Ernesto Kahan

Death and injury from motor vehicle crashes in Colombia

We report data on the distribution and determinants of road deaths and injuries for all victims in Colombia, with the aim of defining targets and priorities for highway death prevention in that country and other rapidly urbanizing nations. Using information from Colombias Fund for the Prevention of Road Injury and the national death registry, we studied data on deaths and injuries from 1991 to 1995 for the nation as a whole and for the countrys two largest cities, Santa Fe de Bogotá and Medellín. Deaths and injuries are rising in the nation as a whole. Of the deaths, 75% occur in urban areas, and 80% are in males. Pedestrians aged 15-34 are a peak subgroup. Thirty-four percent of deaths are attributable to speeding and/or alcohol consumption. Death tolls are highest at night and on weekends. Specific priority targets for intervention are indicated by the fact that 75% of road deaths in Colombia occur in urban areas and that 80% of all victims are males.

Empiric Treatment of Uncomplicated Urinary Tract Infection with Fluoroquinolones in Older Women in Israel: Another Lost Treatment Option?

Background: Current guidelines for the treatment of uncomplicated urinary tract infection (UTI) in women recommend empiric therapy with antibiotics for which local resistance rates do not exceed 10–20%. We hypothesized that resistance rates of Escherichia coli to fluoroquinolones may have surpassed this level in older women in the Israeli community setting. Objectives: To identify age groups of women in which fluoroquinolones may no longer be appropriate for empiric treatment of UTI. Methods: Resistance rates for ofloxacin were calculated for all cases of uncomplicated UTI diagnosed during the first 5 months of 2005 in a managed care organization (MCO) in Israel, in community-dwelling women aged 41–75 years. The women were without risk factors for fluoroquinolone resistance. Uncomplicated UTI was diagnosed with a urine culture positive for E. coli. The data set was stratified for age, using 5 year intervals, and stratum-specific resistance rates (% and 95% CI) were calculated. These data were analyzed to identify age groups in which resistance rates have surpassed 10%. Results: The data from 1291 urine cultures were included. The crude resistance rate to ofloxacin was 8.7% (95% CI 7.4 to 10.2). Resistance was lowest among the youngest (aged 41–50 y) women (3.2%; 95% CI 1.11 to 5.18), approached 10% in women aged 51–55 years (7.1%; 95% CI 3.4 to 10.9), and reached 19.86% (95% CI 13.2 to 26.5) among the oldest women (aged 56–75 y). Conclusions: Physicians who opt to treat UTI in postmenopausal women empirically should consider prescribing drugs other than fluoroquinolones. Concomitant longitudinal surveillance of both antibiotic utilization patterns and uropathogen resistance rates should become routine practice in this managed-care organization.

Impact of a single-session education program on parental knowledge of and approach to childhood fever

We evaluated knowledge of and approach to childhood fever in parents before and after attending a single reinforced educational session on the subject given by the pediatrician during a visit with their sick child. The study group consisted of 155 consecutive parents of children who visited the pediatrician for treatment of low-grade fever (<38.5 degrees C) once during the period of July 1999-2000, and again, within 6 months later. The parents received the standard short explanation for fever at the first visit and a reinforced educational session which included discussion supported by written and pictorial material at the second. At the follow-up examination, performed 3-7 days after each visit, the parents completed a questionnaire on their approach to the management of childhood fever, and the responses to the two questionnaires were compared. High-grade fever was correctly defined by 75% of the parents after the reinforced education session compared to 46% before, and over 95% of the parents correctly treated fever after the reinforced session compared to only 50% before. Knowledge of the correct utilization of health services was also improved after the intervention. All these differences were statistically significant. This study suggests that parental knowledge of fever management in children can be significantly improved by a reinforced educational session.

Bacterial contamination of spacer devices used by asthmatic children.

Objectives. To investigate bacterial contamination in spacer devices used by asthmatic children and the device maintenance procedures practiced by parents. Methods. Spacer devices used by 62 asthmatic children were examined. Swabs taken from the inner surface of the reservoirs and face masks were cultured. Parents were interviewed regarding their spacer cleaning and disinfection routines. Results. Bacterial contamination was noted in 22 reservoirs (35.5%) and 16 masks (25.8%). Pseudomonas aeruginosa was isolated from 21.0% of the reservoirs and 14.5% of the face masks, Klebsiella pneumoniae from 6.5% and 4.8%, and Staphylococcus aureus from 9.7% and 8.1%, respectively. Only 34 parents (54.8%) reported that they received cleaning and maintenance instructions from the medical staff at initiation of spacer use by their child, and only 38 (61.8%) cleaned the device after each use. Conclusion. Bacterial contamination is common in spacer devices. This study demonstrates that contamination rates are significantly lower when parents clean and actually dry (preferably with an air blower) spacer devices after each use. Spacer device maintenance should be emphasized in education programs for managing asthma.

Factors associated with family physicians' involvement in research in Israel.

OBJECTIVES: To identify the factors that encourage or deter family medicine physicians and residents in Israel from participating in research. METHOD: In October 1995, a questionnaire containing items on demographic variables, research attitudes, and academic and research activities in primary care settings was mailed to a random sample of 200 family medicine physicians and residents (out of approximately 600) employed by the General Sick Fund, the largest health maintenance organization in Israel. The questionnaire also contained items regarding difficulties in participating in research and asked for opinions about several general statements about research in family practice. RESULTS: In all, 190 physicians responded, for a response rate of 95%. Based on their responses, the respondents were divided into four groups by amount of research involvement. Univariate analysis using the chi-square test was used for the comparison of variables among the four groups. The respondents reporting greater knowledge of and involvement in research were, by and large, men (p = .01) who were qualified specialists with academic status (p < .00001). They also taught students (p = .0005) and residents (p < .0005), participated in more conferences (p < .0005), and while in residency training had had a mentor who encouraged involvement in research (p = .0001). CONCLUSION: Research is essential to family medicine with regard to both primary care practice and academic activities, its development, however, has been inhibited. Given the results of this preliminary study, family medicine residency programs would be well advised to assign a research mentor to every resident; also, time and resources should be devoted to research in postgraduate training programs. Perhaps more important, women physicians in Israel should be encouraged to participate more actively in research, and support for them in their special needs should be made available.

Microbial colonization of nebulizers used by asthmatic children.

Background: The aim of the present study was to determine the microbial colonization of nebulizers used at home by asthmatic children, and to investigate their parents’ cleaning and maintenance routines.

Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money

Context:  Current Israeli guidelines for the empiric treatment of uncomplicated urinary tract infection (UTI) in women recommend nitrofurantoin for 5 days. Some physicians nevertheless opt for ofloxacin, which should be prescribed for 3 days according to universally accepted guidelines.

Prevalence of and Change in the Prescription of Methylphenidate in Israel Over a 2-Year Period

AbstractIntroduction: The use of methylphenidate for the treatment of attention deficit-hyperactivity disorder (ADHD) has increased dramatically in the past decade in some countries in Europe and North America. In response to a public debate in Israel, several Knesset members introduced a legislative initiative that aims to limit the prescription of methylphenidate by physicians. The objective of this study was to examine the rate methylphenidate prescriptions dispensed for the treatment of ADHD in children in northern and central Israel in 1999 and 2001. Patients and study design: The population included all children aged 0–18 years living in central or northern Israel and insured by the largest national health management organisation who were prescribed methylphenidate at least once in 1999 or 2001. This was a population-based prevalence study comparing the two timepoints using data from the health management organisation and descriptive statistics. Results: The overall 1-year prevalence of methylphenidate prescriptions dispensed to children was 1.01% in 1999 and 1.22% in 2001 (relative risk [RR] 1.21, 95% CI 1.15–1.26), an increase of 21%. Seventy-seven percent of those prescribed methylphenidate were boys. The prescription rate ranged from 0.2% (RR 1.24, 95% CI 0.76–2.05) in Arabic cities to 5.99% (RR 1.19, 95% CI 1.09–1.30) in kibbutzim; this wide variation by type of residence apparently involved cultural, racial and economic factors. Conclusion: Israel shows no unusual or unexpected patterns in methylphenidate prescriptions dispensed to children and a lesser increase over time than other developed countries. This suggests that limiting physician freedom to prescribe methylphenidate to children may not be justified.

Thyroid Cancer in Patients 70 Years of Age or Older Retrospective Study of 50 Patients

This report presents our experience with 50 thyroid cancer patients 70 years of age or older, out of 606 patients of all ages. Comparing this series to those describing thyroid cancer patients of all ages, we found that thyroid carcinoma in the 70 + age group presents at a more advanced clinical stage, behaves more aggressively, and has a higher death rate. These findings are attributed mainly to the higher incidence of undifferentiated carcinoma and the more aggressive course of the differentiated types of carcinoma in the older age group. If suspected thyroid nodules are managed by initial radical treatment, carcinoma can be diagnosed earlier and patients will survive longer.

Empiric treatment of uncomplicated UTI in women: wasting money when more is not better

Context:  Trimethoprim–sulfamethoxazole (TMP–SMX) and nitrofurantoin were until recently the two drugs recommended in clinical guidelines in Israel for empiric treatment of uncomplicated urinary tract infection (UTI) in women.