Israel Medical Association Journal

Background: High sensitivity C-reactive protein, a marker of inflammation, has been proposed to stratify coronary artery disease risk and is lowered by HMG-CoA reductase (statin) therapy. However, the reproducibility of persistently elevated hs-CRP[1] levels and association with other markers of inflammation in patients with stable CAD[2] on aggressive statin therapy is unknown.

Objectives: To determine the reproducibility of hs-CRP levels measured within 2 weeks in patients with documented CAD with stable symptoms and to identify associations with other markers of inflammation.

Methods: Levels of hs-CRP were measured twice within 14 days (7 ± 4) in 23 patients (22 males and 1 female, average age 66 ± 10 years) with stable CAD and hs-CRP ≥ 2.0 mg/L but ≤ 10 mg/L at visit 1. All patients had received statins for cholesterol management (low density lipoprotein-cholesterol 84 ± 25 mg/dl) with no dose change for > 3 months. None had a history or evidence of malignancy, chronic infection or inflammation, or recent trauma. There was no change in medications between visits 1 and 2, and no patient reported a change in symptoms or general health during this interval. White blood cell count and pro- and anti-inflammatory cytokines were measured at both visits.

Results: hs-CRP levels tended to be lower at visit 2 (median 2.4 mg/L, range 0.8–11 mg/L) than at visit 1 (median 3.3 mg/L, range 2.0–9.7 mg/L; P = 0.1793). However, between the two visits hs-CRP levels decreased by more than 1.0 mg/L in 10 patients and increased by more than 1.0 mg/L in 4 patients. Changes in hs-CRP levels were unrelated to changes in levels of white blood cells (P = 0.4353). Of the cytokines tested, only the anti-inflammatory cytokine interleukin-1 receptor antagonist and the pro-inflammatory cytokine interleukin-8 were above lower limits of detection, but there were no correlations between changes in these values and changes in hs-CRP (both P > 0.5).

Conclusions: In stable CAD patients on aggressive statin therapy, hs-CRP levels may fluctuate over brief periods in the absence of changes in health, cardiac symptom status and medications, and without corroboration with other measures of inflammation. Accordingly, elevated hs-CRP levels should be interpreted with caution in this setting.

Preventive medicine is taking an increasingly central place in modern clinical practice, at least in primary care. What, if anything, does the Jewish rabbinic tradition have to say about keeping healthy? The delayed response of contemporary rabbis to the dangers of smoking, in particular, raises questions about the underlying principles that Halakhah* employs to approach health promotion. As is often the case in Halakhah, we may detect different streams of thought in the classical sources, which may be felt in the way contemporary issues are handled. Three approaches will be discussed. First, Maimonides, famous for the practical preventive approach in his medical writings, makes his philosophy clear both in his halakhic works and in his Guide for the Perplexed. For him, a healthy body is a prerequisite for a healthy soul. We must be free of physical suffering in order to be able to do the work of perfecting our souls. Second, the view that health is the reward for goodness and illness a punishment for sin as expounded or implied in the writings of Nahmanides, and of Ibn Ezra that the way to good health is to lead a good life. Third, an early midrashic** source picked up again much later by Rabbi Israel Meir Kagan (the Hafetz Hayim) gives the argument from custodianship – since the body is divine property we have a duty to look after it well. So for Maimonides there is a prior duty to keep healthy, while for Nahmanides the prior requirement is to repent of sin. For the Hafetz Hayim, keeping the body healthy is an independent duty in its own right. These then are the differences in basic approach that may affect the emphases that different rabbis today place on health maintenance and promotion.

Objectives: To assess the risk of microvascular complications associated with the metabolic syndrome in diabetes subjects.

Methods: The study group comprised 415 diabetic subjects attending a primary care clinic. The prevalence of microvascular complications was compared between 270 diabetic subjects with metabolic syndrome (NCEP-III criteria) and 145 diabetic patients without.

Results: We found that as a group, diabetic subjects with metabolic syndrome had significantly higher frequency of microvascular-related complications than diabetic subjects without the syndrome (46.6% and 26.8% respectively, P = 0.0005). These include microalbuminuria (41.5% vs. 23.9%, P = 0.013), neuropathy (10.4% vs. 7.5%, P = 0.38), retinopathy (9.6% vs. 4.1%, P = 0.046) and leg ulcers (7.9% vs. 2.8%, P = 0.044). After adjustment for age, gender, glycemic control, disease duration, lipid profile and blood pressure, metabolic syndrome was associated with a significantly higher risk of microvascular complications: odds ratio (95% confidence interval) for nephropathy 2.27 (1.53–3.34), neuropathy 1.77 (0.79–4.0), retinopathy 3.42 (1.2–9.87), and leg ulcers 3.57 (1.08–11.95).

Conclusions: In addition to hyperglycemia and disease duration, the metabolic syndrome is a significant risk factor for the development of microvascular complications in diabetic subjects.

Background: Cardiovascular disease is now well established as a multifactorial disease. In a given individual, the level of cardiovascular risk is due to the interaction between genetic and environmental components. The BIP cohort comprised 3000 patients with cardiovascular disease who were tested for the benefits of bezafibrate treatment. This cohort has the data for the lipid profile of each individual, fibrinogen, Insulin, as well as clinical, demographic and lifestyle parameters

Objectives: To genotype up to 64 variable sites in 36 genes in the BIP cohort. The genes tested in this assay are involved in pathways implicated in the development and progression of atherosclerotic plaques, lipid and homocystein metabolism, blood pressure regulation, thrombosis, rennin-angiotensin system, platelet aggregation, and leukocyte adhesion.

Methods:  DNA was extracted from 1000 Israeli patients from the BIP cohort. A multilocus assay, developed by the Roche Molecular System, was used for genotyping. Allele frequencies for some of the markers were compared to the published frequencies in a healthy population (the French Stanislas cohort, n=1480).

Results: Among the 26 comparable alleles checked in the two cohorts, 16 allele frequencies were significantly different from the healthy French population: ApoE (E3, E2, E4), ApoB (71ile), ApoC (3482T, 455C, 1100T, 3175G, 3206G), CETP (405val), ACE (Del), AGT (235thr), ELAM (128arg); p<0001 and LPL (93G, 291Ser, 447ter); p < 005.

Conclusions: Although a comparable healthy Israeli population study is needed for more precise interpretation of these results, frequency differences in these polymorphic alleles, associated with lipid metabolism, renin-angiotensin system and leukocyte adhesion mechanism, between CVD patients and healthy individuals nevertheless implicate these candidate genes as predisposing for CVD.lic safety.
 

Objective: To assess the prevalence of diabetes in an Arab community, the contribution of obesity to diabetes development, and the therapeutic potential of a preventive program.

Methods: Data were obtained from the medical files of diagnosed diabetes patients attending a primary care clinic in an Arab village in northern Israel.

Results: Type 2 diabetes was diagnosed in 323 patients of whom 63% were women. The prevalence of diabetes below age 65 years was significantly higher among women than men. Diabetic women were younger than men at diagnosis (48.27 vs. 59.52 respectively) and were found to have higher body mass index (34.35 vs. 30.04 respectively) at diagnosis. The age at diagnosis of diabetes was strongly correlated with BMI[1] (r = 0.97, P < 0.0001).

Conclusions: Women of Arab origin are at higher risk of developing type 2 diabetes compared to men. Obesity in women seems to be associated with higher diabetes risk as well as earlier appearance of the disease. Therefore, they will have the disease for longer and, consequently, a higher risk for complications.

Objectives: To assess the prevalence of metabolic syndrome and different glucose intolerance states in healthy, overweight Arab individuals attending a primary healthcare clinic in Israel.

Methods: We randomly recruited 95 subjects attending a primary healthcare clinic who were healthy, overweight (body mass index >27) and above the age of 40. Medical and family history was obtained and anthropometric parameters measured. Blood chemistry and oral glucose tolerance test were performed after overnight fasting.

Results: Twenty-seven percent of the subjects tested had undiagnosed type 2 diabetes according to WHO criteria, 42% had impaired fasting glucose and/or impaired glucose tolerance and only 31% had a normal OGTT[1]. Metabolic syndrome was found in 48% according to criteria of the U.S. National Cholesterol Education Program, with direct correlation of this condition with BMI[2] and insulin resistance calculated by homeostasis model assessment. Subjects with metabolic syndrome had a higher risk for abnormality in glucose metabolism, and the more metabolic syndrome components the subject had the higher was the risk for abnormal glucose metabolism. Metabolic syndrome predicted the result of OGTT with 0.67 sensitivity and 0.78 specificity. When combined with IFG[3], sensitivity was 0.83 and specificity 0.86 for predicting the OGTT result.

Conclusions: According to our initial evaluation approximately 70% of the overweight Arab population in Israel has either metabolic syndrome or abnormal glucose metabolism, indicating that they are at high risk to develop type 2 diabetes and cardiovascular morbidity and mortality. This population is likely to benefit from an intervention program.

_________________________

[1] OGTT = oral glucose tolerance test

[2] BMI = body mass index

[3] IFG = impaired fasting glucose
 

Background: Despite the controversy regarding the risks and benefits of hormone replacement therapy, studies in various countries indicate a two- to threefold increase in the use of HRT[1] during the last decade.

Objectives: To estimate the prevalence of HRT use among post-menopausal Jewish women in Israel and to determine the variables predicting current HRT use.

Methods: A cross-sectional telephone survey was conducted in 1998 on a random sample of Jewish women aged 45–74. Of 935 women who were located and eligible, 704 (75%) were interviewed by means of a structured questionnaire.

Results: A total of 589 women (85%) were peri-menopausal or post-menopausal.  Ninety-nine of them (16.8%) were currently using HRT and 78 (13.2%) were past users. Higher rates of current use were found among women who had undergone hysterectomy and/or oophorectomy (38%) than among all other women (13.5%).  Among naturally menopausal women the highest rate of current use (25.6%) was found in those aged 55–59.  A multiple logistic regression showed that the variables associated with current HRT use among naturally menopausal women  were: having a regular gynecologist (odds ratio 3.6, 95% confidence interval 1.7–7.5), visiting a gynecologist during the past year (OR[2] 2.9, 95% CI[3] 1.4–6.0), experiencing symptoms of menopause (OR 2.0, 95% CI 1.01–3.8), having more than a high-school education (OR 1.9, 95% CI 1.04–3.6), and a lower body mass index (OR 0.91, 95% CI 0.85–0.99).

Conclusions: The factors associated with HRT use may be markers for other socioeconomic or psychological characteristics. The disparities noted between population subgroups may be indicative of differences in awareness or in the delivery of preventive healthcare services to women in Israel, and as such need to be addressed by the health system.

___________________________

Background: The importance of health promotion and disease prevention in health policy and clinical practice is widely accepted in many countries. However, a large number of medical schools do not dedicate a significant part of their curriculum to these aspects. In Israel, there are no reports on the training of the future physician towards his or her role as health promoter in general, or in the areas of cardiovascular and cancer diseases specifically.

Objectives: To examine the preparation of Israel medical students for the role of health promoter in cancer and cardiovascular diseases.

Methods: The study was carried out over 2 years in two of the four medical schools in Israel: the Sackler Faculty of Medicine at Tel Aviv University and the Faculty of Health Sciences at Ben Gurion University in Beer Sheva. The students (n=172, 70% response rate) were surveyed during 1999-2000 by means of a questionnaire, which included assessment of their training towards the role of health promoter, their clinical experiences and exposure to patients at different stages of illnesses at various medical sites, and the specific skills and relevant knowledge they acquired.

Results: Most of the students’ learning experiences occurred in hospitals with patients at the treatment stage and little time was dedicated to prevention, especially in the community. They demonstrated better knowledge, skills and satisfaction with their learning experiences in CVD than in cancer; and reported having insufficient exposure to several common cancer diseases and lacking examining skills for early detection of cancer. The students in Beer Sheva had significantly more interaction with patients at different stages of CVD and acquired more examination skills than the Tel Aviv students.

Conclusions: A change in the curriculum is urgently needed: namely training medical students in community settings and preparing them to promote the well-being of their patients, including prevention. Attention should be given to launching new learning modes in the pre-clinical and clinical curriculum. We propose that: a) pre-clinical courses include prevention techniques in CVD and cancer, problems of cancer patients, and some examining skills; and b) the clinical phase should integrate oncology concepts and total cancer and CVD care into existing clerkships in the hospitals and in the community.
 

Background: A mass influx of immigrants from the former Soviet Union to western countries and Israel followed the demise of the Soviet Bloc at the beginning of the 1990s. It was expected that these immigrants would have a higher morbidity and mortality rate similar to that in Russia.

Objectives: To measure and compare self-reported diseases, subjective health and health services utilization of a representative sample of veteran Israeli Jews and immigrants from the former USSR.

Methods: A cross-sectional survey of Israeli adults was performed by telephone interviews. The survey included 793 Israeli Jews, of whom 124 were immigrants from the former USSR who arrived in Israel after 1989 (response rate 52%).

Results: The immigrants reported a higher rate of diseases and sub-optimal health after adjustment for other variables. However, no excess in health services utilization was reported. A time trend of reporting sub-optimal subjective health was observed: the longer the immigrants spent in Israel the more their reporting patterns resembled those of immigrants who arrived in Israel before 1970. Those who arrived after 1994 more frequently reported having a chronic disease.

Conclusions: Acculturation seems to have been the main effect on the immigrants' health, together with a healthy migrant effect at the beginning of the 1990s. The immigrants' health was worse in the later years of the immigration wave, partially reflecting the poor state of health in Russia compared to Israel.
 

Background: Which medical specialties do Israeli medical graduates choose? Answers to this question can serve as an essential means of evaluating both Israeli medical education and the healthcare system.

Objectives: To determine the distribution of medical specialty choice, its change over time and the posible influence of the medical school on the choice; to study the graduates’ gender, gender variability in specialty choice of family medicine as a career among the graduates as a group, by medical school, gender, and time trends.

Method: The study population comprised all graduates of the four medical schools in Israel during 16 years: 1980-1995 inclusive. Data were obtained from the four medical schools, the Israel Medical Association’s Scientific Council, and the Ministry of Health. Data allowed for correct identification of two-third of the graduates.

Results: A total of 4,578 physicians graduated during this period. There was a significant growth trend in the proportion of women graduates from 22.6% in 1980 (lowest: 20.0% un 1981) to 35.3 in 1995 (highest: 41.5% in 1991). Overall, 3,063 physicians (66.8%) started residency and 1,714 (37.4%) became specialists. The four most popular residencies were internal medicine. Ten percent of Israeli graduates choose family medicine.

Conclusions: The overall class size in Israel was stable at a time considerable population change. Women’s place in Israeli medicine is undergoing significant change. Family medicine is one of the four most popular residencies. Amonitoring system for MSC in Israel is imperative.
 

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.