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עמוד בית
Mon, 22.07.24

January 2001

Zvi Stern, MD

The Management of a 750-bed tertiary care university hospital that serves the Jerusalem area and nationwide referrals initiated a total overhaul of all its supporting systems. This program, with parallel contingency plans, ensured a smooth transition of all computer-depended and othe services into the year 2000. Because this extraordinary project proved successful, its outcomes are noe being utilized as a unique impetus for implementation of hospital-wide continuous quality improvement programs. This paper reports how the established QI procedures, which were introduced also during the campaign, are now being activated from the baseline of those outcomes that have provided absolute efficacy in all hospital activities. The success of the campaign was achieved through the total involvement of all staff. This involvement was enhanced by the popular appeal of the dramatic deadline of the date 2000, as well as by focusing attention on personnel dynamics. Strategies for sustaining the momentum must be considered.

Original Articles
Gabriel Szendro MD FRCS, Luis Golcman MD, Alex Klimov MD, Charach Yefim MD, Batsheva Johnatan RVT, Elizabeth Avrahami RVT, Batsheva Yechieli RVT and Shemuel Yurfest MD

Background: Both diagnostic and therapeutic options in the management of iatrogenic false aneurysms have changed dramatically in the last decade, with surgery being required only rarely.

Objective: To describe our experience, techniques and results in treating pseudoaneurysms at a large medical center with frequent arterial interventions. We emphasize upper limb lesions.

Materials and Methods: We reviewed the data of all consecutive patients diagnosed by color-coded duplex Doppler between August 1992 and July 1998 as having upper limb and lower limb pseudoaneurysms (mainly post- catheterization). We accumulated 107 false aneurysms (mainly post- catheterization lesions): 5 were upper limb lesions and 102 were groin aneurysms.

Results: In the lower limb cases 94 of the 102 lesions were not operated upon (92.1%). Seventy lower limb cases were treated non-operatively by ultrasound-guided compression obliteration with a 95.7% success rate (67 cases). Two cases were treated by  percutaneous thrombin injection (2%) and 23 by observation only (22.5%). Altogether 12 patients underwent surgery (11.2%): 4 upper extremity and 8 lower extremity cases. None of the lower limb group suffered serious complications regardless of treatment, but all five upper limb cases did, four of them necessitating surgical intervention. Three of the five upper limb cases had a grave outcome with severe or permanent or neurological damage.

Conclusion: Most post- catheterization pseudoaneurysms can be managed non-surgically. False aneurysms in the upper extremity are rare, comprising less than 2% of all lesions. However, upper extremity pseudoaneurysms present a potentially more serious complication and require early diagnosis and prompt intervention to minimize the high complication rate and serious long-term sequelae. Prevention can be achieved by proper puncture technique and site selection, and correct post-procedure hemostatic compression with or without an external device. Some upper limb lesions are avoidable if the axillary artery is not punctured.

Pnina Langevitz MD, Avi Livneh MD, Lily Neumann PhD, Dan Buskila MD, Joshua Shemer MD, David Amolsky MD and Mordechi Pras MD

Background: Familial Mediterranean fever is a genetic disorder manifested by recurrent attacks of peritonitis, pleuritis and arthritis, and characterized by clinical, histological and laboratory evidence for localized and systemic inflammation. Colchicine treatment usually prevents the attacks and the associated inflammation. Inflammation of atherosclerosis and ischemic heart disease.

Objective: To study the effect of inflammation and its prevention on occurrence of IHD, using FMF as a model.

Methods and Patients: We studied the presence of IHD and its risk factors in 290 FMF patients aged 40 years or more, and in two control groups – 233 spouses of the FMF patients’ and 126 patients with inflammatory diseases obtained from other outpatient clinics. FMF patients were also compared with age and gender-matched individuals from the population reference data of the Israel Ministry of Health.

Results: The prevalence of IHD in FMF patients was significantly lower than in the group of controls from other outpatient clinics (15.5% vs. 30.2% P< 0.05) and comparable with their spouses (11.2%) and with the matched general population in Israel (16%).

Conclusion: These findings suggest that despite the evidence of recurrent inflammation, colchicines-treated FMF patients are not more predisposed to IHD than the normal population.

Yuksel Cavusoglu, MD, Bulent Gorenek, MD, Seref Alpsoy, MD, Ahmet Unalir, MD, Necmi Ata, MD and Bilgin Timuralp, MD

Background: inflammation is an important feature of atherosclerotic lesions and increased production of the actuephase reactant. The contribution of coagulation factor to the development of coronary artery disease has not yet been clearly established.

Objective: To test whether C-reactive protein, fibrinogen and antithrombin-III are associated with angiograpic CAD, history of myocardial infarction and extensive atherosclerotic involvement.

Methods: Blood samples were tested for CRP, fibrinogen and AT-III levels from 219 individuals undergoing coronary angiography.

Results: CRP was higher in patients with CAD (0.95 + 1.31, n=180, vs. 0.39 + 0.61 mg/dl, n=39, P<0.0001) and in those with a history of MI (1.07 + 1.64, n=96, vs. 0.65 + 0.72 mg/dl, n=84, P<0.05) than in control subjects. The patients who developed unstable angina had higher CRP levels than the patients with stable CAD (2.07 + 2/38, n=7, vs. 0.80 + 1.13 mg/dl, n=173, P<0.001).

Fibrinogen was significantly higher in patients with CAD (298 + 108 vs. 258 + 63 mg/dl, P<0.01). In patients with CAD, mean AT-III value was less than in patients without CAD, but this difference was found in CRP, fibrinogen and AT-III values among the patients with single, double or triple vessel disease.

Conclusion: CRP is elevated in patients with CAD and a history of MI. Elevated levels of CRP at the time of hospital admission is a predictive value for future ischemic events.

There is an association between higher levels of fibrinogen and CAD. The association of AT-III levels with CAD needs testing in further studies.

Matityahu Lifshitz MD, Vladimir Gavrilov MD, Aharon Galil MD and Daniella Landau MD

Background: Narcotic abuse has steadily become more prevalent in Israel and may result in an increasing number of children exposed prenatally to narcotics, with a consequent increase in the number of infants born with neonatal abstinence syndrome.

Objective: To report our experience with infants born to narcotic-addicted women between the years 1995 and 1998 at the Soroka University Medical Center.

Methods: The medical records of 24 newborns and their drug-addicted mothers admitted to our Medical Center for parturition were analyzed retrospectively. A diagnosis of NAS was established on the basis of the clinical presentation and anamnesis. The Finnegan Neonatal Abstinence Scoring System was used to assess drug withdrawal. Urine toxicological analysis for narcotics was done only for year 1998.

Results: Of the 24 newborn infants exposed prenatally to narcotics 23 (96%) developed NAS, and 78% (18 of the 23) had a Finnegan score of 8 or more. These 18 infants were treated pharmacologically (tincture of opium and/or Phenobarbital) until the score was reduced to less than 8, after which they received supportive treatment. In one child who became lethargic after the first dose of tincture of opium, the medication was stopped and supportive treatment alone was given. Four of the five neonates with scores of 7 and less were given supportive treatment. One of five infants who had a low Finnegan score at birth nevertheless received pharmacological therapy to prevent further deterioration of his physical state since he was born with severe dyspnea. Ten of the 24 children (42%) were followed for lengths of time ranging from 6 to 22 months after discharge, all of whom showed normal development.

Conclusion: About three-quarters of newborns exhibiting withdrawal syndrome required pharmacological therapy. Previous information on maternal drug abuse is a crucial criterion for early detection and treatment.

Ervin Stern MD, Carlos A. Benbassat MD, Avishai Nahshoni MD and Ilana Blum MD

Background: Diabetes mellitus is a serious, costly and growing public health problem. Very few studies have been published on the economic impact of diabetes in Israel.

Objective: To estimate health fund expenditures and rates of hospitalization for general conditions among the diabetic population in Israel.

Methods: The total number of hospitalization. All hospitals in Israel were included.

Results: There were 618,317 general admissions for a total of 3,005,288 hospitalization days. Analysis by age revealed that diabetic patients over age 45 represented 18.3% of all admissions and 17.5% of all hospitalization days. The average stay in hospital expenditure of the GSF for general medical conditions among diabetic patients in 1998 was estimated at US $173,455,790, of which 57% accounted for the daily hospitalization cost. Of the total hospital expenditures for that year, 13.3% was allocated to patients with diabetes of whom 96.4% were over 45 years old.

No significant difference was found between males and females.

Conclusion: Hospital expenditures for diabetic people increase with patient age and represent one-fifth of the total health insurance expenditure for the middle-aged and elderly population.

Ofer Nativ MD, Edmond Sabo MD, Ralph Madeb MSc, Sarel Halachmi MD, Shahar Madjar MD and Boaz Moskovitz MD

Objective: To evaluate the feasibility of using combined clinical and histomorphometric features to construct a prognostic score for the individual patient with localized renal cell carcinoma.

Patients and Methods: We studied 39 patients with pT1 and pT2 RCC who underwent radical nephrectomy between 1974 and 1983. Univariate and multivariate analyses were used to determine the association between various prognostic features and patient survival.

Results: The most important and independent predictors of survival were tumor angiogenesis (P=0.009), nuclear DNA ploidy (P=0.0071), mean nuclear area (P=0.013), and mean elongation factor (P=0.0346). Combination of these variables enabled prediction of outcome for the individual patient at a sensitivity and specificity of 78% and 89% respectively.

Conclusion: Our results indicate that no single parameter can accurately predict the outcome for patients with localized RCC. Combination of neovascularity, DNA content and morphometric shape descriptors enabled a more precise stratification of the patients into different risk categories.

Hani S. Shakhatreh MD

Background: Proximal femur fractures represent a challenging medical problem worldwide. In recent years numerous reports have documented. a progressive increase in the incidence of hip fractures. In Jordan, this problem has not received sufficient attention, and to my knowledge, this is the first study to address the problem.

Objective: To analyze the predisposing factors involved in the occurrence of proximal femur fractures seen at a major medical center in Jordan.

Methods: A retrospective analysis was conducts of all patient admitted with hip fractures to King Hussein Hospital and the Royal Jordanian Rehabilitation Center at the King Hussein Medical Center over a 2 year period (1 January 1995 to 31 December 1996). We determined the associated chronic diseases and medications, mechanisms of injury, types of fractures and other circumstances in order to suggest preventive measures to decrease the incidence of this clinical problem.

Results: We identified 216 cases of fracture: 43% occurred in people over the age of 80 years, 95% were due to low energy injuries (falls), and 69.5% occurred in females. Two or more co-morbid medical conditions were present in 70% of the cases.

Conclusion: Since fractures of the hip in the study population in Jordan occurred predominantly as low energy injuries in the elderly, preventive measures should focus on fall avoidance.

Abraham Matitiau, MD, Einat Birk, MD, Ludmyla Kachko, MD, Leonard C. Blieden, MD and Elchanan Bruckheimer, MB, BS

Background: Secundum atrial septal defect is a common congenital heart defect that causes right heart volume overload and produces symptoms usually after the third decade of life. Treatment until the last few years has been open heart surgery.

Objective: To review our early experience with transcatheter closure of ASD2 using the Amplatzer septal occluder.

Methods: Between November 1999 and February 2000, 20 children and young adults with a median age of 9.1 years (4.2-35.1 years) were referred for transcatheter closure of ASD2. Diagnosis was established by transthoracic echocardiography. Implantation was performed under general anesthesia through the femoral vein with the guidance of transesophageal echocardiography and fluoroscopy. Femoral arterial puncture was performed for blood pressure monitoring during the procedure. The device size chosen was similar to the balloon-stretched diameter of the ASD2.

Results: Implantation was completed successfully in 18 patients. Two patients were referred for elective surgery: one had an unsuitable anatomy for transcatheter closure by TEE in the catheterization laboratory and the device could not implanted properly, the other patient had a large multiperforated septal aneurysm that was retrieved. Mean ASD2 diameter by TTE and TEE was similar (13.9 + 3 mm, 13.4 + 3.5 mm) and mean stretched diameter was 18.3 + 4.3 mm. Mean Qp:Qs (pulmonary flow: systemic flow) was 2.2 + 0.6. Mean fluoroscopy time for the procedure was 14.8 + 4.8 minutes.

The patients were discharged the day after the procedure.

Four patients had a tiny leak immediately post-procedure, and none had a leak at one month follow-up. The only complication was a small pseudoaneurysm of the femoral artery in one patient, that resolved spontaneously.

Conclusion: Transcatheter closure of ASD2 with the Amplatzer septal occluder is a safe and effective alternative to surgical closure. Long-term outcome has to be evaluated.

Patrick Sorkine, MD, Ron Ben Abraham, MD, Shlomo Brill, MD and Oded Szold, MD

In recent years liver transplantation was shown to be the only clinically effective method of treating acute or chronic hepatic failure due to various causes. However, this ultimate therapeutic approach is limited by the growing disparity between organ donation and the number of patient on the waiting list.

Factors such as high cost, morbidity, and the need for lifelong immunosuppression accelerated the research on alternative methods to support the failing liver. Recently, new technologies incorporating hepatocytes and extracorporal circulation devices were introduced for liver support systems and their role in the treatment of acute liver failure.

Rasmi Magadle, MD, Paltiel Weiner, MD, Alexander Sotzkover, MD and Noa Berar-Yanay, MD
Robert Slater, DPM Yoram Ramot, MD and Micha Rapoport, MD
Case Communications
Ofer Levy, MD, Marcel Topilski, MD, Eli Brazowski, MD, Michael Yaron, MD and Moshe Tishler, MD
Aharon Kessel, MD, Elias Toubi, MD, Theo Dov Golan, MD, Aurora Toubi, MD, Jorge G. Mogilner, MD and Michael Jaffe, MB ChB, CPD, CH
Paul E. Slater, MD, MPH, Alex Leventhal, MD, MPH, MPA and Emilia Anis, MD, MPH
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