigarettes had a bad taste and deterred them from smoking, 4 (3.6%) stated that they were afraid of illness. The main factors associated with remaining in the maintenance stage were the quitters' age, heavy smoking before smoking cessation, and quitters' strong character and ability to overcome relapse and temptations to re-start smoking.

Acute asthma associated with sustained-release verapamil.

OBJECTIVE: To describe a patient with asymptomatic bronchial asthma and hypertension who developed an acute asthma attack after receiving sustained-release verapamil. CASE SUMMARY: A 66-year-old white woman with a 10-year history of hypertension and bronchial asthma was switched from immediate-release verapamil hydrocloride 40 mg tid to sustained-release verapamil 240 mg/d po for better hypertension control. After taking the first tablet, she developed dyspnea, cough, and wheezing. Antiasthmatic medications were prescribed, but the asthma symptoms did not improve. She continued taking verapamil for 6 months, then, on her own, stopped all medications including the sustained-release verapamil, and her asthma symptoms disappeared. On rechallenge she developed severe dyspnea, cough, and wheezing 20 minutes after administration. The asthma resolved within 24 hours following three albuterol inhalations. The next day similar symptoms developed with rechallenge of the same brand of sustained-release verapamil in a 120-mg formulation, and verapamil was discontinued. Six months later she was again prescribed sustained-release verapamil 240 mg in another clinic where the physician was unaware of her previous reaction. Once again, severe dyspnea, cough, and wheezing developed. DISCUSSION: On four separate occasions the patient was challenged advertently or inadvertently, with sustained-release verapamil. Similar symptoms developed after each challenge and resolved after discontinuing this preparation. Although dyspnea associated with verapamil administration has been reported, this is the first report of an elderly asymptomatic asthmatic patient with hypertension who developed an acute asthma attack following sustained-release verapamil administration. CONCLUSIONS: Sustained-release verapamil is thought to be the cause of the asthma attack in this patient because she was not taking any other preparations; the symptoms started with the administration of sustained-release verapamil and were relieved after its discontinuation.

[Use of aspirin for fever by Russian immigrant children].

This study describes the therapeutic drug approach in fever in Russian immigrant children. 974 recent immigrants with their 208 children were under medical treatment at 2 primary care clinics during 1991-1995. They came from 10 republics of the Commonwealth of Independence States (CIS, formerly the Soviet Union). In the CIS more than 3/4 of children aged 1-18 years had been given aspirin for fever. Immigrants brought with them stocks of drugs and their children continued to take them as they had in the CIS. This form of treatment is described in the official CIS pharmacology book without any mention of potential danger. Use of aspirin for fever may be an important factor in the severe hepatic injury and encephalopathy seen in Reye's syndrome. Only after intervention of the family physician did the immigrants stop this dangerous use of aspirin. During the study Reye's syndrome was not seen. Since in Israel purchase of aspirin does not require a physician's prescription, family physicians and pediatricians should be aware of the potential deleterious effects of aspirin in fever among children.

[Pattern of visits to a primary care clinic by recent Russian immigrants].

The pattern that characterized 2790 visits to a primary care clinic by recent immigrants from the former Soviet Union during their first 2 years in Israel was studied. The control group comprised 2689 visits of veteran Israeli patients to the same primary care clinic during the same period. 2/3 of the immigrants visited the clinic in the first year of the study and 1/3 in the second year. Half the veteran Israeli patients visited the clinic in the first year and the other half in the second. The mean number of clinic consultations for the immigrants was 5.2 per patient in the first year as opposed to 3.2 in the second. In the control group there was an average of 3.8 visits in the first year, and 4.1 in the second. The commonest reasons for consultations by immigrants were circulatory diseases, and for the controls, respiratory diseases. In both years there was a significant statistical difference between the number of visits by immigrants which were associated with elevated blood pressure, angina pectoris and psychological problems, compared to veteran Israelis. Thus, most of consultations by immigrants took place in the first year for circulatory diseases. There followed a gradual decrease in consultations, indicating successful management of their medical problems and perhaps adaptation to the behavioral pattern of veteran Israelis.

Characterization of patients refusing professional psychiatric treatment in a primary care clinic.

The purpose of this study was to characterize patients' refusal to meet a psychiatrist in a primary care clinic. Three hundred and seven patients were diagnosed as suffering from mental disorders: 57 of them were referred to the psychiatrist. Forty-seven patients who refused specialized psychiatric care formed the study group. The main measures were expressions, statements and reactions given by the patient for his/her refusal to undergo psychiatric care. Among nine types of expressions, statements and reactions, the most prevalent were: "I am afraid people would think I'm insane", "it might interfere with my social relationships and threaten my job," "I'm sufficiently strong to be able to deal with the problem myself," "it won't help, it won't solve my problems." We believe that a team approach involving the psychiatrist, social worker and the family physician should initiate and develop strategies for dealing with the stigma of psychiatric "treatment" as the refusal to undergo such treatment may result in the deterioration of these patients' mental condition.

[Use of medication for hypertension and coronary heart disease by Russian immigrants].

397 recent immigrants (olim) were under medical treatment at a primary care clinic during their first year (1990-1991) after immigration to Israel (aliya) from 14 republics of the Commonwealth of Independent States (CIS, formerly the Soviet Union). While in the CIS 3/4 had used medication for hypertension intermittently for only 2-4 weeks, whenever blood pressure was elevated. More than 3/4 took prophylactic drugs for coronary heart disease only when chest pain appeared and for only approximately 4 weeks, in contrast with continuous, prolonged treatment used in Israel and western countries. Immigrants brought with them stocks of drugs and continued to take them intermittently as they had in the CIS. This form of treatment is described in the official pharmacology book. Only after intervention of the family physician did the immigrants begin to take their drugs for hypertension and coronary heart disease continuously.

Sweet's syndrome associated with erythema nodosum.

The association between Sweet's syndrome and erythema nodosum in the same patient is rare. However, it is important that family physicians recognise how to differentiate these conditions clinically and histopathologically. A case is described with a combination of Sweet's syndrome and erythema nodosum, and appropriate treatment is discussed.