The State of Pediatric Rheumatology in Israel

Yosef Uziel MD, MSc¹ and Philip J Hashkes MD, MSc²

Affliations:

1. Sapir Medical Center, Pediatric Rheumatology, Kfar Saba, Israel, Sackler School of Medicine, Tel Aviv University

2. Cleveland Clinic Foundation, Section of Pediatric Rheumatology, Cleveland, USA

Contact:

Yosef Uziel MD, MSc

Sapir Medical Center, Kfar Saba, Israel

Sackler School of Medicine, Tel Aviv University

Tel 972 9 7472975

Fax 972 9 7471303

uziely@zahav.net.il

Introduction

Among the various subspecialties in pediatrics, pediatric rheumatology is gaining a leading role in international collaboration. In the present manuscript we strive to present an overview of the clinical, research, and educational programs of pediatric rheumatology in Israel. Presenting this comparable information from Israel and various other countries and regions should help improve our understanding of pediatric rheumatic diseases, promote effective communication, and foster collaboration amongst pediatric rheumatologists worldwide.

General Overview

Similar to other subspecialties in pediatrics, pediatric rheumatology is developing recognition and importance in Israel. Although in the past, 1980 to the present, adult rheumatologists or general pediatricians treated most Israeli children with rheumatic diseases, trained pediatric rheumatologists currently treat almost all patients.

Pediatric rheumatology services exist in 11 hospitals throughout the country from Safed in Northern Israel to Beer-Sheba in the Negev desert, and are administered by 11 pediatric rheumatologists (two physicians serve in two hospitals). There is a team of two pediatric rheumatologists in 2 hospitals (Schneider Children’s Hospital, Petah Tikva, Sheeba medical center, Ramat-Gan). Allied health professionals, including physical and occupational therapists, are part of the rheumatology team only in some centers, while in other centers these services are available only in outside community facilities. (Table 1 and PRINTO website http://www.printo.it/pediatric-rheumatology).

Rehabilitation centers with units dedicated to children are placed in the major cities throughout the country. While their main work is in neurological morbidities, they acquire experience in rheumatic conditions as well.

Patients are typically referred from primary pediatricians or family practitioners or through hospital consultations [1]. New patients are referred until the age of 18 years, while existing patients with chronic conditions may continue to be seen past that age, until transition to the care of an adult rheumatologist.

Currently the population of Israel is 6.7 million people, about one-third in the pediatric age group. Therefore, Israel has the highest density of pediatric rheumatologists per pediatric population in the world (1 per approximately 200,000 children). The pediatric rheumatology training of physicians was performed in USA- 4 physicians, Toronto, Canada – 3, and one physician trained in England. Two physicians were trained primarily in immunology/allergy with rotations in rheumatology (one in USA, and one in Israel). One is a practicing pediatric rheumatologist by long term clinical experience and some training by adult rheumatologists in Israel. All but one physician has a part-time position in pediatric rheumatology, filling the rest of his or her time with general pediatrics duties in pediatric wards, ambulatory day units or administration (department chiefs).

Most subspecialties in Israel, including pediatric rheumatology, exist in both tertiary care hospitals and in smaller community hospitals. This differs from the situation in most parts of the world, where pediatric rheumatology services exist primarily in tertiary university affiliated hospitals. This fact explains the part time position dedicated to pediatric rheumatology.

Since pediatric rheumatology clinics are available throughout the country, the service is relatively accessible to patients. Waiting times for clinic appointments is usually short, and urgent patients are seen in less than one week. Each citizen in Israel has basic health insurance in 1 out of 4 supplying health insurance companies, which cover all needs, according to the "health basket", which defines appropriate and approved treatments for various diseases. Biologic therapy (anti TNF) is included in the health basket only for juvenile arthritis patients who failed DMARD.

Currently, our subspecialty is not formally recognized as a separate specialty by the Israel Medical Association Academic Section. We are in the process of seeking recognition. A syllabus has been submitted, suggesting combining fellowships between 2-3 hospitals on a regional basis, in order to increase exposure to patients and different mentors.

Patient Population

Most of the data on patient demographics and disease frequencies was derived from the National Registry Project (see below). The patients seen in Israel are of diverse ethnicity; Jewish (Ashkenazi, Sephardic North African, Middle East origin), Arabs (Muslims and Christians), Druze, Jewish Ethiopians and others (including foreign workers). Only about 40% of the patients have classic rheumatic diseases, similar to other publications from around the world. Hashkes published his experience from the Northern Israel, which may represent the experience of other centers [1]. Besides common rheumatic diseases, Israel has a large population of patients with recurrent fever syndromes mainly familial Mediterranean fever (FMF) (450 children in the Israeli registry), or periodic fever, aphthous-stomatitis, pharyngitis and adenitis (PFAPA) (more than 100 in registry). Several centers perform diagnostic genetic studies for FMF at reasonable prices. These are usually paid by the patient, and not by the health insurance, since this service is not part of the official “health basket”. Since patients with FMF are also seen by general pediatricians and gastroenterologists, many patients are not included in our registry. A more complete FMF registry exists in Sheeba Medical Center, Tel-Hashomer.

For classic rheumatic diseases we have registered about 600 patients with juvenile idiopathic arthritis (JIA), of whom 105 have systemic JIA, 350 have oligoarticular disease, 90 with seronegative polyarticular disease, and 16 with seropositive polyarticular JIA. More than 100 patients with SLE have been registered, as well as 30 with JDMS, 30 with localized scleroderma and four with systemic sclerosis. 250 cases of rheumatic fever have been registered, but the actual number is probably higher since many patients are treated by general pediatricians, and are not included in the database. The frequency of these diseases appears to be evenly distributed among the various ethnic groups in Israel. A detailed registry of patients can be found (ref 2, and at www.moshe-r.net/pedrheumdemo).

National Registry Project

Philip Hashkes initiated a project of establishing an internet-based registry of all pediatric rheumatology cases. The registry is active since March 2001, and all pediatric rheumatologists actively register new patients by a simple method via the web. The data is automatically analyzed and updated for each pediatric rheumatologist’s practice and for a national statistics databse [2]. The project is currently coordinated by Judith Barash.

As of April 2004, approximately 3850 patients have been registered. The data bank is designed to be used as a national resource for the Israeli pediatric rheumatology community. We hope to be able to calculate the prevalence of common chronic pediatric rheumatic diseases in Israel. The database also serves us as a source for multicenter studies on a national level, and as a basis for future services needed for pediatric rheumatology.

Academic and Teaching Activities

All pediatric rheumatologists in Israel have academic appointments and are affiliated with medical schools in one of four universities (Hebrew University – Jerusalem, Sackler School of Medicine – Tel Aviv University, Technion School of Technology– Haifa, Ben Gurion University – Beer Sheba). All participate actively in teaching residents and medical students according to a validated syllabus in each university. Currently, two have appointments at the level of associate professors (equivalent to a full professor in North America), four as senior lecturers (equivalent to an associate professor), and four as lecturers (equivalent to assistant professor). One does not have an academic appointment.

Academic positions in Israel are granted by the universities and are based mainly on research, and by evaluating publication quality and quantity. For example, in order to be nominated as a senior lecturer (equivalent to associate professor) one needs to publish at least 25 original articles (case reports and reviews are not counted), with extra consideration given to articles published in prestigious journals. Furthermore, the candidate for promotion must be first, second or senior author in at least half of the papers. Other considerations of academic performance include participation in teaching of medical students and residents.

We have 3-4 meetings per year of the pediatric rheumatology community to discuss research projects, difficult patients, and administrative issues. Living in a small country, we do not utilize telemedicine among our pediatric rheumatologists, but will participate occasionally in international telemedicine consults.

The relationships and collaboration with the adult rheumatology community is excellent. We have a formal pediatric section within the Israeli Society of Rheumatology (ISR), which includes about 100 rheumatologists, and have a member on the ISR board (Masza Mukamel). We actively participate in their academic activities: intercity rounds of case presentations, research days, international meetings in Israel, and the annual ISR meeting [3]. Travel funds to participate in EULAR or ACR are given by the ISR to one or two of the pediatric rheumatologists each year.

We also are active in the Israeli Pediatric Association (IPA) and present our research and clinical activities to local and national meetings affiliated with the IPA. We also participate in continuing medical education for pediatricians and family practitioners, organized by two medical schools (Sackler School of Medicine, Tel Aviv University, and Hanegev University Beer Sheba). This pediatric rheumatology syllabus is presented every 4 years. Another program from Sackler involving pediatric rheumatologists is a satellite telemedicine course which is broadcast to community hospitals and continuing medical education classes. The program is interactive and pediatric rheumatologists and participating physicians can communicate directly.

Research Cooperation – The Pediatric Rheumatology Study Group of Israel*

Since we are a small country, we decided to establish the PRSGI in order to perform multi-center projects in our field. We have published several studies including: a series of 37 cases with pediatric SLE [4], a series of 30 pediatric patients with Behçet’s disease [5], a study on the seasonal onset of systemic onset juvenile arthritis [6], and two studies on the use of naproxen to treat rheumatic fever, one retrospective [7], and the other a randomized prospective trial [8]. Members of our group have performed studies on the clinical presentation of FMF, its treatment and genotype-phenotype correlation [9, 10].

Several research projects utilizing the registry data have been initiated. A study was started comparing the clinical manifestations, laboratory findings, treatment and outcomes of known pediatric SLE cases (about 100 cases in the database) to the national cohort of adults with SLE. This study will be performed in collaboration with the adult SLE registry of Israel. This new registry was developed by six major hospitals in Israel, with pediatric patients serving as the seventh center.

Other studies have been initiated to describe the outcome and etiology of patients with recurrent transient hip synovitis, to describe the clinical and laboratory findings and outcomes of children with primary antiphospholipid antibody syndrome, and to describe the thyroid autoantibody profile in patients with JIA.

* The Pediatric Rheumatology Study Group of Israel

Barash J, Berkon Y, Brik R, Harel L, Hecht Y, Mukamel M, Navon P, Padeh S,

Press J, Tauber T, Uziel Y

International Cooperation

Since 1997, we are members in PRINTO and participate in its projects. The national coordinator is Yosef Uziel. Hebrew versions of the CHAQ and CHQ questionnaires were developed and validated in order to participate in international outcome studies and clinical trials [11]. The Israeli contribution is significant relative to the small size of the country. In the recent SLE and JDMS outcome measure study, we contributed 20 SLE patients and 4 JDM patients. Several centers have also participated in industry initiated multinational drug studies.

Summary and future directions

As a small country, we have many pediatric rheumatologists active in clinical care, education and clinical research. We aim to give the optimal therapy to children with rheumatic conditions, and enhance cooperative research projects on a national level, and international level via PRINTO. With the advantage of a small united group, we hope to be more active in future clinical studies. We are part of the globalization of pediatric rheumatology, and have excellent clinical and scientific relations with colleagues throughout the world.

We hope for peace in our area, which hopefully will enable us to collaborate with our Middle East colleagues for the sake of the health of all children in the Middle East.

References

1. Hashkes PJ. Profile of a pediatric rheumatology practice in Israel. Clin Exp Rheumatol 2003; 21:123-8.

2. Hashkes PJ, Uziel Y, Rubenstein M, Navon P, Padeh S, Mukamel M, Brik R, Press J, Tauber T, Harel L, Berkon Y, Barash J, An internet-based pediatric rheumatology registry: A novel concept of multicenter data collection-The Israeli experience. Ped Rheum Online J 2004; 2:37-50.

3. Perez S, Hashkes PJ,Uziel Y. The impact factor of the annual scientific meetings of the Israel rheumatology society as measured by publication rates of the abstracts in peer-reviewed journals. Harefuah 2004;143:

4. Brik R, Padeh S, Mukamel M, Navon P, Uziel Y, Kornmehl P, Tauber Z, Barash Y.

Systemic lupus erythematosus in children in Israel, Harefuah 1995;129:233-5.

5. Uziel Y, Brik R, Padeh S, Barash J, Mukamel M, Harel L, Press J, Tauber Z, Rakover Y, Wolach B, Juvenile Behçet’s disease in Israel, Clin Exp Rheumatol 1998;16:502-5.

6. Uziel Y, Pomeranz A, Brik R, Navon P, Mukamel M, Press J, Barash J, Tauber Z, Harel L, Virgilis D, Bibi H, Haldenberg D, Wolach B. Seasonal variation in systemic onset juvenile rheumatoid arthritis in Israel. J Rheumatol 1999;26:1187-9.

7. Uziel Y, Hashkes P, Kassem I, Padeh S, Goldman R, Wolach B. The use of Naproxen in the treatment of children with rheumatic fever. J Pediatr 2000;137:269-71.

8. Hashkes PJ, Tauber T, Somekh E, Brik R, Barash J, Mukamel M, Harel L, Lorber A, Berkovitch M, Uziel Y. Naproxen as an alternative to aspirin for the treatment of the arthritis of rheumatic fever: a randomized trial, J Pediatr 2003;143:399-401.

9. Padeh S, Shinar Y, Pras E, Zemer D, Langevitz P, Pras M, Livneh A. Clinical and diagnostic value of genetic testing in 216 Israeli children with Familial Mediterranean fever. J Rheumatol. 2003;30:185-90.

10. Gershoni-Baruch R, Shinawi M, Shamaly H, Katsinetz L, Brik R. Familial Mediterranean fever: the segregation of four different mutations in 13 individuals from one inbred family: genotype-phenotype correlation and intrafamilial variability. Am J Med Genet. 2002;109:198-201.

11. Hashkes P, Uziel Y, Press J, Brik R, Navon Elkan P, Mukamel M, Libman E, Tauber T, Ruperto N, Barash J. The Hebrew version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ), Clin Exp Rheumatol 2001;19 (Supp.23): S86-90.

Table 1 – A map of pediatric rheumatology service in Israel

Place/Hospital Name Physicians Allied health team

Safed (Sieff) 1 -

Afula (Haemek) 1 -

Haifa(Rambam) 1 +

Haifa(Carmel) 1 -

Kfar -Saba (Meir) 1 +

Petach Tikva (Schneider) 2 +

Ramat Gan (Sheeba) 2 +

Zerifin (Assaf Harofeh) 1 +

Rehovot (Kaplan) 1 +

Jerusalem (Shaarei- Tzedek) 1 +

Beer- Sheba (Soroka) 1 +