Physician-Patient Communication Course: When the Inauguration of a New Israeli Medical School Coincided with COVID-19 Pandemic.

Purpose: The curriculum of the Adelson School of Medicine at Ariel University, the newly established sixth medical school in Israel, includes a simulation center-based extended course on physician-patient communication, aiming to help students master the core competency of interpersonal and communication skills. For more than a year following the emergence of the COVID-19 pandemic, the school suspended most face-to-face (F2F) encounters, transforming most teaching activities to remote platforms. The paper outlines the ways we adapted teaching of this course to these circumstances, the reactions of students and mentors to the changes and results of 1st year students' survey. Methods: During the lockdown in the first year 48 of 70 first-year students participated in a voluntary anonymous online evaluation of the course assessing motivation to become a physician; perceptions, feelings and attitudes towards the communication course, and advantages and disadvantages of online and F2F medical interviews. Results: 46.1% of the responding students reported that the pandemic strengthened their desire to become physicians. 56.3% claimed that they were able to a relatively large extent to empathize with COVID-19 patients who were exposed to the virus; 79.1% viewed their mentors as positive role models of communication skills. The students were able to receive and offer social support to their peers. They evaluated very highly the short instructional videos produced by the faculty. Conclusion: During the lockdown, the respondents generally indicated positive attitudes towards the communication course, the mentors and the inclusion of physician-patient communication as a topic in medical education. The students and mentors reported many disadvantages and few advantages of remote learning. Yet inevitably remote learning including online-based simulations is a step towards preparations for future practice within virtual medical care and telemedicine. The limitations of this study include the cross-sectional design, small sample size and self-reporting.

Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial.

OBJECTIVES: To test the hypothesis that individualized nutritional treatment during and after discharge from acute hospitalization will reduce mortality and improve nutritional outcomes. DESIGN: Randomized, controlled trial. SETTING: Internal medicine departments. PARTICIPANTS: Two hundred fifty-nine hospitalized adults aged 65 and older at nutritional risk were recruited and randomized according to hospitalization ward into one intervention and two control groups during hospitalization. INTERVENTION: Group 1 (intervention group) received individualized nutritional treatment from a dietitian in the hospital and three home visits after discharge. Group 2 received one meeting with a dietitian in the hospital. Group 3 received standard care. Groups 2 and 3 were combined into a single group that served as the control group in the analysis. MEASUREMENTS: Mortality, health status, nutritional outcomes, blood tests, cognition, emotional, and functional parameters were assessed at baseline and after 6 months. All participants were contacted monthly. RESULTS: The overall dropout rate was 25.8%. After 6 months, rise in Mini Nutritional Assessment score, adjusted for education and hospitalization ward, was significantly higher in the intervention group than in the control groups (3.01 ± 2.65 vs 1.81 ± 2.97, P =.004) mainly on the subjective assessment part (0.34 ± 0.86 vs. -0.04 ± 0.87, P=.004). The only laboratory parameter for which a difference was observed between the groups was albumin; 9.7% of the intervention group had serum albumin levels of less than 3.5 g/dL, versus 22.9% of the control group (P =.03). Mortality was significantly lower in the intervention group (3.8%) than in the control group (11.6%, P =.046). CONCLUSION: Lower mortality and moderate improvement in nutritional status were found in patients receiving individualized nutritional treatment during and after acute hospitalization.

Examination of a modified version of the Psychological Medical Inventory among medical students.

BACKGROUND: The Psychological Medical Inventory (PMI) assesses the level of interest, confidence, and perceived clinical abilities in addressing psychological aspects of patient care. The scale has been used solely among physicians and other healthcare professionals. AIMS: To examine the psychometric properties and factor structure of a modified student version (PMI-S) of the PMI among medical students. METHOD: Sixty eight freshmen medical students completed a self-reporting questionnaire that included the PMI-S scale and a measure of perceived overall communication abilities. RESULTS: Consistent with the original scale, the factor analysis yielded a two-factor solution-psychological abilities and psychological sensitivity. The modified scale also demonstrated a high percentage of explained variance. Additionally, positive correlations were found between students' ratings of their perceived psychological abilities, psychological sensitivity, total scale score, and overall communication abilities. CONCLUSIONS: The results support the factor structure of the original scale. The PMI-S scale might be incorporated in the evaluation of the effectiveness of psycho-educational programs and interventions aimed at improving the psychosocial abilities of students of medicine and health professions. Further examination of the scale with a larger sample size is needed.

Characteristics of undernourished older medical patients and the identification of predictors for undernutrition status.

BACKGROUND: Undernutrition among older people is a continuing source of concern, particularly among acutely hospitalized patients. The purpose of the current study is to compare malnourished elderly patients with those at nutritional risk and identify factors contributing to the variability between the groups. METHODS: The study was carried out at the Soroka University Medical Center in the south of Israel. From September 2003 through December 2004, all patients 65 years-of-age or older admitted to any of the internal medicine departments, were screened within 72 hours of admission to determine nutritional status using the short version of the Mini Nutritional Assessment (MNA-SF). Patients at nutritional risk were entered the study and were divided into malnourished or 'at risk' based on the full version of the MNA. Data regarding medical, nutritional, functional, and emotional status were obtained by trained interviewers. RESULTS: Two hundred fifty-nine elderly patients, 43.6% men, participated in the study; 18.5% were identified as malnourished and 81.5% were at risk for malnutrition according to the MNA. The malnourished group was less educated, had a higher depression score and lower cognitive and physical functioning. Higher prevalence of chewing problems, nausea, and vomiting was detected among malnourished patients. There was no difference between the groups in health status indicators except for subjective health evaluation which was poorer among the malnourished group. Lower dietary score indicating lower intake of vegetables fruits and fluid, poor appetite and difficulties in eating distinguished between malnourished and at-risk populations with the highest sensitivity and specificity as compare with the anthropometric, global, and self-assessment of nutritional status parts of the MNA. In a multivariate analysis, lower cognitive function, education <12 years and chewing problems were all risk factors for malnutrition. CONCLUSION: Our study indicates that low food consumption as well as poor appetite and chewing problems are associated with the development of malnutrition. Given the critical importance of nutritional status in the hospitalized elderly, further intervention trials are required to determine the best intervention strategies to overcome these problems.

Naso- and oropharyngeal potential respiratory pathogens in adults with nonpneumonic lower respiratory tract infection.

The objective of this prospective study was to determine positive isolation rates for potential respiratory pathogens (PRPs) in the naso- and oropharynx of adults hospitalized for nonpneumonic lower respiratory tract infection (NPLRTI), compared with patients with community-acquired pneumonia (CAP) and healthy controls. The study population was 315 non-chronic obstructive pulmonary disease adults hospitalized with febrile lower respiratory tract infection (158 NPLRTI and 157 CAP) and 450 control subjects. Each participant was sampled by oropharyngeal swab, nasopharyngeal swab, and nasopharyngeal washings that were tested by conventional bacteriologic methods to identify PRP. At least 1 of the samples was positive for at least 1 of the 3 PRP bacteria in 55 NPLRTI patients (35%) compared with 51 CAP patients (33%) (NS) and 100 controls (22%) (P = 0.003 compared with NPLRTI and P = 0.02 compared with CAP). Samples were positive for Streptococcus pneumoniae in 14 NPLRTI patients (9%) compared with 29 CAP patients (19%) (P = 0.02) and 16 controls (4%) (NPLRTI P = 0.015, CAP P < 0.0001). The corresponding rates for Haemophilus influenzae were 23 (15%), 16 (10%), and 60 (13%) (NS for all 3 comparisons), and for Moraxella catarrhalis, 28 (18%), 25 (16%), and 48 (11%), respectively (NPLRTI versus controls, P = 0.03, NS other comparisons). We conclude that the rate of positive naso/oropharyngeal isolates for at least 1 of the 3 PRP bacteria in NPLRTI patients is similar to the corresponding rates for CAP patients and is higher in both groups than in controls.

Gender differences in factors associated with nutritional status of older medical patients.

OBJECTIVES: To evaluate gender differences in nutritional risk of older people admitted to an acute-care general medical department, and identify gender-specific risk factors. DESIGN: Cross-sectional study. SETTING: Internal Medicine Department in an acute care, university-affiliated hospital in southern Israel. SUBJECTS: 204 cognitively intact patients aged 65 and over, admitted during a 12-month period to a general medical department. MEASURES OF OUTCOME: Evaluation included demographic and clinical data consisting of the sum of medical conditions and of prescribed medications, evaluation of nutritional status, cognitive status, depression assessment and functional ability. Statistical analyses were conducted to evaluate the gender specific risk factors for under-nutrition. RESULTS: 32.5% of the men and 48.1% of the women admitted to an internal medicine department were at risk for under-nutrition. Those at nutritional risk had a higher rate of depression, lower cognitive and physical ability, poorer reported health status and more diagnosed diseases. Nutritional risk for men was associated with higher depression score, longer hospitalization, and poor appetite. For women, nutritional risk was associated with lower functional status and more diagnosed diseases. In a multivariate analysis, being a female increased the risk of under-nutrition by 3.3 fold. CONCLUSION: Risk of under-nutrition is prevalent among older in-patients and is gender-related. Female inpatients are at markedly increased risk for under-nutrition. The mechanism of the gender discrepancy in factors related to nutritional deterioration is complex and poorly understood.

Nasopharyngeal versus oropharyngeal sampling for isolation of potential respiratory pathogens in adults.

The optimal methodology for the identification of colonization by potential respiratory pathogens (PRP) in adults is not well established. The objectives of the present study were to compare the sensitivities of sampling the nasopharynx and the oropharynx for identification of PRP colonization and to compare the sensitivities of samples from the nasopharynx by swab and by washing for the same purpose. The study included 500 participants with a mean age of 65.1 +/- 17.8 years. Of these, 300 patients were hospitalized for acute febrile lower respiratory tract infection and 200 were controls. Each participant was sampled by oropharyngeal swab (OPS), nasopharyngeal swab (NPS), and nasopharyngeal washing (NPW). The samples were tested by conventional bacteriological methods to identify Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. OPS detected colonization by S. pneumoniae in 30% of the subjects compared with 89% by NPS and NPW (P < 0.000001). The corresponding rates for H. influenzae were 49% and 64%, respectively (no significant difference [NS]), and for M. catarrhalis were 72% and 46%, respectively (P < 0.0004). NPS identified 61% of the cases of colonization with S. pneumoniae, compared with 76% by NPW (NS). The corresponding rates for H. influenzae were 31% and 56%, respectively (P < 0.04), and for M. catarrhalis were 39% and 33%, respectively (NS). We conclude that the sensitivities of nasopharyngeal and oropharyngeal sampling for identification of PRP colonization in adults are different for each of the three bacteria in this category. The combined results of sampling from both sites are necessary to obtain a true picture of the rate of colonization. NPW is superior to NPS.

Marked secular increase in the incidence rates of osteoporotic hip fractures in women and men in southern Israel.

BACKGROUND: For the last 35 years, our medical center has been the only referral center and provider of emergency medical services for a well-defined geographic area in southern Israel. OBJECTIVES: To evaluate trends in the incidence of hip fractures in this population. METHODS: The study was based on two surveys done approximately 20 years apart. It included women and men 50 years and older with radiographic evidence of a new hip fracture caused by low impact trauma. Only fractures that resulted from low or moderate trauma were considered for the current study. Incidence rates were calculated based on population data obtained from the official Central Bureau of Statistics. RESULTS: There was an overall twofold increase in the incidence rate of hip fractures. However, this increase occurred almost exclusively in the over-75 year old age groups (2.5-fold increase, both in women and men). The mean (and median) age of patients with hip fractures increased significantly over the study period, corresponding to the increase in longevity between the two periods. CONCLUSIONS: There was a marked secular increase in the incidence of proximal hip fractures in both genders, primarily because of an increase in the fracture rate in the very old. The increase in median age of fracture patients suggests that the observed increase in fracture rate can be attributed mainly to aging of the population rather than to deterioration in bone quality over the generations.

Hypovitaminosis D among inpatients in a sunny country.

BACKGROUND: Hypovitaminosis D is an important risk factor for osteoporosis and its complications. Previous studies found that the incidence of hypovitaminosis D among patients in an internal medicine ward reached up to 57%. OBJECTIVE: To determine the prevalence and determinants of hypovitaminosis D among patients in internal medicine wards in a sunny country. METHODS: We measured 25-hydroxyvitamin D, parathyroid hormone and various other laboratory parameters, and assessed the amount of sun exposure, dietary vitamin D intake and other risk factors for hypovitaminosis D in 296 internal medicine inpatients admitted consecutively to the Soroka University Medical Center, which is situated in a sunny region of Israel. RESULTS: We found hypovitaminosis D (serum 25-HO-D < 15 ng/ml) in 77 inpatients (26.27%). The amount of sunlight exposure, serum albumin concentration, being housebound or resident of a nursing home, vitamin D intake, ethnic group, cerebrovascular accident and glucocorticoid therapy were all significantly associated with hypovitaminosis D. Multivariate analysis showed a significant association between hypovitaminosis D and Bedouin origin, sun exposure, vitamin D intake, and stroke. Hypovitaminosis D was also found among inpatients who reported consuming more than the recommended daily amount of vitamin D. Parathyroid hormone levels were significantly higher in patients with 25-OH-D levels below 15 ng/ml. In a subgroup of 74 inpatients under 65 years old with no known risk factors for hypovitaminosis D, we found 20.3% with hypovitaminosis D. CONCLUSIONS: Hypovitaminosis D is common in patients hospitalized in internal medicine wards in our region, including patients with no known risk factors for this condition. Based on our findings, we recommend vitamin D supplementation during hospitalization and upon discharge from general internal medicine wards as a primary or secondary preventive measure.

[Incidence of osteoporotic fractures in southern Israel].

BACKGROUND: Very little is known about the epidemiology of osteoporotic fractures in Israel. AIM: We aimed to provide an estimate on the incidence of low-impact fractures in southern Israel. METHODS: The study included women and men 50 years and older with radiographic evidence of a new fracture. We screened and reviewed all the emergency room and hospital charts to identify all patients with low impact fractures who attended the Soroka Hospital during the corresponding months of January and February of 1998 through 2001. RESULTS: There were a total of 580 fracture patients (461 women and 119 men). The estimated incidence of all low-impact fractures in the entire population aged 50 and older was 1064:100,000 (95% C.I. 981: 1153) per year. The estimated incidence of low-impact fractures in women was three fold higher than in men [1526:100,000 (95% C.I. 1390: 1675) vs. 490/100,000 (95% C.I. 408: 580) per year, respectively]. Fractures of the distal forearm and proximal hip (26% each) were, by far, the most common in women, followed by fractures of the humerus (18%), ankle (12%) and pelvis (5%). In men, proximal hip fractures (39%) were the most common, followed by fractures of the humerus (18%), distal forearm (15%) and ankle (14%). Multiple concurrent fractures occurred in 2.5% of the patients. CONCLUSIONS: Our data provides a preliminary estimate of the incidence of osteoporotic fractures, not including most vertebral collapse fractures, among women and men in southern Israel. Further studies are warranted to characterize fracture risk in other regions of the country and population sub-groups.

Clinical and epidemiologic investigation of two Legionella-Rickettsia co-infections.

BACKGROUND: We treated two patients diagnosed with legionellosis and simultaneous Rickettsia conorii co-infection. OBJECTIVES: To report the clinical and laboratory characteristics of this unusual combination, and to describe the execution and results of our environmental and epidemiologic investigations. METHODS: Serial serologic testing was conducted 1, 4 and 7 weeks after initial presentation. Water samples from the patients' residence were cultured for Legionella. Follow-up cultures were taken from identical points at 2 weeks and at 3 months after the initial survey. RESULTS: Both patients initially expressed a non-specific rise in anti-Legionella immunoglobulin M titers to multiple serotypes. By week 4 a definite pattern of specifically elevated IgG titers became apparent, with patient 1 demonstrating a rise in specific anti-L. pneumophila 12 IgG titer and patient 2 an identical response to L. jordanis. At 4 weeks both patients were positive for both IgM and IgG anti-R. conorii antibodies at a titer > or = 1:100. Heavy growth of Legionella was found in water sampled from the shower heads in the rooms of both patients. Indirect immunofluorescence of water cultures was positive for L. pneumophila 12 and for L. jordanis. CONCLUSIONS: Although most cases of community-acquired Legionella pneumonia in our region appear simultaneously with at least one other causative agent, co-infection with R. conorii is unusual and has not been reported to date. This report illustrates the importance of cooperation between clinicians and public health practitioners.

Impact of subsidizing effective anti-osteoporosis drugs on compliance with management guidelines in patients following low-impact fractures.

Early in 2000, proven-effective antiresorptive drugs (alendronate and raloxifene) were included in the national "health basket" in Israel. We carried out the present study to evaluate the effect of subsidizing antiosteoporosis drugs on the use of antiosteoporosis drugs in patients following low-impact fractures. The rates of dispensation of antiosteoporosis drugs, in the hospital and in the community, before and after an incident of a newly diagnosed low-impact fracture, respectively, were evaluated during January and February 1998 and 1999 ("pre-basket") and the corresponding months of 2000 and 2001 ("post-basket"). The study was carried out in a 950-bed teaching hospital, the only one serving the area, and the largest health maintenance organization in the area. Hospital charts of women and men age 50 years and older with new fractures following low- or moderate-impact trauma treated in the emergency room, or admitted to the orthopedic surgery and rehabilitation departments, were reviewed. A centralized pharmacy computerized database was used to follow antiosteoporosis drug dispensation in the community. A significant, approximately two-fold, increase in the baseline (before fracture) rate of osteoporosis drug dispensation was observed between the pre- and post-basket periods. The rate of patients treated after a fracture incident also increased significantly, 1.6 fold, in the post-basket period; however, even in the post-basket period, two-thirds of the patients remained untreated following a fracture incident, and most of those treated received only calcium and vitamin D; only 17% received potent antiosteoporosis drugs. In a multivariate analysis, female gender, hospitalization, having the incident of fracture in the post-basket period, and above all being treated for osteoporosis before the fracture incident, had the greatest effect on the likelihood of being treated following a low-impact fracture incident. The increase in the pooled use of antiosteoporosis drugs and/or calcium/vitamin D supplements was continuous, and subsidizing created no step-up effect, besides a transient increase in the use of potent antiosteoporosis drugs in the first year following the health-basket amendment. We conclude that while subsidizing may have a significant, positive effect on antiosteoporosis drug utilization, other factors may be even more important. There is an ongoing need to find ways to encourage the use of effective pharmacological interventions for primary and secondary prevention of osteoporotic fractures.