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.

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.

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.

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.

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.

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.

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.

[Shigellosis in a primary care practice]

The epidemiological and clinical characteristics of 47 patients infected with Shigella in 3436 patients at a primary care clinic during 30 months were reviewed. Most cases were seen during the winter. The prominent clinical features were abdominal pain (91.5%), headaches (72.5%), bloody diarrhea (66%), mucoid stools (63.8%), fever (53.2%) and 75% had 4-10 stools per day. Most patients presented the first day of the illness (75%). S. sonnei has been found the most prevalent among 4 types of shigella. Resistance to ampicillin was complete and to Resprim 95%, but to nalidixic acid and to tetracycline, 4.9%. A third of the patients were treated with oral fluids and an appropriate diet and 2/3 received antibiotics. Children between 1-4 years of age who attend kindergartens are the main risk group for Shigellosis.

[Chronic diseases in immigrants from Russia (CIS) at a primary care clinic and their sociodemographic characteristics]

397 new immigrants to Israel ("olim") were under medical treatment at a primary care clinic during the first year (1990-1991) after their immigration to Israel ("aliyah") from 14 republics of the Commonwealth of Independent States (CIS, formerly the Soviet Union). Most of the olim were between 1-19 years of age. More than three-quarters were married and about a third of the women were widowed or divorced. The other patients were bachelors, separated men or women, or divorced men. More than a third had 16 years or more of education. More than a third of the families consisted of 2 members, while more than three-quarters had both parents, and about a quarter only 1 parent, usually the mother. Half the families had children; more than a quarter of the adults had not been employed in the CIS, while in Israel 58.8% were. 464 diagnoses of chronic diseases had been made in the CIS, (1.2/person), of which 75% were verified in Israel. 185 cases (0.5/person) not previously reported were diagnosed or had developed in Israel. The most frequent were cardiovascular, and next digestive tract disease, followed by endocrine, metabolic and musculoskeletal-connective tissue diseases. The overall prevalence rate of ischemic heart disease among men aged 20 < or = 65 years was 18.8%, compared to 5.8% among veteran Israelis. Among women the rates were 9.5% and 4.0%, respectively. The prevalence of hypertension (> or = 160/95) was 14% among men and 21% among women; in veteran Israelis it was 14% for both men and women. The prevalence of diabetes among men was 4.1%, and 5.4% among veteran Israelis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mental disorders in severely dysfunctional and in well-functioning families]

The types of mental disorders and their prevalence in severely dysfunctional (SD) and well-functioning (WF) families were compared. SD families were characterized by chronic conflicts, absence of closeness and lack of trust between parents, and bad relations and lack of support between parents and their children. WF families were characterized by high levels of psychological intimacy, warm and satisfying relationships between parents and children, and a warm, affectionate, optimistic family mood. 23 SD families (44 parents and 60 children) and 61 WF families (121 parents and 184 children) were followed for over 4 years by the author of this study. There was a high prevalence of mental disorders in parents of SD families in comparison to the WF families (43.2% vs 6.6%). This excess was significantly less in men (p = 0.05), in whom the risk ratio was 3.3 (p = 0.03), while for women it was 10.2 (p less than 0.0001). Most prominent was the higher prevalence of chronic anxiety: 25% vs 5% with a risk ratio for men of 2.9 (p = 0.09), and for women 7.1 (p less than 0.0001). Among children as well, there was greater prevalence of psychiatric illness in SD families--56.6% vs 3.8%, risk ratio 14.9 (p less than 0.0001). The prevalence of developmental speech and language disorders in SD families was 33.2 times greater, of hyperkinetic syndrome 12.3 times, and of enuresis 7.2 times. In contrast to the parents, the overall rate of illness was not significantly different between the sexes. We feel that it is important to discover such families because treatment and intervention early in childhood may increase the effectiveness of treatment.

[Clerambault syndrome in an elderly woman]

Prompt diagnosis of the uncommon Clerambault syndrome is important. We describe a 62-year-old woman with this disorder who developed a delusional conviction that a 65-year-old male physician was very much in love with her. She was treated by her family physician with perphenazine and psychotherapy. Her mental status improved and her delusion about the physician ceased.

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.

[Enuresis in children 5-18 years old in severe dysfunctional families]

In a primary care setting 698 children aged 5-18 years were examined and 27 in 21 families were found to have enuresis nocturna. The control group included 127 children in 79 families who did not have enuresis. 13 (48.1%) children with enuresis, but only 8 (6.3%) control children, were from severe dysfunctional families. Such families are characterized by chronic and persistent conflicts, absence of closeness and lack of trust between parents and children, and lack of parental support (p < 0.001). Results were similar for boys and girls. The rate of parents with 8 or fewer years of education was significantly higher among children with enuresis as compared to controls, both with regard to fathers (p = 0.05) and mothers (p < 0.01). These findings indicate that severe dysfunctional families do not support maturation and personality development of their members. Early discovery of severe dysfunctional families promotes early intervention and effective treatment of enuresis in childhood.

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.

[Use of stethoscope by mothers of asthmatic children ages 1-5]

The mothers of 24 asthmatic children aged 1-5 years, who visited a department of family medicine at the time of the attacks, were assigned alternately to 2 groups. The experimental study group got guidance and instruction in the use of the stethoscope, and also participated in a self-management educational program led by the family physician. The control group only got guidance and participated in the latter program. The purpose of the study was to determine whether mothers could assume more responsibility in decision-making with regard to their children's asthmatic attacks after basic technical guidance in the use of the stethoscope and in the interpretation of auscultatory findings. The results show that the initial steps in self-management were adequate in the 2 groups. These included recognition of the first signs of asthma in the child, a relaxed attitude (not to panic), the dispensing of suitable amounts of fluid, and the administration of bronchodilator medication without waiting for the physician's examination. Instructions to continue bronchodilator drugs, both oral and by inhaler, were more detailed in the experimental group. During the year of follow-up there were fewer visits to the clinic and the emergency room and no hospital admissions by those in the experimental group. The main conclusion of this study is that in conjunction with a self-management program, it is possible to teach mothers to use a stethoscope, to correctly interpret the auscultatory findings and accordingly, to give adequate treatment. This reduces clinic and emergency room visits and hospital admissions, relieves anxiety, and increases confidence in coping with this illness.

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.

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.

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.

[Evaluation of visits to an emergency department in rural population]

In an emergency department within a rural population far from a hospital, 1265 patients requested urgent medical care over a 3-year period; they were treated by the duty family physician, who carried out this study. Most patients were residents (insured by Kupat Holim) but a few were inland or foreign tourists. There were 647 males and 618 females, with 13% under the age of 1 year or over the age of 65; age did not affect the number of visits significantly. There were more visits on holidays, Fridays and Saturdays than on other days. There was a slight increase in the proportion of patients referred to hospital during the course of the 3-years, but only a few had to be transferred to hospital by ambulance accompanied by a physician. Most visits were not considered urgent. 32.3% of visits were considered unnecessary in the first year, 19.6% in the second and 21.1% in the third. All visits involving accidents, injuries, poisoning and violence, and almost all involving circulatory system diseases, were considered urgent and appropriate. This is the first attempt of its kind in this country to characterize visits to an emergency room distant from a hospital, and to evaluate their urgency and appropriateness.

[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.