Israel Medical Association Journal

Background: Human dignity has a pivotal role within the health care system. There is little experience using simulation-based medical education (SBME) programs that focus on human dignity issues in doctor-patient relationships.

Objectives: To describe and assess a SBME program aimed at improving physicians’ competence in a dignifying approach when encountering adolescents and their parents.

Methods: A total of 97 physicians participated in 8 one-day SMBE workshops that included 7 scenarios of typical adolescent health care dilemmas. These issues could be resolved if the physician used an appropriate dignifying approach toward the patient and the parents. Debriefing discussions were based on video recordings of the scenarios. The effect of the workshops on participants’ approach to adolescent health care was assessed by a feedback questionnaire and on 5-point Likert score questionnaires administered before the workshop and 3 months after. 

Results: All participants completed both the pre-workshop and the feedback questionnaires and 41 (42%) completed the post-workshop questionnaire 3 months later. Practice and competence topics received significantly higher scores in post-workshop questionnaires (P < 0.001). A score of high to very high was given by 90% of physicians to the contribution of the workshop to participants understanding the dignifying approach, and by 70% to its influence on their communicative skills.

Conclusions: A one-day simulation-based workshop may improve physicians’ communication skills and sense of competence in addressing adolescents’ health care issues which require a dignifying approach toward both the adolescent patients and their parents. This dignity-focused methodology may be expanded to improve communication skills of physicians from various disciplines. 

 

Background: One of the most alarming ocular injury trends in recent years has been the proliferation of paintball guns and the proportional increase in the number of ocular eye injuries caused by paintballs.

Objectives: To describe five cases of paintball eye injuries that resulted in loss of functional vision in four of them.

Methods: We conducted a retrospective interventional case series of the clinical course of five patients with paintball eye injuries treated in the ophthalmology departments of two medical centers. 

Results: Five young males were evaluated for paintball injuries caused by blunt trauma. There was one case of full-thickness laceration (globe rupture). Four patients required one to five surgical interventions: three of these involved the removal of traumatic cataract including two eyes with significant zonular dehiscence treated by lens capsule conservation using anchoring devices, one retinal surgery and two glaucoma filtration surgeries. However, final visual outcome was not favorable due to irreversible retinal damage.

Conclusions: Paintball trauma often results in significant ocular injury and loss of functional vision despite successful surgical interventions. Most injuries are easily preventable and occur in under-supervised settings. Improved safety measures, strict regulation enforcement and appropriate public education could prevent such serious damage.

 

Background: Selection of appropriate reference charts for fetal biometry is mandatory to ensure an accurate diagnosis. Most hospitals and clinics in Israel use growth curves from the United States. Charts developed in different populations do not perform well in the Israeli population.

Objectives: To construct new reference charts for fetal biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL), using a large sample of fetuses examined at 14–42 weeks gestational age in a medical center and a community ultrasound unit located in two different regions of Israel. 

Methods: Data from the medical center and the community clinic were pooled. The mean and standard error of each measure for each week was calculated. Based on these, reference charts were calculated using quantiles of the normal distribution. The performance of the reference charts was assessed by comparing the new values to empirical quantiles.

Results: Biometric measurements were obtained for 79,328 fetuses. Growth charts were established based on these measurements. The overall performance of the curves was very good, with only a few exceptions among the higher quantiles in the third trimester in the medical center subsample.

Conclusions: We present new local reference charts for fetal biometry, derived from a large and minimally selected Israeli population. We suggest using these new charts in routine daily obstetric practice.

 

Background: Evidence suggests that prolonged bisphosphonate (BP) treatment predisposes to atypical fractures (AF), but the etiology has yet to be determined. Addressing causality begins with case identification, which requires radiological adjudication. However, many trials based their case findings on coded diagnoses. 

Objectives: To investigate the feasibility of case findings by the coding system and the reproducibility of radiological evaluations in two hospitals in Israel, and to compare BP exposure of AF patients to a control group with typical (intertrochanteric of femoral neck) fractures. 

Methods: Diagnostic databases from 2007–2010 were reviewed and admission X-rays of patients were examined in two steps by two radiologists. Fractures were classified as atypical or not atypical according to published criteria. A 2:1 control group was created. Ambulatory drug acquisition was reviewed. 

Results: Of the 198 patients who fulfilled the search criteria, 38 were classified by initial radiological opinion as AF. Subsequent radiological opinion judged 16 as not atypical. Of the AF patients, 80% were exposed to BP. Of those, 81% continued to receive BP treatment for 2.4 years after AF. Only one AF patient was discharged with suspected AF diagnosis. In the control group, 27% were exposed to BP prior to fracture (P < 0.001). 

Conclusions: Thorough radiological revision is mandatory for proper classification of AF, and even when performed there is significant inconsistency in interpretation. Conclusions drawn from trials based solely on coded diagnoses lead to significant bias. BP exposure was significantly higher in the AF group. Caregiver unawareness of AF leads to improper management. 

 

Background: Atypical presentation of tuberculosis (TB) during pregnancy may cause diagnostic delay and adversely influence pregnancy outcome. 

Objectives: To examine the incidence and clinical and epidemiological features of TB during pregnancy and investigate infection control measures at delivery and during the postpartum period.

Methods: We retrospectively evaluated all reported cases of TB diagnosed during pregnancy to 6 months postpartum in Israel’s Northern Health District (2002–2012). 

Results: Active TB was detected in six patients; all were negative for human immunodeficiency virus (HIV). Two patients were diagnosed in the postpartum period, and four had pulmonary involvement. The average incidence during this period (3.9 per 100,000 pregnancies) was similar to that in the general population. Five patients were at high risk of contracting TB due to either recent immigration from a high-burden country or being in contact with another individual with active TB. Patients with pleuropulmonary involvement had prolonged cough and abnormal chest X-rays, without fever. Diagnosis was delayed for 3 to 7 months from symptom onset. Investigation of the newborn to rule out intrauterine infection was conducted in only one of four relevant cases. All patients were infected with organisms susceptible to all first-line drugs, and all were cured with standard therapy.

Conclusions: There was a considerable delay in the diagnosis of TB among pregnant women, and investigation of the newborn upon delivery to rule out TB infection was routinely omitted. Effective management of TB during pregnancy and the postpartum period requires a multidisciplinary approach including an obstetrician, pediatrician, TB specialist, and public health physician.

 

Background: The activated NLRP3 inflammasome is associated with the etiology of fibrotic diseases. The role of inflammasomes in SSc is still poorly understood.

Objectives: To determine the expression of NLRP3 (nucleotide-binding domain, leucine-rich-repeat-containing family, pyrin domain-containing 3) in the skin of patients with systemic sclerosis (SSc) and its relationship with pro-inflammatory cytokines and vascular mediators expression.

Methods: Skin biopsies were taken from 42 patients with either limited or diffuse SSc (21 lcSSc and 21 dcSSc), and from 13 healthy individuals. Using real-time polymerase chain reaction (PCR), the relative expression of caspase-1, IL-1β, IL-18, IL-33, TGF-β, ET-1, iNOS and eNOS genes, were measured. The location of NLRP3 and IL-1β were also determined by immunohistochemistry. Clinical characteristics were evaluated.

Results: The mean age of the patients was 49.3 ± 12.9 (lcSSc), 44.6 ±1 3.8 (dcSSc), and 45 ± 14.1 (healthy individuals). Compared to healthy individuals, the skin of both subtypes of SSc showed a significant increase (P < 0.05) in NLRP3, caspase-1, IL-1β, IL-18 and ET-1. Samples of lcSSc also showed a significant increase of eNOS (P < 0.029), iNOS (P < 0.04) and TGF-β (P < 0.05). Dermal fibrosis evaluated by modified Rodnan skin score (MRSS) had significant correlation with NLRP3, IL-1β, IL-18, and ET-1. Immunohistochemical analysis showed stronger staining of NLRP3 and IL-1β cytoplasmic expression in the keratinizing squamous epithelium of skin from SSc patients compared to controls.

Conclusions: This study identified NLRP3 over-expression in skin of patients with SSc. Skin thickness correlates positively with the NLRP3 inflammasome gene expression and with the vascular mediator and pro-fibrotic ET-1, suggesting that NLRP3 inflammasome plays a role in the pathophysiology of skin fibrosis in human SSc.