Unexplained complaints in primary care: evidence of action bias.

PURPOSE: Primary care physicians sometimes encounter patients with clinical complaints that do not fit into a recognized diagnostic pattern. This study was undertaken to assess the way physicians respond to patients whose symptoms are unusual or unexplained that is, what approach they take in the absence of a working hypothesis. METHODS: We surveyed 130 primary care physicians affiliated with 3 academic centers in Israel, presenting 5 clinical vignettes describing patients who had unusual complaints, no clear diagnosis, and no apparent need for urgent care. We asked physicians to provide the most likely diagnosis for each case and to rate their level of confidence in that diagnosis;respondents were also asked to provide a management strategy for each case and their level of confidence in the chosen approach. Finally, we asked the physicians to estimate how many of their own patients have presentations similar to the individuals in the clinical vignettes. RESULTS: Physicians proposed, on average, 22 diagnoses for each case. Most indicated that they would choose action (testing, consulting, sending the patient to the emergency department, or prescribing) rather than follow-up only (87% vs 13%; P<.01). Respondents' confidence in the management approach they had chosen for all the cases was higher than their confidence in the diagnoses (5.6 vs 4.3, respectively, on a scale of1-10; P<.001). Physicians estimated that 10% to 20% of the patients they see in their practice have unusual or unexplained symptoms that are difficult to diagnose. CONCLUSION: Uncertain diagnosis is a regular challenge for primary care physicians. In such cases, we found that physicians prefer a workup to follow-up, an inclination consistent with"action bias."

[Cancer survivorship: an evolving medical field].

More than a quarter of a million IsraeLi citizens live today with the diagnosis of cancer being a part of their past medical history. The volume of this population is going to enlarge in coming years. These patients tend to suffer from several unique medical and psychosocial difficulties due to their original malignant disease and its risk factors, as a consequence of the antineoplastic treatments they had received, and as a result of exceptional presentation of concomitant non-neoplastic diseases. In this review, we describe the current dilemmas that exist in the medical community concerning the appropriate setting and extent of care that are needed in order to deliver suitable care for this growing population, and emphasize the need for further research and the development of clinical excellence in the treatment of this population.

Imported melioidosis, Israel, 2008.

In 2008, melioidosis was diagnosed in an agricultural worker from Thailand in the southern Jordan Valley in Israel. He had newly diagnosed diabetes mellitus, fever, multiple abscesses, and osteomyelitis. Burkholderia pseudomallei was isolated from urine and blood. Four of 10 laboratory staff members exposed to the organism received chemoprophylaxis, 3 of whom had adverse events.

Head lice treatments and school policies in the US in an era of emerging resistance: a cost-effectiveness analysis.

BACKGROUND: Head lice are a common infection in school-age children worldwide. Several authorities in the US have recommended different treatments and school policies in order to control this disease. Recent concerns of emerging lice resistance worldwide raise the necessity to reassess the current recommendations. OBJECTIVES: To perform a cost-effectiveness analysis (from the US caregiver perspective) of three head lice treatments commonly used in the US, permethrin 1%, malathion 0.5% and the lice comb, in order to evaluate the cost effectiveness of different treatments in the current era, and to explore the effect of different factors in this analysis. METHODS: We used a decision-tree model to represent the costs and effectiveness of the different treatment strategies. A patient/caregiver perspective was applied, with a time horizon of 2 weeks. Probabilities of treatment success or failure of the three treatments were based on the literature. Effectiveness was measured as the successful eradication of head lice, and costs - including the costs of the treatment, the physician co-pay and the costs of days out of school - were calculated. One-way and multi-way analyses were performed using decision analysis software (Treeage Pro Healthcare 2008). RESULTS: Combing was dominated by permethrin 1%. The incremental cost-effectiveness ratio of malathion 0.5% versus permethrin 1% was $US161.75 per cure. For caregivers whose willingness to pay is <$US161.75 per cure, permethrin 1% is the most cost-effective option. For those with a willingness to pay of > or =$US161.75 per cure malathion 1% may offer the highest net monetary benefit. Twenty percent of the uncertainty in the model is due to variation in permethrin 1% resistance, and approximately 73% of the total variability of the model is attributed to the number of days the student has to be out of school because of the school's policy. CONCLUSIONS: Our study suggests that permethrin 1% was the most cost-effective treatment for those with a willingness to pay of <$US162 per cure. Sensitivity of lice to permethrin and the specific school head lice policy had major effects on the model. Thus, informing communities in a given geographical area about the degree of head lice resistance and sensitivity is necessary in order for the public to make a rational decision regarding treatment. Schools' head lice policies have a major effect on the cost of head lice treatments.

The effect of brushing on hair loss in women.

BACKGROUND: Hair loss is a common, bothersome problem among women. OBJECTIVE: To evaluate the effect of different brushing frequencies on hair loss in women. METHODS: This was a non-randomized crossover study. During a 4-week period, 14 women were asked to brush their hair with different frequencies during each of the 4 weeks. The amount of hairs lost during each week was counted and the average hairs lost during each week was compared with that of a week with a different brushing frequency. RESULTS: In all comparisons analyzed, hair loss was reduced by reducing brushing frequency. A subgroup analysis found strong association (p < 0.05) between brushing frequencies and the magnitude of hair loss. A limitation of the study was that the majority of the subgroup analyses did not find a statistically significant association between brushing frequency and amount of hair lost. CONCLUSION: Brushing is associated with hair loss. Reducing the brushing frequencies may reduce the amount of hair shed.