Yehuda L. Danon MD and Esther Saiag MD
Background: Over the last 5 years Israel has implemented a nationwide health insurance plan covering the entire population of the country. We have developed a clinical information system based on electronic-chip health care medical smart cards. Health care cards are used in several European countries and chip smart cards have been successful in many sectors. Our project involves the community use of the MSC, thereby enabling health care professionals to skillfully employ card systems in the health care sector. This system can easily arrange electronic medical charts in clinics, facilitating the confidential sharing of personal health databases among health professionals.
Objectives: To develop an MSC applicable for daily use in the community and hospital system.
Results and Conclusions: The MSC project, currently underway in Israel and the USA, will aid in determining the costs, benefits and feasibility of the MSC. Successful implementation of the MSC in chosen clinics will promote a nationwide willingness to adopt this promising technology.
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MSC= medical smart card
Ron Ben-Abraham MD, Avi A. Weinbroum MD, Yoram Kluger MD, Michael Stein MD, Zohar Barzilay MD FCCM and Gideon Paret MD
Background: General pediatricians in Israel are actively involved in the initial evaluation, resuscitation and management of traumatized children. However, pediatric trauma care is not a part of pediatric specialty training in Israel, and the few Advanced Trauma Life SupportR courses per year are insufficient for most pediatricians working in accident and emergency care.
Objective: To examine the value of the course in relation to the limited resources available for such training.
Methods: A telephone survey of 115 pediatricians who had taken the course between 1990 and 1994 was conducted. The responding physicians (67%) were asked to complete a specially designed questionnaire on life-saving procedures that were taught in the course. In addition, they were asked to subjectively assess the practical utility of the course.
Results: Forty-three (56%) pediatricians reported that they routinely treated both adult and pediatric trauma cases. Of these, 81% performed 27 life-saving ATLSR procedures. Pediatric trauma was treated by only 22 (28%), of whom 72.3% performed 18 life-saving ATLSR procedures. These pediatricians ranked the courses as being "very high" to "high" in impact.
Conclusions: These figures indicate that an ATLSR course designed specifically for pediatricians can markedly improve pediatric trauma care. To ensure standard education and patient care, such a course should be developed and made a mandatory component of residency training. Further studies to examine the objective impact of the courses on pediatric trauma care should be carried out.
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ATLS= Advanced Trauma Life Support
Richard Nakache MD, Avi Weinbroum MD, Hadar Merhav MD, Eli Kaplan MD, Yehuda Kariv MD, Wessam Khoury MD, Mordechai Gutman MD and Joseph M. lausner MD
Background: In simultaneous pancreas-kidney transplantation, with both organs coming from the same donor, the addition of a pancreas to the kidney transplant does not jeopardize the kidney allograft outcome despite higher postoperative SPK morbidity. Pancreas allograft outcome has recently improved due to better organ selection and more accurate surgical techniques.
Objective: To demonstrate the positive impact of SPK on kidney allograft outcome versus kidney transplantation alone in insulin-dependent diabetes mellitus patients with end-stage renal failure.
Methods: We performed 39 consecutive SPKs in 14 female and 25 male IDDM patients with renal failure after an average waiting time of 9 months. Multi-organ donor age was 30 years (range 12-53). The kidneys were transplanted in the left retroperitoneal iliac fossa following completion of the pancreas transplantation; kidney cold ischemia time was 16±4 hours. Induction anti-rejection therapy was achieved with polyclonal antithymocytic globulin and methylprednisolone, and maintenance immunosuppression by triple drug therapy (prednisone, cyclosporine or tacrolimus, and azathioprine or mycophenolate mofetil). Infection and rejection were closely monitored.
Results: All kidney allografts produced immediate urinary output following SPK. Two renal grafts had mild function impairment due to acute tubular damage but recovered after a short delay. Three patients died from myocardial infarction, cerebrovascular event and abdominal sepsis on days 1, 32 and 45 respectively (1 year patient survival 92%). An additional kidney allograft was lost due to a renal artery pseudo-aneurysm requiring nephrectomy on day 26. Nineteen patients (49%) had an early rejection of the kidney that was resistant to pulse-steroid therapy in 6. No kidney graft was lost due to rejection. Patients with acute kidney-pancreas rejection episodes suffered from severe infection, which was the main cause of morbidity with a 55% re-admission rate. Complications of the pancreas allograft included graft pancreatitis and sepsis, leading to a poor kidney outcome with sub-optimal kidney function at 1 year. Kidney graft survival at one year was 89% or 95% after censoring the data for patients who died with functioning grafts.
Conclusions: Eligible IDDM patients with advanced diabetic nephropathy should choose SPK over kidney transplantation alone from either a cadaver or a living source.
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SPK= simutaneous pancreas-kidney transplatation
IDDM= insulin-dependent diabetes mellitus
Roni Peleg MD, Meron Froimovici MD, Aya Peleg PhD, Vered Milrad BA, Georgette Ohana BA, Shimon Fitoussi, Eli Dryfuss MA, Michael Sharf MD MPH and Pesach Shvartzman MD
Background: Israeli physicians are very familiar with the problem of interruptions during encounters with patients. However, a thorough search of the medical literature revealed only one report of this problem from Israel, and none from other countries.
Objectives: To characterize the phenomenon of interruptions to the patient-physician encounter in a clinic in Dimona and to assess the effect of an intervention program designed to reduce the magnitude of this problem.
Methods: During an 8 day work period in March 1997 all patient-physician encounters were recorded and characterized. An intervention program was then designed and implemented to reduce the number of interruptions. Data were again collected a year after the initial data collection.
Results: During the 8 day study period prior to the intervention program there were 528 interruptions to 379 encounters (mean of 1.39 per encounter). The main causes of interruptions were entrance of uninvited patients to the examination room (31%) and telephone calls (27%). Most of the interruptions occurred during the morning hours between 8 and 10 a.m. (45%) and at the beginning of the week (Sunday 30%). After the intervention program there were 402 interruptions to 355 encounters (mean of 1.13 per appointment, P=0.21).
Conclusions: There was no statistically significant improvement in the number of interruptions following the intervention program. This finding is either the result of a local cultural phenomenon, or it indicates a national primary care health system problem that may require a long-term educational program to resolve it. Further research is needed on the magnitude, causes and consequences of interruptions in family practice and, if warranted, methods will have to devised to cope with this serious problem.
Miguel Iuchtman MD, Ricardo Alfici MD, Ehud Sternberg MD, Leonid Trost MD and Menachem Litmanovitch MD
Background: Trauma is the leading cause of death in children. In abdominal lesions the spleen is the most commonly involved organ. During the last two decades much effort has focused on spleen tissue conservation.
Objectives: To analyze the rationale of a multimodality management policy that includes autotransfusion and mesh wrapping.
Methods: Data gathered over 14 years illustrate the introduction of new techniques and their impact on cases of severe spleen rupture.
Results: A total of 122 children were treated during the 14 year period, 1985-98. In 16 children an absorbable mesh wrapping, alone or in combination with other techniques, was used to obtain hemostatis and save spleen tissue.
Conclusions: Mesh wrapping, partial splenectomy and autotransfusion can be used, alone or in combination, to preserve severely injured spleens. According to our records, all children survived with a functional spleen. There were no cases of rebleeding. In only one case of prolonged postoperative fever could the cause be traced to an infected spleen hematoma that was drained transcutaneously. Autotransfusion is performed simply and without the use of a "cell saver." Its use can be crucial in small or field hospitals or in a situation of mass casualty.
Aziz Mazarib MD, Ely S. Simon MD, Amos D. Korczyn MD MSc, Zipora Falik-Zaccai MD,Ephraim Gazit MD and Nir Giladi MD
Objective: To report a unique hereditary, juvenile onset, craniocervical predominant, generalized dystonia and parkinsonism affecting four members of one family.
Family Description: A father and three of his four daughters presented to us over the past 30 years with a similar picture of generalized dystonia, starting in the craniocervical region in the second or third decade of life. They later developed moderate parkinsonism, mainly manifesting bradykinesia, rigidity and abnormal postural reflexes. Biochemical and genetic tests excluded Wilson's disease, Huntington's disease and Oppenheim's dystonia.
Conclusion: This is a new type of familial dystonia-parkinsonism where the craniocervical dystonic symptoms are most prominent in the early stages while parkinsonism becomes the predominant problem later in life. A search for the genetic mutation in this family is underway.
H.Ralph Schumacher Jr, MD
Anne Bordron, BSc, Ronan Revelen, BSc and Pierre Youinou, MD, DSc
David B. Geffen, MD and Jacob Horowitz, MD
Jonathan Cohen, FCP (S.A) Maury Shapiro, MD, Elad Grozovski, MD, Menashe Haddad, MD, Nissim Hananel, MD and Pierre Singer, MD,
Boaz Sagie, MD, Hanoch Kashtan, MD and Yoram Kluger, MD
Raul Colodner, MSc and Yoram Keness, PhD
Background: Many beside urine culture devices have been developed with the aim of reliability, simplicity and use in both the physician’s office and the clinical laboratory.
Objective: To compare a novel beside urine culture device (DipStreak, Novamed Ltd. Israel) comprising a combination of MacConkey and Colombia CAN blood agar with conventional seeding on the same culture media.
Methods: A total of 1000 urine specimens sent to our microbiology laboratory were simultaneously processed by both methods. Results were evaluated after 24 and 48 hours incubation at 370C.
Results: Altogether, 171 (17.1%) and 124 (12.4%) specimens were defined as positive by the conventional method using cutoff values of 104 colony-forming units/ml and 105 CFU/ml respectively; 178 specimens (17.8%) were defined as contaminated. The sensitivity, specificity, positive and negative predictive values of DipStreak for urinary tract infection were 98.8%, 98.6%, 96% and 99.6% respectively, using a cutoff value of 104 CFU/ml, and 99.3%, 99.2%, 96% and 99.8 respectively, using cutoff value of 105 CFU/ml. Full agreement between both techniques was 95%.
Conclusion: The agreement rate between DipStreak and conventional seeding was remarkably high. These results suggest that DipStreak in the agar combination tested in this study is a useful and precise tool for diagnosing urinary tract infection.