Director:
Alan Rubinow, M.D.
Associate Professor of Medicine, Hirschfeld Chair in Allergy

Faculty:
Eldad Ben Chetrit, M.D. Professor of Medicine; Head, FMF Clinic Dror Mevorach, M.D., Senior Rheumatologist Suhil Aamar M.D., Fellow

The Rheumatology Unit at the Hadassah University Medical Center is an integral part of the Division of Internal Medicine. The Unit is very active in providing patient services on an out-patient and in-hospital basis, as well as being involved in academic activities such as teaching and research.

The unit is headed by Prof. Alan Rubinow, who received his rheumatology training in the Arthritis Division at Boston University Medical School. He is aided by a rheumatology fellow, residents in Internal Medicine (without sub-speciality training) and a specially trained registered nurse. The nurse has developed skills that enable her to interact independently with patients and provide them with the necessary support and assistance. These include education of patients and their families regarding the nature of the specific illnesses, medications, blood tests, activity of disease and complications. She counsels them regarding government and municipal resources for assistance in coping with their disabilities. In addition, she is the nurse/clinical coordinator of all clinical research studies.

In order to provide optimal clinical services, the Unit has access to an excellent, sophisticated clinical immunology laboratory that provides all the laboratory tests needed for evaluation and diagnosis of rheumatic disease.

The Unit's out-patient arthritis clinic meets five times a week and sees patients referred for consultation and treatment by community and hospital-based physicians from all over Israel. Approximately three thousand patients, representing a wide spectrum of rheumatic diseases, are seen annually.

Arthritis is the number one cause of crippling disease in the United States, where approximately 3 million people suffer from rheumatoid arthritis and over 16 million from osteoarthritis. Arthritis literally means inflammation of a joint. However, it is widely used to cover close to 100 different conditions that cause aching, pain and loss of function. Not all of these entities necessarily involve inflammation and the source of the illness may be in anatomic structures around the joint, e.g. muscle, tendon, bursa, etc. It may occur at all ages and almost everyone, if he lives long enough, will develop some form of arthritis. For many, fortunately, symptoms are mild and cause no problems. Incessant inflammation and cartilage degeneration causes pain, swelling and destruction, leading to disability.
The total impact of arthritis and its' related conditions is enormous. Individual pain and suffering takes its toll on society, and is beyond measurement. In addition to huge direct patient costs, e.g. hospitalization, drugs, physician and rehabilitation services, indirect costs are even greater. Loss of work, decreased productivity, lost wages and disability insurance payments place a great burden on the labor force and society, estimated in billions of dollars.
Unfortunately, reliable statistics of the prevalence of these diseases in Israel are not available, but initial impressions are that they are proportionately similar. Conservative estimates suggest that in Jerusalem and vicinity alone over 20,000 people suffer from arthritis and whose health care status could be markedly improved via the care of a trained rheumatologist. The paucity of rheumatological services in Jerusalem results in the sub-optimal care for patients who suffer the chronic pain and disability of rheumatic disease. There is an urgent need in Israel to develop programs and strategies to combat pain and suffering, restore individual self-esteem and counteract the economic and social impact of rheumatic disease.

Consultation
The Unit provides in-hospital consultation services for patients with rheumatic diseases. The Unit has strong affiliation in Hadassah with the departments of medicine, pediatrics, orthopedics, neurology and rehabilitation medicine. In Ein Kerem and Mount Scopus, internal medicine day-care facilities have been established. The Unit is an important source of patients who are referred to these facilities for evaluation and treatment.

Teaching
The Rheumatology Unit is actively engaged in teaching at the undergraduate and postgraduate levels. A number of rheumatologists from other medical centers and the community are active in education. Formal instruction in the form of courses, lectures, seminars and bedside teaching are given on a regular basis to medical students. The course in rheumatology, given to fourth-year students as part of an introduction to clinical medicine, is consistently ranked highest by the students. The Unit also provides teaching to students in the sixth (final) year, as well as to the Nursing School, Pharmacy School, new immigrants and residents in training (internal medicine or family medicine). The Unit is committed to informing patients, their families, and the general community about the rheumatic diseases and their impact on individuals and society. Through Inbar (an Israeli self-help patients' group) lectures and informal sessions are held regularly.

Physician Training
In 1985 the Scientific Council of the Israel Medical Association officially recognized the Rheumatology Clinic for residents in Internal Medicine who wish to spend an elective period in rheumatology. This rotation has proved to be very popular and has attracted residents from Hadassah and other centers in Jerusalem. .In some cases this exposure has made a major impact on career choice. Residents who have spent a number of months learning about rheumatic disease have chosen to specialize in Rheumatology. In this regard Dr. Rubinow has been instrumental in motivating the physicians and helping them obtain prestigious fellowship positions in the United States. Unfortunately, due to financial restraints the Unit has been unable to reabsorb them on their return to Israel.
In 1991, the Rheumatology Unit was recognized by the Scientific Council of the Israel Medical Association for fellowship training of physicians wishing to become Rheumatologists and the first fellow was accepted for training in May of that year. The presence of a fellow has greatly enhanced the spectrum of patients seen, and the exposure of many more physicians and students to arthritis. Furthermore, the number of patients seen in the clinic has grown accordingly. Regrettably, funds are not available for accepting new trainees, despite numerous applications from very bright young physicians. The continuation of a fellowship program is crucial if the services, teaching and research goals of the Rheumatology Unit are to be maintained or upgraded.

Research
The Rheumatology Unit is strongly committed to research and is involved in a number of ongoing basic science and clinical projects in collaboration with other investigators. Research projects presently in progress: Prof. Alan Rubinow, M.D. - Head, Rheumatology Unit. Prof. Rubinow is a Board Member of the Osteoarthritis Research Society International (OARSI).

1. Osteoarthritis

1. Epidemiology and risk factors
2. Clinical studies with potential structure modifying agents
3. Tetracyclines and chrondocyte cytokine production
4. Ethical issues that relate to chronic disabling arthritis in the elderly; Allocation of health care resources and discrimination based on age. ]

2. Fibromyalgia

1. Clinical characterization
2. Behavioural research
3. Clinical drug trials

3. Rheumatoid Arthritis

1. Clinical drug trials with Etanercept (TNF alpha receptor) with and without concomittant methotrexate.
2. Efficacy of Leflunamide in refractory RA.

The Future
It is the ultimate aim of the Unit to develop an arthritis center at the Hadassah Medical Center. The overall goal of this center will be to decrease the physical, economic and psychosocial impart of arthritis and related musculoskeletal disease on individuals and communities. To achieve this major objective, a variety of educational, epidemiological, biomedical research, and community services research projects as they relate to arthritis will be developed. For each of these components, individual objectives will be defined so that a combination of carefully designed projects will create an active, vibrant and productive center.

Education Objective
To develop education programs in arthritis so as to improve the quality of arthritis education for the broad variety of health professionals, e.g. physicians, nurses, physiotherapists, occupational therapists, etc. who interact with arthritic patients. Talented physicians training in internal medicine need to be motivated to study rheumatic disease and positions made available for fellowship training created through appropriate funding. Our center needs to play a greater role in community education via radio, cable television, internet, etc. Specific projects will include the preparation, in Hebrew, of pamphlets and resource materials for health professionals and the lay public.

Epidemiological Component
To define the scope of rheumatic disease and to determine the impact of arthritis-related disability on Israel society in general and the labor force in particular. Specific projects would include the study of incidence, prevalence, and social impact of different rheumatic illnesses among various cohorts of Israeli society. In addition, evaluation of the effect of total arthritis management on such factors as work, school, social interaction, etc. will be undertaken. The reliability and validity of available instruments, such as the Arthritis Impact Measurement Scales (AIMS) Health Assessment Questionnaire (HAQ) will be tested within the social and cultural environments of Israel. If unreliable, new instruments for evaluating health care delivery in this area will need development.

Biomedical Research Objective
To maintain a productive program of basic and clinical research into the causes and treatments of various forms of arthritis. The numerous research projects discussed above need to be expanded, consolidated and coordinated into a comprehensive research endeavor aimed at achieving the overall goal. A well-equipped research laboratory is essential and staff including laboratory technicians and a career scientist will be recruited. Projects discussed above and others, will be planned and implemented as manpower is trained, interest is created and funds become available. Clinical research projects will be administered by a full-time clinical coordinator whose job will be to procure patients, administer questionnaires, carry out evaluations and verify patient compliance with study protocol.

Community Program Objective
To develop and maintain a comprehensive system of arthritis care for the urban population of Jerusalem and surrounding rural areas. To develop programs that emphasize the elderly and home-bound members of the community. To develop programs for children suffering from rheumatic disease and their immediate families. These would include interaction with health practitioners, teachers and social workers. To conduct health services research efforts into major non-biological aspects of rheumatic disease. An arthritis center without a strong community commitment would be unable to meet the overall objective stated above.

FUNDING

Financial support for the activities of the Rheumatology Unit from sources in Israel has been sparse due to the local economic climate. In the past the procurement of contributions has allowed us to maintain our activities at an acceptable standard, but we have not been able to break out into new exciting areas. It is our goal to establish a clinical and research arthritis center at Hadassah, which will cater to the needs of all people seeking help in this area of medicine. We welcome the support of a single benefactor through whose generosity we will be able to establish the Center, or many donors each contributing to the program that best fits their desire.

Training of Rheumatologists
We wish to establish a clinical fellowship in Rheumatology for the training of young physicians. The program, recognized for subspeciality training by the scientific committee of the Israel Medical Association, will expose the fellow to a wide spectrum of clinical problems as they relate to Rheumatology, as well as clinical research. Many very bright physicians have expressed an interest in this area and undoubtedly this fellowship will attract the best. We wish to establish a stipend for this program at an annual cost of $40,000. Support form donor(s) will be appropriately acknowledged in publications and research reports.

Clinical Coordinator
We wish to establish a position for an individual whose role would be to supervise clinical research projects within the unit. The job description would entail administration of projects, procurement of patients, evaluation and patients' compliance verification. The unit is about to embark on a number of exciting clinical studies and a central study coordinator is essential. The expected annual salary for this position would be $20,000.

Arthritis Nurse
We wish to establish a position for a nurse practitioner in Rheumatology. The chronic nature of many rheumatic diseases and related disability requires intense education and support for afflicted individuals and their families. A nurse trained in the clinical and rehabilitative aspects of arthritis, knowledgeable in the medications taken by patients as well as their adverse affects, and informed about disability compensation issues will prove a much-needed service for the unit. Although such a person already functions in the unit, we wish to guarantee her salary. The expected annual cost of salary would be $20,000.

Career Scientist
We wish to establish a position for a career post-doctoral basic scientist in Rheumatology. With the allotment of laboratory space for the Unit, there will be a need for a Ph.D. investigator in either collagen/matrix biochemistry or immunolgy. The job description would entail supervision of all basic research studies, hiring appropriate technical staff, grant application requests and teaching. The individual would be expected to be an independent investigator and pursue his/her individual research interests. The expected annual salary would be $50,000.

Library
An active academic Rheumatology Unit that provides training and teaching for physicians, nurses, students and basic science investigators needs readily available sources in the form of books and journals. It is intended that the library subscribe to current rheumatology journals and be able to purchase a number of books in the field of rheumatology. The expected annual cost of this service is $4,000. Support from the donor will be appropriately acknowledged.

Annual Lectureship
We wish to establish an annual lectureship in rheumatology at the Hadassah Medical Center. It is intended that an internationally renowned physician in the field of rheumatology be invited to Jerusalem for a period of 5-7 days. He/she will deliver a lecture in his/her field of expertise. The event would attract rheumatologists and physicians in related fields from all over Israel and over time be regarded as most prestigious by local and international scientists. This lectureship will be named after the benefactor or any person(s) he/she wishes to honor. The expected annual cost of the lectureship would be $7,500-$10,000.

Endowment Fund
In view of the limited funds from sources in Israel, circumstances make it mandatory to secure the necessary funding for the programs of the Unit. Such security could be attained by the establishment of an endowment fund and allow us to focus on our research activities over the long term. Interest generated from the endowment would provide the financial means by which we may achieve our many goals.
We wish to establish an endowment fund of $1,000,000. The income of approximately $50,000-$70,000 annually will be budgeted for the research programs. Support from donors will be appropriately acknowledged in the Rheumatology Unit and in research reports and publications.