מכאן שהרפואה המשולבת, זו המנסה לעשות שימוש בשני העולמות, הקונבנציונלי והאלטרנטיבי, מתמקדת באדם לא פחות מאשר במחלה. ...
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רפואת המשפחה בישראל - נספח - רשימת פרסומים של פרופסור חרמוני

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רפואת המשפחה בישראל - Family Medicine in Israel
מאת פרופסור חיים דורון, פרופסור שפרה שורץ, פרופסור שלמה וינקר

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תקציר
קיים מצב של תת-איבחון דיכאון ברפואה הראשונית. כמענה לבעיה פותח כלי-עזר איבחוני המורכב משני שלבים לסקירת דיכאון.
המטרות במאמר להלן הן בדיקת יישום כלי-עזר זה ברפואה ראשונית, יעילות ההסתייעות בו, ומידת המיתאם בין הממצאים העולים ממנו לבין התיעוד הרפואי ובדיקת שיעור הפנייה לרפואה הראשונית של חולים שאובחנו כלוקים בדיכאון.
לשם כך חולק למבקרים בחמש מירפאות ראשוניות שאלון למילוי עצמי המכיל פרטים דמוגרפיים ושלוש שאלות בנושא דיכאון. נבדקים שענו בחיוב על אחת מהשאלות לפחות נתבקשו למלא שאלון נוסף, מפורט ובעל רגישות גבוהה לאיבחון דיכאון. נבדק שיעור החולים שאובחנו כלוקים בדיכאון, הטיפול שניתן להם ומספר הביקורים של כל נבדק במירפאה במהלך חצי שנה.
חמש-מאות-חמישים-ואחד מטופלים מילאו את השאלון הראשון: 222 (40%) ענו בחיוב על אחת השאלות, 113 מתוכם (51%) הסכימו למלא את השאלון השני ו-15 מהם (13.3%) אובחנו כלוקים בדיכאון. רק בשלושה מהמאובחנים באופן זה נמצא רישום של דיכאון בתיק הרפואי. חמישה מטופלים (כ-4.4%) אובחנו על ידי רופאיהם כלוקים בדיכאון, אולם אבחנה זו לא עלתה מתוצאות השאלונים המלאים. בבדיקת מידגם של 50 תיקים רפואיים מאלה שענו בחיוב על השאלון הראשון אך סירבו למלא את השאלון השני אובחנו 10 מטופלים נוספים (20%) על ידי רופאיהם כלוקים בדיכאון ו-12% עם בעיה נפשית כלשהי. מטופלים הלוקים בדיכאון פונים לרופא הראשוני 12.7 פעמים בממוצע בחצי שנה לעומת 7.14 בחולים שאינם לוקים בדיכאון (P>0.028).
לסיכום, מטופל הלוקה בדיכאון פונה לרופא בתדירות גבוהה יותר. ההסתייעות בכלי דו-שלבי לסקירה בקרב מטופלי מירפאה ראשונית מדגימה פערים משמעותיים בשיעורי האיבחון באמצעות הכלי לרשום בתיק הרפואי, ותועלתו של כלי סקירה זה מוטלת בספק. עם זאת, נראה כי מישלב של שלוש שאלות סיקור באוכלוסייה המצויה בסיכון ללקות בדיכאון (כגון המרבים לבקר במירפאה) יכול להיות כלי-עזר ראשוני יעיל לאיתור מטופלים הלוקים בדיכאון.
  • Hermoni, D., Mankuta, D., Sivan, A., Kolander, Y., & Porter, B. (1987). Community Health Activists Program: A new model of community health involvement. Isr J Med Sci, 23, 1084-1087.
  • Hermoni, D., Friedman, M., Morel, D., Mankuta, D., Sivan, A., & Porter, B. (1989). Effects of Health Activist Course on Knowledge and Awareness of Antibiotic Use. Fam Pract, 6, 27-32.
Abstract
A cohort study investigated the specific outcomes of a health education coursed carried out by recently graduated physicians in an urban primary care setting in Israel. Questionnaires were used to study the effects of the programme on knowledge and awareness concerning antibiotic usage. The results showed a significant gain in knowledge about the causes of infectious disease, appropriate duration of antibiotic intake, side effects of antibiotics and the importance of compliance. In contrast with other studies, low income blue collar workers with less than high school education showed the most significant gains from the programme. Inexperienced physicians were able to implement a community health education programme with clearly defined goals.
  • Hermoni, D., Mankuta, D., & Reis, S. (1990). Failure to Keep Appointments at a Community Health Center – Analysis of causes. Scand J Prim Health, 8, 107-111.
Abstract
The scheduled appointment system in primary care clinics became popular recently in Israel. Failed appointments created a problem for the doctors, patients and the clinic in Netivot. During 11 months, 2,317 appointments were surveyed. The survey showed 36% of failed appointments, with a decrease to 28% one year later. Rates of failed appointments were 38% for the paediatric population, 35% for adults, and 34% for pensioners. Market days and holidays predisposed to more failed appointments, representing community customs. The presence of a chronic disease that needed follow-up ensured a higher rate of attendance (76%), especially among the paediatric population (92% attendance rate). By contrast, a geriatric patient with an acute disease had difficulty attending the clinic (only 16% attending). 512 people (35% of the population) were responsible for the 827 failed appointments, and among them only 12% of the population accounted for 59% of the failed appointments. These findings have important implications in the planning of an appointment system in an urban health centre, and they strengthen the assumption that a small number of patients cause a large number of failed appointments.
  • Hermoni, D., Bluzer, Z., Strulov, A., & Reis, S. (1991). Evaluation of a Rapid Method for Diagnosing Streptococcal Pharyngitis in a Rural Community Clinic. Isr J Med Sci, 27, 192-195.
Abstract
Group A beta-hemolytic streptococcal pharyngitis is a common ailment whose accurate diagnosis is dependent on laboratory testing. Transport problems common to rural practices, for laboratory testing, could be resolved by a reliable rapid test. Laboratory evaluations of rapid streptococcal tests, performed mostly in research settings, indicate that the tests have acceptable specificity and sensitivity. This paper describes a comparison study of 248 consecutive throat swab specimens using a commercially available agglutination test with routine throat culturing. All agglutination testing was done by the office staff under actual working conditions, in a rural primary care clinic. The cultures were processed in the main regional microbiology laboratory. As a result of transportation delay, swabs were plated either within 6 h from collection or after 6 h. The test sensitivity (72%) and specificity (88%) compared well with that reported in the literature from microbiology laboratories, especially for swabs plated within six hours (80% and 93% respectively). The rapid test is an acceptable alternative to the standard culture technique in the family practice office under normal working conditions, provided that patients with negative results follow up with throat cultures.
  • Hermoni, D., Nijim, Y., & Spencer, T. (1992). Preventable Deaths: 16 year study of consecutive deaths in a village in Israel. Brit J Gen Pract, 42, 521-523.
http://bjgp.org/content/bjgp/42/365/521.full.pdf
Abstract
The aims of this study were to examine mortality in one village in Israel and to determine which deaths could have been prevented by identifying those which were associated with avoidable factors or were caused by conditions which would have been amenable to preventive measures. The medical records of all 171 patients (91 males and 80 females) who died in the geographically defined population of 1800 during the 16 year period 1974-89 were reviewed. The mortality rate, adjusted for age, in the second eight year period (1982-89), was significantly lower for females (4.0 deaths per 1000 females per year) than for males (8.5) (P < 0.01). Downward trends in the birth rate, stillbirth rate and perinatal mortality rate were found, while there was an upward trend in both mean and median age at death. Of the 171 deaths, 36 (21%) were classified as being associated with a total of 44 factors which could be perceived as being avoidable. Twenty five of the avoidable factors were patient related and of these 17 were smoking (more than 20 cigarettes a day in patients aged less than 70 years who died of a smoking related disease). These findings confirm the need for continuous health education for patients. An audit of mortality in general practice is valuable and may contribute towards the prevention of some deaths.
  • Froom, J., & Hermoni, D. (1993). The Inventory to Diagnose Depression (IDD) in Primary Care Patients. Fam Pract, 10, 312-316.
Abstract
Major depressive disorder (MDD) is highly prevalent in ambulatory primary care patients. Severe functional impairment and risk of suicide are features of the condition. Although treatment can reduce morbidity, detection of MDD by primary care physicians is suboptimal. The aim of this study is to assess the inventory to diagnose depression (IDD) as compared with clinical psychiatric assessment for case finding in primary care patients. Adult members of an Israeli kibbutz (communal settlement), where all psychiatric diagnoses made by the family physician are confirmed by psychiatric consultation, were asked to complete the IDD; a 22 question, self-administered questionnaire. Patients whose scores indicated MDD, if not previously diagnosed, were also referred to psychiatrists. Patients' medical charts were reviewed for the diagnosis of MDD and response to therapy prior to the administration of the IDD. Of the sample of 312 patients, 207 (66.3%) completed the IDD. Refusers were younger (P = 0.04), more likely to be native born Israelis (P = 0.02), and had a higher prevalence of known MDD (P = 0.05) than participants. MDD by IDD scores was present in seven patients, in three of whom the diagnosis had previously been established; the other four were newly diagnosed. In the three previously diagnosed patients, one (metastatic carcinoma) refused treatment and two were receiving psychotherapy; all were clinically depressed. Four additional previously diagnosed patients whose IDD scores were insufficient for MDD had had a successful response to current therapy.(ABSTRACT TRUNCATED AT 250 WORDS
  • Froom, J., Aoyama, H., Hermoni, D., Mino, Y., & Galambos, N. (1995). Depressive Disorders in Three Primary Care Populations: United States, Israel, and Japan. Fam Pract, 12, 274-278.
Abstract
Primary care patients in the United States, Israel and Japan received the Inventory to Diagnose Depression and the Dartmouth COOP Functional Status Charts modified for international use. Patients were classified as having major depressive disorder or minor depression. Although demographic characteristics varied by country, the rank order and frequency of the depressive symptoms were similar for both major and minor depression. Functional impairment was most severe in patients with major depression, less severe in those with minor depression and was least impaired in those not depressed. The results suggest that depressive disorders have similar presentations in the three countries studied, although the separate cultures confer different consequences on patients receiving these diagnoses.
  • Froom, P., Melamed, S., Triber, I., Ratson, N. Z., & Hermoni, D. (2004). Predicting Self-reported Health: The CORDIS study. Prev Med, 39(2), 419-423.
Abstract
BACKGROUND: There have been few attempts to determine factors important in predicting subsequent self-reported health (SRH) in population studies of men or women.
METHODS: In the following study, we determine the predictive value of behavioral and biomedical risk factors for self-evaluated health 7.7-11.5 years later in 2,962 male industrial workers.
RESULTS: We found that age [odds ratio (OR) per 10 years = 1.5, 95% confidence interval (CI) = 1.30,1.74], current smoking (OR = 1.63, 95% CI = 1.23,2.16), higher systolic blood pressure (SBP) measurements (OR = 1.16 per 10 mm Hg, 95% CI = 1.03,1.31), use of chronic medications (OR =2.75, 95% CI = 2.03,3.71), diabetes mellitus (OR = 2.83, 95% CI = 1.73-4.63), low educational status (OR = 1.67, 95% CI = 1.23, 2.25), and lack of regular leisure sports activity (OR = 1.67, 95% CI = 1.04, 2.17) significantly added to a logistic regression model predicting poorer self-evaluated health 7.7-11.5 years later ]area under the receiver-operator curve (ROC) = 76.0%]. There was a trend for poorer self-rated health in the obese workers (OR = 1.40, 95% CI = 0.97-2.01).
CONCLUSIONS: Behavioral and biomedical risk factors for mortality predict self-evaluated health 7.7-11.5 years later.
  • Kafman, M., Hermoni, D., & Kitai, E. (1996). Complementary or Alternative Medicine (Heb.). Harefuah, 131(1-2), 46-50.
Abstract
Interest in, and use of alternative medicine has increased in the past few years in Israel. Still, little is known about the extent to which it is utilized, the more common treatments, patterns of use, and its influence on the conventional primary care system. We surveyed a kibbutz community to determine prevalence and patterns of use of alternative medicine and satisfaction with the outcome. The entire kibbutz population was asked to fill out a questionnaire (parents answered for their children). They were questioned as to their use of alternative medicine in the previous 5 years, types and dates of treatment, duration of treatment, and whether it had helped.
Of 1044 subjects, 830 responded (79.5%). 16.4% had used alternative medicine at least once in the previous 5 years. Of these, more than a 1/4 were treated by 2 or more types of alternative therapy. About 2/3 of those responding were women. Most had muscle-skeletal (36%), upper respiratory and/or atopic problems (19.3%). The most common treatments were homeopathy (31%) and acupuncture (20%). In approximately 2/3, the treatment was considered helpful, and either solved the problems or gave long-lasting improvement. 70% of those who used alternative medicine were treated within the previous 15 months and about 40% within the previous 3 months. The use of alternative medicine is increasing and it is now include in standard medical services. Most of those who used alternative therapy felt it had helped.
  • Halamish, L. D., & Hermoni, D. (2007). The Weeping Willow: Encounters with grief. New York, NY: Oxford University Press.
Abstract
This book is a practical and direct handbook for grieving. It presents 30 stories from real life that examine how we grieve and how we can help those who grieve—whether the griever is oneself, someone we care about, or a client or patient. The authors present vignettes from practice that show how death—lingering, unexpected, violent, or self-inflicted—and the loss of a relationship—to oneself or with a child, sibling, parent, mate, grandparent, or friend—give life to grief, together with the process by which each person fully encounters his or her grief. Each story is no more than two or three pages, and the authors follow each one with a short summary of its teachings and a selection of annotated recent references for those who wish to read more about a topic.
  • Hermoni, D., Borkan, J., Pasternak, S., Van-Raalte, R., Lahad, A., Biderman, A., & Reis, S. (2000). Doctor-Patient Concordance and Patient Initiative during Episodes of Low Back Pain. Brit J Gen Pract, 50, 809–810.
Abstract
Doctor-patient concordance and patient initiative were examined in a prospective network interview study, with telephone follow-up, of a cohort of 100 patients presenting with low back pain to their family physician. The average overall rate of concordance was 60% (95% CI = 53 to 66), with the highest rates for radiographic imaging studies and sick leave. No correlation was found between concordance and patient parameters. Subjects initiated an average of two (95% CI = 1.7 to 2.3) diagnostic or therapeutic procedures, the most common of which were for medications (40%), followed by bed rest (26%) and back school (22%). One out of every six subjects initiated a referral to a complementary therapist. Positive correlation was found between patient initiatives and pain severity (P = 0.022) and disability (P = 0.02). There was a negative correlation between the subjects' initiatives and their belief that the physician understood the cause of their pain and its influence on their life (P = 0.02). Overall, those patients who described more pain or disability sought more types of diagnostic and therapeutic measures, while those who felt they had been understood sought less.
  • Dahan, R., Reis, S., Van-Raalte, R., & Hermoni, D. (2001). Changing the Approach for Teaching Medical Students in the Primary Care Setting. Educ Gen Pract, 12(1), 41-46.
  • Borkan, J., Reis, S., Hermoni, D., & Biderman, A. (1995). Talking about the Pain: A patient-centered study of low back pain in primary care. Soc Sci Med, 40, 977-988.
Abstract
Despite considerable research, low back pain (LBP) often proves resistant to treatment. This study was designed to increase the understanding of low back pain through access to patients' perceptions, beliefs, illness behaviors and lived experiences. The findings are based on focus groups, individual interviews and participant observation conducted in primary care practices and community settings in three regions in Israel. Inclusion criteria for the interviews and groups include age greater than 18 years and a history of at least one episode of LBP. Seventy-six LBP subjects between the ages of 18 and 67 (mean 39.5) participated, 65% male and 35% female. The analytic method is content analysis, consisting of a formal, multi-step process designed to elucidate inherent patterns and meanings. This research finds that LBP subjects articulate a rich world of pain sensation, awareness and meanings. From subjects' own words and experiences we present a patient-centered classification system of backache symptoms based on typical pain intensity, dysfunction, duration and treatment. An elaborate system of explanatory models of LBP and a typology of dominant coping styles designed to either minimize pain or maximize function are also derived. Subjects choose multiple conventional and alternative treatments based on 'what works', and articulate ample criticisms of and suggestions for the medical system. In addition, we find that variations in the social construction of the back pain experience vary sharply, even between similar neighboring communities. Given the difficult state of diagnosis and treatment and the frustration of practitioners, attempts at greater understanding of patients' health beliefs, experiences, and behaviors are warranted.(ABSTRACT TRUNCATED AT 250 WORDS)
  • Reis, S., Hermoni, D., Borkan, J. M., Biderman, A., Tabenkin, C., & Porat, A. (1999). A New Look at Low Back Complaints in Primary Care: A RAMBAM Israeli family practice research network study. J Fam Pract, 48(4), 299-303.
Abstract
Background: Low back pain (LBP) is one of the most frequent reasons patients seek consultations in primary care, and it is a major cause of disability. Our research examines the natural history of LBP and the prediction of chronicity in the context of patients presenting to family medicine clinics.
Methods: We performed a prospective cohort study of new episodes of LBP within the framework of a national family practice research network. The setting was 28 primary care family practice clinics located throughout Israel. Of 238 eligible subjects, 219 (92%) completed the study.
Results: During the 2-month study period, 2 subjects were referred to the emergency department and discharged, and 2 others were hospitalized. Forty-five percent did not require bed rest, and 38% of the employed were not absent from work. Seventy-one percent showed improvement in functional status; however, only 37% noted complete pain relief. Clinical and demographic data usually did not predict LBP-episode outcomes. The strongest predictors of chronicity were depression, history of job change due to LBP in the past, history of back contusion, lack of social support, family delegitimization of patient's pain, dissatisfaction with first office visit, family history of LBP or other chronic pain, coping style, and unemployment.
Conclusions: The cohort patients displayed a relatively benign natural history of LBP, matched by benign clinical behavior from their physicians. In Israeli primary health care, acute LBP is infrequently associated with hospitalization or prolonged work absenteeism. Although most patients have functional improvement, pain often lingers. Almost all predictors of chronicity are psychosocial.
  • Nehar, J. O., Borkan, J. M., Wilkinson, M. J. B., Reis, S., Hermoni, D., & Hobbs, F. D. R. (2001). Doctor-Patient Discussions of Alternative Medicine for Back Pain. Scand J Prim Health, 19, 237-240.
http://web.b.ebscohost.com.clalit-ez.medlcp.tau.ac.il/ehost/pdfviewer/pdfviewer?vid=72&sid=73bfae75-9e24-4a86-9317-b56ef1eba7b7%40sessionmgr120
Abstract
Objective: To document the frequency of conversations about alternative medicine during primary care consultations for back pain in diverse settings.
Design: "Exit interview" type patient survey.
Settings: General practices in Seattle, Washington; rural Israel; and Birmingham, England.
Patients: A convenience sample of 218 adults completing a doctor visit for back pain.
Main Outcome Measures: Frequencies of doctor-patient discussions of alternative medicine.
Results: Alternative medicine was discussed in a minority of visits (US site 40%, Israel site 37%, UK site 14%, p < 0.05). At each site, patients initiated at least half of the discussions. Users were five to six times more likely to discuss alternative medicine with their doctor than non-users (p < 0.05 for comparison at each site). The percentage of patients who used alternative medicine but left the consultation without discussing it was similar at all sites (US site 17%, Israel site 23%, UK site 15%).
Conclusions: Discussions of alternative medicine occurred in a minority of consultations for back pain although the rate varied considerably by site. Discussions were initiated primarily by patients who use it.
Abstract
Study Design: Review of advances in the primary care research on low back pain (LBP) from a unique international forum, and analysis of open-ended questionnaires from participants.
Summary Of Background Data: LBP continues to be one of the most common and challenging problems in primary care. It is associated with enormous costs in terms of direct health care expenditures, and indirect work and disability-related losses.
Objective: To ascertain the current status and state of the art regarding LBP in primary care.
Methods: Four reviewers independently assessed the content and implications of presentations at the Fourth International Forum for Primary Care Research on LBP, pooled the data, and then augmented it with open-ended questionnaires completed by 35 participants.
Results: The Fourth Forum documented the field's emergent new paradigm-a transition from thinking about back pain as a biomedical "injury" to viewing LBP as a multifactorial biopsychosocial pain syndrome. The paradigm shift has occurred in the context of increased interest in evidence-based medicine regarding LBP in primary care. The Forum demonstrated the strides taken in moving from research and evidence gathering, through guidelines and policy formulations and finally to the dissemination and implementation imperative. There was an increasing confidence among the Forum researchers that LBP can be managed successfully in primary care settings through a combination of encouraging activity, reassurance, short-term symptom control, and alteration of inappropriate beliefs about the correlations of back pain with impairment and disability. There is also recognition that a wide range of international, evidence-based guidelines now exists that have very similar messages.
Conclusions: The Fourth Forum reflected a major shift in the conceptualization of LBP in primary care and an increased emphasis on implementation and dissemination of LBP research findings and clinical guidelines. Although there is a wide array of challenges ahead, the Fourth Forum provided a clear message regarding the need to focus research energies on changing practitioner behavior.
  • Ben-Arye, E., Bar-Sela, G., Frenkel, M., Kuten, A., & Hermoni, D. (2006). Is a Biopsychosocial-Spiritual Approach Relevant to Cancer Treatment? A study of patients and oncology staff members on issues of complementary medicine and spirituality. Support Care Cancer, 14(2), 147-152.
Abstract
BACKGROUND:
Complementary and alternative medicine (CAM) is increasingly being used by patients with cancer.
OBJECTIVES:
Our aim is to compare the attitudes of cancer patients who use CAM to those of nonusers, on issues of CAM, biopsychosocial considerations, and spiritual needs.
METHODS:
Questionnaires were administered to patients and medical care providers in a tertiary teaching hospital with a comprehensive cancer center.
RESULTS:
Forty-nine percent of the study patients reported integrating CAM into their conventional care. Health care providers considered psychological and spiritual needs as major reasons for CAM use, while patients considered the familial-social aspect to be more important.
CONCLUSIONS:
Cancer patients do not correlate CAM use with spiritual concerns but expect their physicians to attend to spiritual themes. Health care providers involved in oncology cancer care should emphasize spiritual as well as CAM themes. The integration of these themes into a biopsychosocial-spiritual approach may enrich the dialogue between patients and health providers.
  • Frenkel, M., Gross, S., Popper Giveon, A., Sapire, K., & Hermoni, D. (2015). Living Outliers: Experiences, insights and narratives of exceptional survivors of incurable cancer. Future Oncol, 11(12), 1741-1749.
Abstract
AIM:
Unexplained prolonged survival given a diagnosis of incurable advanced cancer is a puzzling phenomenon that recently has attracted more scientific research. The purpose of this study was to add to the understanding of how exceptional patients perceive and explain their unusual experience.
METHODS:
We recruited patients for interviews from a population registry, patients with advanced lung or pancreatic malignancy who experienced exceptional survival.
RESULTS & CONCLUSION:
In total, 15 participants were interviewed. The main recurrent themes in most of the interviews were patient-doctor communication, family support and the patient's proactive attitude. In this study, patients attribute their longevity to relationships with their doctor and their family - not the type of treatment they received. Further research on this phenomenon is needed.
  • Twito, O., Ahron, E., Jaffe, A., Afek, S., Cohen, E., Granek-Catarivas, M., Klein, P., & Hermoni, D. (2013). New Onset Diabetes Mellitus in Elderly Subjects: Association between HbA1c levels, mortality and coronary revascularization. Diabetes Care, 36(11), 3425-3429.
Abstract
OBJECTIVE:
New-onset diabetes mellitus (DM) in elderly patients is associated with increased risk of diabetes complications and mortality. It is unknown whether glycemic control in this population influences the mortality risk.
RESEARCH DESIGN AND METHODS:
The current study was conducted using the computerized database of the Sharon-Shomron District of Clalit Health Services in Israel. Included in the study were subjects 65 years of age and above with new-onset DM. The primary outcome measures were all-cause mortality and coronary revascularization procedures with either percutaneous coronary intervention or coronary artery bypass grafting.
RESULTS:
Participants (n = 2,994) were stratified into four groups according to their mean HbA1c levels during the follow-up period (<6.5% [48 mmol/mol], 6.5-6.99% [48-52 mmol/mol], 7-7.49% [53-57 mmol/mol], and ≥7.5% [58 mmol/mol]). During a mean follow-up of 5.54 ± 2.1 years, 1,173 (39.17%) participants died and 285 (9.51%) underwent coronary revascularization. An HbA1c level >7.5% (58 mmol/mol) was associated with a significantly increased all-cause mortality rate (hazard ratio [HR] 1.74 [95% CI 1.2-1.8], P < 0.0001). This difference remained statistically significant after a multivariate model adjusted for the conventional cardiovascular risk factors and for the use of hypoglycemic agents and statins. Kaplan-Meier survival plots revealed lower survival rates in this group of patients. Coronary revascularization rates were highest among subjects with HbA1c 6.5-6.99% (48-52 mmol/mol) (HR 1.6 [1.01-2.4], P < 0.05) and lowest in patients with HbA1c ≥7.5% (58 mmol/mol).
CONCLUSIONS:
An HbA1c level >7.5% (58 mmol/mol) is associated with increased risk for all-cause mortality and with a lower revascularization rate in elderly patients with new-onset DM.
  • Pereg, D., Elis, A., Neuman, Y., Mosseri, M., Leader, A., Segev, D., Granek-Catarivas, M., Lishner, M., & Hermoni, D. (2013). Lipid Control in Patients with Coronary Heart Disease Treated in Primary Care or Cardiology Clinics. J Clin Lipidol, 7(6), 637-641.
Abstract
BACKGROUND:
Guidelines recommend low-density lipoprotein-cholesterol (LDL-C) target of <70 mg/dL in patients with coronary disease. However, this goal is not achieved in many patients.
OBJECTIVES:
We compared LDL-C control in patients with coronary disease treated by a primary care physician or with the addition of a cardiologist.
METHODS:
Included were patients with coronary disease who had full lipid profile. Primary end points included the percentage of patients who achieved the LDL-C goals of <100 mg/dL and <70 mg/dL.
RESULTS:
Of the 27,172 patients, 12,965 (47.7%) were followed only by a primary care physician and 14,207 (52.3%) were also followed by a cardiologist. Overall, 18,366 patients (67.6%) achieved the LDL-C goal of <100 mg/dL, and 6517 patients (24%) achieved the LDL-C goal of <70 mg/dL. Patients followed by a cardiologist more frequently achieved the LDL-C goal of <100 mg/dL (74.3% and 60.3%; P < .0001, in patients treated by a cardiologist or by a primary care physician, respectively), as well as the lower LDL-C goal of <70 mg/dL (27.2% and 20.4%; P < .0001, in patients treated by a cardiologist or by a primary care physician, respectively). Differences in LDL-C control remained significant after a multivariate adjustment. Patients followed by a cardiologist were more commonly treated with highly potent statins and with non-statin cholesterol-lowering drugs.
CONCLUSIONS:
Among patients with coronary disease, those followed by a cardiologist receive a more aggressive antilipid treatment and more frequently achieve lipids goals. Nevertheless, the disappointingly poor lipid control in both groups warrants an effort to improve adherence for guidelines in both primary care and cardiology clinics.
  • Pereg, D., Elis, A., Neuman, Y., Mosseri, M., Lishner, M., & Hermoni, D. (2010). Cardiovascular Risk in Patients with Fasting Blood Glucose Levels within Normal Range. Am J Cardiol, 106(11), 1602-1605.
Abstract
Fasting glucose levels elevated beyond the normal range have been associated with increased cardiovascular risk. However, it is unknown whether this association exists for variations of fasting glucose within the normal range. The present study was conducted using the computerized database of the Sharon-Shomron District of Clalit Health Services. Included in the present study were subjects with fasting glucose levels within the normal range (< 100 mg/dl). We excluded patients with a history of cardiovascular disease or diabetes. The primary outcome was the incidence of coronary revascularization with either percutaneous coronary intervention or coronary artery bypass grafting. The 28,263 participants (age 53.7 ± 12.2 years) were divided into quartiles according to the fasting glucose level (75.4 ± 4.5, 83.6 ± 1.7, 88.9 ± 1.4, and 95.1 ± 2.2 mg/dl). During a mean follow-up of 5.9 ± 0.7 years, 424 subjects required coronary revascularization. A progressive increase was seen in the risk of coronary revascularization as the fasting glucose levels increased within the normal range (hazard ratio 1.73, 95% confidence interval 1.3 to 2.3, p > 0.001, between the fourth and first quartiles). However, this association lost its statistical significance after adjustments for the conventional coronary risk factors (hazard ratio 1.17, 95% confidence interval 0.85 to 1.62, p = 0.328). In conclusion, elevated fasting glucose levels within the normal range were associated with an increased cardiovascular risk. This association was caused by the greater prevalence of the other conventional risk factors and not by the glucose level itself.
  • Pereg, D., Tirosh, A., Elis, A., Neuman, Y., Mosseri, M., Segev, D., Lishner, M., & Hermoni, D. (2012). Mortality and Coronary Heart Disease in Euthyroid Patients. Am J Med, 125(8):826.e7-12.
Abstract
BACKGROUND:
Subclinical thyroid dysfunction is associated with increased mortality and cardiovascular risk. It is unknown whether this association remains within normal thyroid function range.
METHODS: The study was conducted using the computerized database of the Sharon-Shomron district of Clalit Health services. Included were subjects aged ≥40 years with normal thyroid function. Patients with a history of thyroid or cardiovascular diseases or diabetes were excluded. The primary end points were all-cause mortality and the need for coronary revascularization with either percutaneous coronary intervention or coronary artery bypass grafting.
RESULTS:
The 42,149 participants were stratified into 3 groups of equal thyrotropin intervals (0.35-1.6, 1.7-2.9, and 3-4.2 mIU/L). During a mean follow-up of 4.5±2.1 years, 4239 (10.1%) participants died and 1575 (3.7%) underwent coronary revascularization. For both women and men, the lowest mortality rates were observed in the intermediate thyrotropin group. Nevertheless, only for the low thyrotropin group, mortality risk remained significantly higher as compared with the intermediate thyrotropin group, even following multivariate model adjusted for the conventional cardiovascular risk factors, in both women (odds ratio 1.22; 95% confidence interval, 1.09-1.36 for the low thyrotropin group, compared with the intermediate group) and men (odds ratio 1.14; 95% confidence interval, 1.01-1.3 for the low thyrotropin group, compared with the intermediate group). There was no significant difference in the need for coronary revascularization among the 3 thyrotropin groups in both men and women.
CONCLUSIONS:
Low thyrotropin level within the reference range is associated with increased risk for all-cause mortality.
  • Pereg, D., Neuman, Y., Elis, A., Minha, S., Mosseri, M., Segev, D., Lishner, M., & Hermoni, D. (2012). Comparison of Lipid Control in Patients with Coronary versus Peripheral Artery Disease Following the First Vascular Intervention. Am J Cardiol, 110(9), 1266-1269.
Abstract
Peripheral arterial disease (PAD) is a strong risk factor for cardiovascular morbidity and mortality. Therefore, target low-density lipoprotein (LDL) cholesterol level in patients with PAD is ≤70 mg/dl, similar to patients with coronary artery disease (CAD). However, despite their high cardiovascular risk, patients with PAD less frequently achieve LDL cholesterol goals compared to patients with CAD. We aimed to compare LDL cholesterol control in patients after first coronary or peripheral vascular intervention. Included were patients ≥18 years of age without a history of cardiovascular disease who underwent first coronary or peripheral vascular intervention from 2004 through 2010. Primary end points were percentage of patients who achieved the LDL cholesterol goal of <100 and <70 mg/dl. Of 9,138 patients available for analysis, 7,512 (82.2%) underwent first coronary revascularization and 1,626 (17.8%) underwent first peripheral revascularization. Patients after first coronary revascularization were treated more frequently with any statin and with highly potent statins. Furthermore, they more frequently achieved the LDL cholesterol goals compared to patients after first peripheral intervention. This was true for the LDL cholesterol goal of <100 mg/dl (65% and 46.7%, p <0.0001) and for the lower LDL cholesterol goal of <70 mg/dl (23.3% and 13.3%, p <0.0001). Differences in LDL cholesterol control between the 2 groups remained statistically significant after multivariate adjustment. In conclusion, lipid control in patients with PAD is poor and significantly inferior to that of patients with CAD even after the first vascular intervention.
  • Leader, A., Ayzenfeld, R. H., Lishner, M., Cohen, E., Segev, D., & Hermoni, D. (2014). Thyrotropin Levels within the Lower Normal Range are Associated with an Increased Risk of Hip Fractures in Euthyroid Women, but not Men, over the Age of 65 Years. J Clin Endocrinol Metab, 99(8), 2665-2673.
Abstract
CONTEXT:
The contemporary literature on the relationship between serum TSH levels and osteoporotic fractures in euthyroid individuals is limited by conflicting results and analyses conducted on a small number of fractures.
OBJECTIVE:
Our objective was to examine the association between the normal range of variation of TSH and the incidence of hip fractures in male and female euthyroid patients aged 65 years or older.
DESIGN AND SETTING:
We performed a population-based historical prospective cohort study within the Clalit Health Services population.
PARTICIPANTS:
Clalit Health Services members aged ≥65 years with at least 1 TSH measurement during the year 2004. We excluded patients with preexisting hip fracture, thyroid disease, malignancy, or chronic kidney disease.
OUTCOME MEASURES:
The primary outcome was hip fracture, and the secondary outcome was any other osteoporotic fracture.
STATISTICAL ANALYSIS:
Adjusted odds ratios comparing episodes of each outcome across 3 TSH groups (low, 0.35-1.6 mIU/L; intermediate, 1.7-2.9 mIU/L; high, 3-4.2 mIU/L) were generated using logistic regression models.
RESULTS:
The 14 325 included participants suffered from 514 hip fractures (mean follow-up, 102 ± 3 months). Women, but not men, in the lowest TSH group had a higher incidence of hip fractures (odds ratio = 1.28, 95% confidence interval = 1.03-1.59, P = .029) when compared with the intermediate group, after multivariate adjustment for age, comorbidities, and use of drugs affecting bone metabolism. There was no difference in hip fracture incidence between intermediate- and high-TSH groups. No association was found between TSH levels and other osteoporotic fractures.
CONCLUSIONS:
TSH levels within the lower normal range are associated with an increased risk of hip fractures in euthyroid women, but not men, aged 65 years and more.
  • Baytner-Zamir, R., Lorber, M., & Hermoni, D. (2014). Assessment of the Knowledge and Attitudes regarding HIV/AIDS among Pre-clinical Medical Students in Israel. BMC Res Notes, 7, 168.
Abstract
BACKGROUND:
Today's medical students are the future physicians of people living with HIV/AIDS (PLWHA). It is therefore essential that medical students possess the appropriate knowledge and attitudes regarding PLWHA. This study aims to evaluate knowledge and attitudes of pre-clinical Israeli medical students and to assess whether their knowledge and attitudes change throughout their pre-clinical studies.
METHODS:
A cross-sectional study was conducted among all pre-clinical medical students from the four medical schools in Israel during the academic year of 2010/2011 (a total of 1,470 students). A self-administered questionnaire was distributed. The questionnaire sought student responses pertaining to knowledge of HIV transmission and non-transmission routes, basic knowledge of HIV/AIDS treatment and attitudes towards HIV/AIDS.
RESULTS:
The study's response rate was 62.24 percent. Knowledge among pre-clinical medical students was generally high and showed a statistically significant improvement as students progressed through their pre-clinical studies. However, there were some misconceptions, mostly regarding HIV transmission via breastfeeding and knowledge of HIV prevention after exposure to the virus. Students' attitudes were found to include stigmatizing notions. Furthermore, the majority of medical students correlated HIV with shame and fear. In addition, students' attitudes toward HIV testing and providing confidential medical information were contradictory to health laws, protocols and guidelines. Overall, no positive changes in students' attitudes were observed during the pre-clinical years of medical school.
CONCLUSION:
The knowledge of pre-clinical medical students in Israel is generally high, although there are some knowledge inadequacies that require more emphasis in the curricula of the medical schools. Contrary to HIV-related knowledge, medical students' attitudes are unaffected by their progression through medical school. Therefore, medical schools in Israel should modify their curricula to include teaching methods aimed at improving HIV-related attitudes and adherence to medical professionalism.
  • Pshetizky, Y., Tandeter, H., Tabenkin, H., Vinker, S., Lahad, A., Karkabi, K., Kitai, E., Hermoni, D., & Shvartzman, P. (2009). Thirty Years of Family Medicine Publications in Israel (1975-2004) – What, Where, and How Much? J Am Board Fam Med, 22(1), 57-61.
Abstract
BACKGROUND:
Departments of family medicine in Israel were established in the 1970s. Until now, little or no effort has been made to characterize the productivity of Israeli board-certified family medicine physicians in publishing peer-reviewed scientific articles.
METHODS:
Publications were identified by 2 methods. First, a PubMed search by names of current and past faculty from all the departments of family medicine in Israel (1975-2004). Secondly, all of the departments in Israel forwarded a list of all publications by their faculty (including those that do not appear in Medline). The abstracts of all publications were extracted and were separately and blindly evaluated by 2 reviewers. Publications were classified according to Medline citation, language, journal impact factor, and publication type.
RESULTS:
A total of 1165 publications were identified and analyzed. More than half of the articles were published in the last 10 years. Seventy-two percent were cited in Medline. Publications in English encompassed 64.7% of the publications, Hebrew 34.6%, and 0.7% other. Approximately 6% of the articles were published in journals with impact factor > or =3, with research articles accounting for 46.9%. The publication output of family medicine in Israel averaged 85.4 publications per 1000 family medicine physicians per year. Almost 70% of the articles were published in non-family medicine journals. Academically affiliated, board-certified family medicine physicians published at higher rates, averaging 334.3 per 1000 academic family medicine physicians per year (data available for 2000-2004 only).
CONCLUSIONS:
Publishing and research are important to the development of family medicine as an academic profession, in which Israeli family physicians show significant productivity.
  • Gordon, B., Levy, Y., Yemini, T., Carmon, E., Erlich, Y., & Hermoni, D. (2016). The Ecology of Medical Care among Israeli Military Aviators. Aerosp Med Hum Perform, 87(12), 1036-1040.
Abstract
BACKGROUND:
The ecology of medical care model has been used in various populations with varying results. We aimed to apply this model in the population of Israeli Air Force (IAF) aviators.
METHODS:
An anonymous questionnaire was presented to all Israeli Air Force aviators during their mandatory yearly check-up over 1 yr starting on November 26th, 2012. The questionnaire contained items on demographic, personal, and military details, as well as items on the presence of clinical symptoms, and various health care contacts in the previous month. We assessed the differences between career and reserve personnel using a X2 test.
RESULTS:
There were 325 aviators who completed the questionnaire (2 women, 132 reserves). Clinical symptoms were reported by 62.5% of the responders. Over half (52.6%) had any health care encounter: 23.7% with a dentist, 17.9% with non-MD therapists, 12.6% with a specialist, and 11.7% with a primary physician. A significant difference between reserve and career personnel was found only in primary care visits. Out of the aviators who reported having clinical symptoms, 70.9% did not visit a physician. Of those who did not seek medical care, 42.4% reported that the symptoms were viewed as unimportant, 41% thought they would disappear by themselves, 40.3% could not find time for treatment.
CONCLUSIONS:
Aviators in the IAF have similar rate of clinical symptoms as in other unselected populations. Those who report symptoms usually do not visit a physician for treatment. When they do seek advice it is mostly from non-MD practitioners.
  • Leader, A., Zelikson-Saporta, R., Pereg, D., Spectre, G., Rozovski, U., Raanani, P., Hermoni, D., & Lishner, M. (2017). The Effect of Combined Aspirin and Clopidogrel Treatment on Cancer Incidence. Am J Med, 130(7), 826-832.
Abstract
BACKGROUND:
Multiple studies have shown an association between aspirin treatment and a reduction in newly diagnosed cancer. Conversely, there are conflicting clinical and laboratory data on the effect of combined clopidogrel and aspirin therapy on cancer incidence, including analyses suggesting an increased cancer risk. No large-scale cohort study has been performed to address this issue in a heterogeneous real-world scenario. We investigated the effect of clopidogrel and aspirin on cancer incidence compared with aspirin alone and no antiplatelet therapy.
METHODS:
A population-based historical cohort study of subjects aged ≥50 years covered by Clalit Health Services, an Israeli health maintenance organization, was performed. Patients treated with the newer antiplatelet drugs, prasugrel or ticagrelor, which, like clopidogrel, inhibit adenosine diphosphate receptors, and those with prior cancer were excluded. Prescription records of antiplatelet medication were retrieved.
RESULTS:
The cohort included 183,912 subjects diagnosed with 21,974 cancer cases based upon the International Classification of Diseases, Ninth Revision. Dual aspirin and clopidogrel was prescribed in 9.6%, while 49% received aspirin alone and 41% used neither. Compared with nonusers, there was a lower risk of cancer in subjects exposed to aspirin with (hazard ratio [HR] 0.46; 95% confidence interval [CI], 0.44-0.49) or without clopidogrel (HR 0.54; 95% CI, 0.52-0.56), on long-term follow-up. Combined treatment was associated with a lower cancer risk than the aspirin-only group (HR 0.92; 95% CI, 0.86-0.97).
CONCLUSIONS:
Dual clopidogrel and aspirin treatment is safe regarding the cancer risk. This study generates the hypothesis that clopidogrel may reduce cancer incidence.

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