Israel Medical Association Journal

Background: Most of the published documents proposing teaching objectives for undergraduate clerkships were prepared by expert bodies. Seldom have the clinical teachers, who are critical to the learning process and to the implementationof the  teaching objectives, been the actual proponents of its core content.

Objective: To develop a national-scale proposal of teaching, objectives for the family medicine clerckship in medical school, using a consensus method and the actual, community-based teachers as the expert body.

Method: The Delphi method was chosen for that purpose. In the first round all 189 family medicine teachers in Israeli medical schools were asked to propose five teaching objectives. In the second round the objectives, which were generatedin the first round, were characterized by key words and were send to the participants as a second round for ranking according to their importance.

Results: A total of 116 family medicine teachers (61.38%) responded in the first round and 91 of the 116 (78.5%) in the second round. They formulated 51 teaching objectives listed in order of importance, covering a wide array of themes and including knowledge, attitude and skills objectives. The most important objectives were common problems in primary care, recognition of the biopsychosocial model, and understanding the importance of the doctor-patient relationship. The structure of the list provides a uniqe insight into the relative importance of each objective in the context of the whole core content of the clerkship.

Conclusions: Constructing a proposal for teaching objectives is feasible using the Delphi method and the field instructors as the selecting body. The process and its results can provide faculty with relevant and important suggestions on the content and structure of the family medicine clerkship.
 

Background: Familial Mediterranean fever is a genetic disease in which some characteristic gene mutation have been found.

Objective: To analyze the phenotype-genotype correlations in North African Jews and Armedians with FMF.

Methods: We studied MEFV gene mutations and phenotype-genotype correlations in North African Jews and Armedians with Familial Mediterranean Fever living in France.

Results: M694V mutation was the most common mutation in Jews and in Armenians. Patients with M6801 homozygosity or M6801/M694V compound heterozygosity had a phenotype as severe as patients with M694V homozygosity.

Conclusions: This study characterizes the phenotype-genotype in specific ethnic groups of patients with FMF.

Background: Musculoskeletal complaints represent the second most common reason for visits to a physician, second only to the common cold. The limited capability of medical treatment for musculoskeletal disease requires modification of communication with patients by attending to their perception of the disease.

Objectives: To assess patients’ satisfaction with care provided by their primary physicians, and the relationship of patients' satisfaction to their expectations of that care, perceptions of physician performance, and perceived severity of musculoskeletal disease.

Methods: Questionnaires were administered to 90 community-dwelling elderly patients (mean age 76+-8 years) presenting for follow-up appointments with their primary care physicians. Patients were asked to report on their satisfaction with the medical care provided by the primary physicians for musculoskeletal symptoms, their expectations of that care, their perceptions of their primary physicians' interaction (regarding competence, performance, and communication), and their perceptions of disease severity (based on the number of areas involved, pain frequency and intensity, and impact on daily activity). The effects on the degree of satisfaction were assessed with regard to demographic variables, co-morbidity, site involved, and response to recommended treatment.

Results: Most patients (> 85%) expressed overall satisfaction with their doctor's interpersonal skills. Fewer (76.9%) were satisfied with the amount of effort their doctors spend evaluating their musculoskeletal symptoms, the information received regarding their musculoskeletal symptoms (75%), the degree of pain relief (75%), and the degree of functional improvement (61.8%). Level of education and response to recommended treatment for musculoskeletal disease were the only parameters associated with degree of satisfaction (higher education P = 0.005, lower education P = 0.059, medication P = 0.008, rehabilitation P = 0.076). A high level of expectations (regarding physician's care and musculoskeletal disease treatment) was noted.

Conclusions: The high level of patient satisfaction with their primary physicians' care for musculoskeletal symptoms may reflect the overall tendency of the elderly population to be satisfied with its primary care physicians. However, their high level of expectations (related to perceived efficacy of medical treatment) and their unrealistic perceptions of disease may lead to disappointment and non-compliance with their doctor's recommendations. Management of musculoskeletal disease in the elderly should address the patients’ disease perceptions, as well as their therapeutic and functional needs.
 

Background: A beneficial effect was observed in patients with psoriasis vulgaris following balneotherapy with Dead Sea bath salt.

Objectives: To evaluate the possible role of trace elements in the effectiveness of balneotherapy. 

Methods: Serum levels of 11 trace elements were analyzed in 23 patients with psoriasis vulgaris who participated in a double-blind controlled study of balneotherapy, with either Dead Sea bath salt (12 patients) or common salt (11 patients). Thirteen healthy volunteers served as controls.

Results: The mean pre-treatment serum levels of boron, cadmium, lithium and rubidium were significantly lower in patients compared to controls, whereas the mean pre-treatment serum level of manganese was significantly higher in patients compared to controls. Balneotherapy with Dead Sea bath salt resulted in a significant decrease (P = 0.0051) in the mean serum level of manganese from 0.10 ± 0.05 mmol/L to 0.05 ± 0.02 mmol/L. The mean reduction in the serum level of manganese differed significantly (P = 0.002) between responders (% Psoriasis Area and Severity Index score reduction ³ 25) and non-responders (% PASI score reduction < 25). Following balneotherapy with Dead Sea bath salt the mean serum level of lithium decreased in responders by 0.01 ± 0.02 mmol/L whereas its level in non-responders increased by 0.03 ± 0.03 mmol/L. (P = 0.015).
Conclusions: Manganese and lithium may play a role in the effectiveness of balneotherapy with Dead Sea bath salt for psoriasis.

Background: Leiomyoma is the common benign tumor of the female genital tract. The traditional treatment is hysterectomy, myomectomy or medical therapy by hormonal manipulation. Uterine arterial embolization, a recognized treatment for acute pelvic hemorrhage, has recently been applied to the management of non-acute uterine hemorrhage due to leiomyoma.

Objective: To describe our experience with uterine arterial embolization for the management of uterine fibroid.

Methods: Uterine arterial embolization was performed in nine patients with leiomyomas in whom medical therapy failed and who sought to avoid surgery.

Results: Follow-up ultrasound examination after 2 months revealed an average reduction in fibroid volume of 38%. There were no early or long-term complications.

Cunclusions: Uterine arterial embolization appears to be effective and safe in the management of symptomatic leiomyomas. It is a promising alternative to myomectomy or hysterectomy and warrants further investigation in this setting.
 

Fibromyalgia syndrome is a chronic, painful musculoske­letal disorder of unknown etiology and/or pathophysiology. During the last decade many studies have suggested autonomic nervous system involvement in this syndrome, although contradictory results have been reported. This review focuses on studies of the autonomic nervous system in fibromyalgia syndrome and related disorders, such as chronic fatigue syndrome and irritable bowel syndrome on the one hand and anxiety disorder on the other, and highlights techniques of dynamic assessment of heart rate variability, It raises the potentially important prognostic implications of protracted autonomic dysfunction in patient populations with fibromyalgia and related disorders, especially for cardiovas­cular morbidity and mortality.

Background: Fixed dose combination therapy varies among countries.

Objective: To compare the list of fixed-dose combination therapies used in the USA, UK and Israel.

Methods: The total list of drugs and FDC drugs were counted manually from a list of generic names. We also counted the number of drugs in four characteristic subgroups:

cardiovascular, anti-infective, gastrointestinal, and dermatolo­gical. Data for drugs in the USA, UK and Israel were taken from the Physician’s Desk Reference (PDR 1997), the British National Formulary (BNF March 1997) and the Monthly Ethical Drug Indexed Compilation (MEDIC July 1997) respectively.

Results: The global percentage of FDC drugs in the USA and UK was higher than in Israel (20%, 25% and 15% respectively). A similar trend was found in all subclasses of FDC drugs except for the anti-infective category in which the percentage of FDC drugs was low and similar in all countries.

Conclusion: The list of FDC drugs varies greatly between the USA, UK and Israel. reflecting the differences in the outcome of debate between the pharmaceutical companies and the regulatory authorities.

Background: When encountering complaints of pain in the area of the Achilles tendon, the clinician seldom reaches a correct and precise diagnosis based solely on the grounds of physical examination and standard X-rays.

Objectives: To assess the usefulness of ultrasound in diagnosing pathologies of the Achilles tendon.

Methods: We conducted a retrospective review of patients presenting at our orthopedic clinics.

Results: Sonography was used to evaluate 41 patients with achillodynia. This modality enabled the diagnoses of 19 abnormal tendons (46%), peritendinous and other lesions a complete rupture in two patients (5%) a partial rupture of the Achilles tendon in 3 (7%) various degrees of calcification of the tendon in 7 (17%) and peritendinous lesions discerned by the tendon’s hypoechoic regions with disorganized arrange­ment of collagen fibrils in 4 patients (10%). Other lesions included tendonitis (3 patients, 7%), retrocalcaneal bursitis (3 patients, 7%), lipoma (1 patient, 2%), and foreign bodies (2 patients, 5%). The mean diameter of the pathological tendons was 10.4 +2.7 mm, while normal tendons measured 5.2 +0.8 mm (P<0.001).

Conclusion: As in many other soft tissue lesions, ultrasonography is a useful tool in the evaluation of the underlying pathology in patients presenting with achillodynia.