תוצאת חיפוש

Computerization in a Community Health Service Provider

Boaz Porter

Maccabi Health Services, Beer Sheba

As the second largest health service provider organization in Israel, we have been progressively computerized. The process was begun in 1988, focusing on improving administrative and financial processes.

Today there is a single centralized database for 6,000 users. The system monitors member eligibility, accounting procedures and clinical processes, including diagnoses, laboratory tests, imaging procedures and drug-prescribing. The potential of the computer for physician support is now being realized through integration of clinical guidelines and reminder systems into the computerized clinical record. In addition, the centralized database is used for quality improvement, facilitating cost-effective drug-prescribing and efficient use of technology.

The establishment of a computerized working environment for 2,000 physicians and 4,000 other healthcare workers serving 1.3 million patients is a unique model for the development of community health services. Data regarding demographics, disease patterns, drug-prescribing, use of new technology and costs are now readily available to all, from senior management to the individual physician in independent practice.

The computer revolution has also presented a new set of problems such patient-record confidentiality and the effect of the computer on the physician-patient encounter.

Nephron-Sparing Surgery - Initial Experience with 50 Patients

Sarel Halachmi, Alexander Kastin, Boaz Moskovitz, Ofer Nativ

Urology Dept., Bnai Zion Medical Center, Haifa

During recent years the use of the new imaging techniques, ultrasonography and computerized tomography, has increased. The accessibility to these methods has changed the pattern of detection of renal lesions. Over 90% of renal masses are now discovered incidentally, while investigating nonurological symptoms. Therefor, most lesions are discovered in their early stages.

The gold-standard procedure for removing renal masses is radical nephrectomy, which ensures complete removal of an organ-confined lesion, but involves loss of functional tissue. This might be critical in patients with a single kidney, or reduced nephron function. There are several diseases characterized by multiple renal lesions, such as Von Hippel-Lindau and tuberous sclerosis in which radical treatment may lead to chronic dialysis in young patients.

Nephron-sparing surgery was developed in order to preserve as much functional tissue as possible while removing safely any suspicious renal lesion. This new technique, not involving radical surgery, should be evaluated in cases of renal tumors for its ability to achieve the same cancer cures rates. We present our experience with our first 50 patients who underwent nephron-sparing surgery for removal of renal lesions.
 

Laparoscopic Donor Nephrectomy: Initial Experience

Amir Szold, Joseph M. Klausner, Richard Nakache

Advanced Endoscopic Surgery Unit, Transplantation Unit and Depts. of Surgery B-C, Tel Aviv-Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University

We present our initial experience in laparoscopic nephrectomy. 6 patients were operated for a kidney donation and 2 for treatment of a benign disease. All procedures were completed successfully, with no conversion to laparotomy or intra-operative complications. Mean operating time was 210 minutes, and in the donor kidneys the mean warm-ischemic time was 165 seconds. There were 3 postoperative complications, and mean hospitalization was 3.5 days. The transplanted kidneys are all functioning.

From our initial experience, laparoscopic nephrectomy appears to be both feasible and safe. Its implementation requires a combined team with experience in donor surgery and advanced laparoscopic skills. The procedure may increase the availability of living donor kidneys, due to the smaller impact on the donor compared to conventional donor nephrectomy.

Retroperitoneoscopic Lumbar Sympathectomy

D. Seror, O Zamir, D. Eimerl, H.R. Freund

Depts. of Surgery and Anesthesia, Hadassah University Hospital, Mount Scopus and Hebrew University-Hadassah Medical School, Jerusalem

We present our initial experience with retroperitoneoscopic lumbar sympathectomy in a series of 5 men aged 25-45 years. 3 suffered from ischemia of the lower limbs due to Buerger's disease, 1 had severe reflex sympathetic dystrophy and 1 had vasculitis with severe, non-healing lower leg ulcers.

The right retroperitoneal space was developed with a dissecting balloon-trocar introduced via a small lateral muscle- splitting flank incision. 2 additional 5 mm trocars were used for instrumentation and clipping. L2-L3 or L3-L4 ganglia were resected; mean operating time was 120 minutes. Only oral analgesics were needed for postoperative pain control and oral food intake was resumed the following morning. The procedure was successful in all and was without complications. Mean hospital stay was 2 days.

All patients reported significant relief of ischemia or dystrophic pain and/or improvement in trophic changes in the extremities. In the patient with leg ulcers, the largest was successfully covered with a skin graft. The retroperitoneoscopic approach to lumbar sympathectomy successfully combines the advantages of minimal invasive surgery and the reliability and effectiveness of well-established open sympathectomy.

Home Palliative Care of Terminal Cancer Patients, with Family Feedback

Hana Arad, Hana Geva, Valery Rosin, Ruth Kibrik, Isaac Kersz

Home Care Unit of Kupat Holim Haklalit, HaEmek Medical Center, Afula and Quality Improvement Unit, Rambam Medical Center, Haifa

Palliative care of terminal cancer patients is one of the tasks of our Home Care Unit. Increasing hospitalization costs have brought forward the decision to treat them at home, assuming that they would prefer to return and die in their natural surroundings, among family.

Most of our patients are aged, recent immigrants from the Soviet Union, of low socioeconomic status; most live with their close families. Our care model combines social, cultural, economic, medical and nursing aspects. More patients choose to die at home, and that is where costs are minimal. Care management and characteristics of 44 terminal cancer patients, who died between January and October 1996, are described. Living with a family was not required for treatment at home. Length of care by the unit ranged from 1-48 weeks, with an average of 8.5 and a median of 6. 55% of patients were hospitalized, most (58%) for 5-9 days for noncancerous diseases, and then discharged home. 54% died at home, a third were hospitalized for 2-17 days before death. Compared to the average length of stay in palliative care oncology wards, 1044 days and more than NIS 500,000 were saved.

A telephone survey examined families' satisfaction with various components of care. 92% were satisfied with the home treatment. 79%-82% felt that the nurse and doctor of the team met their needs and expectations. Half the families were satisfied with the treatment of pain. Families in which treatment was 24 weeks or more were generally less satisfied than those with shorter treatment at home. We learned that an early entry into treatment is necessary; hospital referral criteria should consider to a greater extent the coping ability of families; nursing aid hours should be increased and professional emotional support added; additional pain control methods should be used. All these would strengthen families, improve quality of care, and contribute to additional savings by decreasing hospital stay.

Laparoscopic Spermatic Vein Ligation for Varicocele in Adolescents

Zahavi Cohen, Alon Yulevich, Vadim Kapuler, Niza Newman, Abraham J. Mares

Pediatric Surgery Dept., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

We report our initial experience with laparoscopic ligation of spermatic veins in the treatment of varicocele in adolescence. 19 boys, 13 to 18 years old, underwent this treatment between I 1997 and III 98. The varicocele was always on the left side. 12 complained of scrotal discomfort and pain, but in 7 it was found incidentally during routine medical examination by the family or school physician. The diagnosis was based only on physical examination.

There has been no morbidity related to the laparoscopic procedure and all returned to normal activity within a few days. Follow-up 2-12 months after surgery showed no varicocele in any. We conclude that laparoscopy is useful in the treatment of varicocele in adolescents.

Liver Surgery - Five Years of Experience

Franklin Greif, Moshe Rubin, Eitan Mor, Israel Nudelman, Arnold Sihon, Arie Figer, Alex Belinki, Shlomo Lelcuk

Hepatobiliary Unit and Depts. of Surgery B, Transplantation, Oncology and Radiology, Rabin Medical Center (Beilinson Campus) and Sackler School of Medicine, Tel Aviv University

Major hepatic resections have been associated with significant morbidity and mortality. In the past decade or so this has changed and such procedures are now done in increasing numbers. In the past 5 years we operated on 129 patients with benign or malignant hepatic lesions (75 females, 54 males; age-range 14-84). the reason for surgery was malignancy in 94 (72.9%) and benign lesions in 35 (27.1%). The most common indication for surgery was liver metastases secondary to colorectal cancer in 45% of all patients or 61.7% of those operated for malignancy. Primary liver cancer was the cause for liver resection in 13.2% of all patients or 18.1% for those with malignancy. Of the 35 patients with benign lesions the leading causes for surgery included: giant cavernous hemangioma, simple liver cysts, echinococcus cysts and focal nodular hyperplasia (11%, 22.8%, 20% and 14.3%, respectively).

76 patients underwent anatomical resection and 63 had either a nonanatomical resection or a different operation. Among the former the most common procedure was right hepatectomy (36) and among the later a nonanatomical resection equal to 1-3 Couinod segments (44). Operating time ranged from 55 min. to 8:41 hours with a mean of 3:31‏1:37. Mean hospital stay was 8.7‏5.8 days and 86.8% received between 0-2 units of blood. Overall mortality was 6.2% and 31.2% of the fatalities had cirrhosis. Overall mortality in noncirrhotic patients was 2.6%. The complication rate was 16.3% and only 7 patients (4.4%) were hospitalized in the intensive care unit. This indicates that major liver resections can be done safely, with morbidity and mortality similar to that of other major abdominal operations. 

Preliminary Report of Experience with Laparoscopic Splenectomy

Joseph Kuriansky, Ron Bilik, Moshe Shabtai, Itamar Avigad, Amram Ayalon

Depts. of General Surgery and Transplantation and Pediatric Surgery, Sheba Medical Center, Tel Hashomer; and Sackler School of Medicine, Tel Aviv University

Laparoscopic splenectomy is effective and technically feasible for treating various hematological diseases such as idiopathic thrombocytopenic purpura (ITP), congenital sphero„cytosis, hemolytic anemia, and Hodgkin's lymphoma. An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is frequently difficult. The laparoscopic posterolateral approach involves dissection of the posterolateral attachments to the diaphragm, followed by the disection and ligation of all splenic branches near the splenic parenchyma. We used it in 9 adults and 4 children: 11 patients had ITP, 1 spherocytosis and 1 Hodgkin's lymphoma.

This procedure was completed in 13 patients, but in 2 it had to be converted to open surgery. Mean operating time was 3 hours and mean postoperative stay 3 days. Blood transfusion was not required and there were no postoperative complications.

Laparoscopic splenectomy is safe in both adults and children, and the posterolateral approach provides excellent visualization and allows control of the branches of the splenic vein and artery in the splenic hilum.

Laparoscopic Repair of Inguinal Hernia Experience in 54 Consecutive Cases

S. Kyzer, I. Kristalni, M. Alis, I. Charuzi

Surgical Dept. B, Wolfson Medcial Center, Holon

We describe our experience in 54 consecutive patients who underwent laparoscopic repair of 86 inguinal hernias. Laparoscopic repair of inguinal hernia is technically feasible, does not prolong the length of the procedure nor of hospitalization and is not accompanied by increased morbidity. Although there is not yet general agreement, in our experience and that of others, it appears that laparoscopic repair will be the preferred approach to the treatment of inguinal hernia.

Intestinal Transplantation: World Experience and Future Perspective

Eytan Mor, Moshe Rubin, Yaron Niv

Depts. of Transplantation, Surgery B and Gastroenterology Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva

Intestinal transplantation, which until recently has been considered an experimental procedure, is now undergoing considerable change and becoming a standard treatment for patient with intestinal failure. The major improvement in results is due to the introduction of new immunosuppressive agents that have led to significant reduction in acute rejection. Nevertheless, reduction in severe infectious complications, which are the main cause of mortality after transplant, as well as improved techniques for early diagnosis of rejection are needed before intestinal transplantation can be widely used.

We describe our experience in post-transplant follow-up of a woman, aged 32-years, who had undergone intestinal transplantation for short bowel syndrome after extensive bowel resection.

Diagnostic and Therapeutic Laparoscopy for Non-Palpable Testis

Zahavi Cohen, Niza Newman, Edna Kurzbart, Vadim Kapuller, Abraham J. Mares

Dept. of Pediatric Surgery, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

From January 1994 to July 1997, 20 boys 1.5-13 years of age underwent laparoscopic examination and treatment for non-palpable testis. In 1 there was bilateral nonpalpable testis. Only 3 had intra-abdominal testes viable for orchiopexy. In 8 atrophic testicles were removed and in 9 laparoscopic examination revealed intra-abdominal blind ending of the spermatic cord and no testicular tissue.

We conclude that laparoscopy is a useful and safe technique for accurate diagnosis and may avoid additional intervention in treating non-palpable testes. Furthermore, intra-abdominal testes may be managed laparoscopically under the same anesthetic.

Methotrexate Treatment in Refractory Juvenile Rheumatoid Arthritis

R. Brik

Pediatrics B Dept., Rambam Medical Center, Haifa

The mean time from initiation of methotrexate (MTX) treatment of juvenile rheumatoid arthritis (JRA) to partial remission of clinical symptoms and total clinical remission was assessed. 9 girls and 8 boys, from 3 to 18 years of age (mean 11.4±5.4) with active JRA by American College of Rheumatology (ACR) criteria (5 systemic, 8 polyarticular and 4 pauciarticular disease onset), who failed to respond to adequate courses of non-steroidal anti-inflammatory drugs (NSAID), steroids or disease-modidrugs were studied.

Clinic visits were scheduled at monthly intervals for physical and laboratory assessment disease activity and drug safety. Partial response to MTX was defined a 25% reduction of the active joint count and/or articular severity score. Total clinical remission was defined as in adult rheumatoid arthritis. The duration of disease activity until enrollment ranged from 6 months to 14 years (4.5±3.7 yr); duration of therapy was 3 months to 3 years (14.6±9.3mo) and dosage ranged from 5 to 15 mg/m²/week. Prednisone in doses below 10 mg/day and NSAID were permitted.

14 of 17 patients (82%) had a 25% reduction in joint activity after 6 weeks to 4 months (9.2±3.2 weeks); 10 (59%) went into full clinical remission after 5 to 26 months (14.3±9 months); 3 relapsed after an initial response to treatment, and 4 (23%) did not respond to MTX. The non-responders were males who required higher doses of prednisone (p<0.0001).

MTX appears to be effective therapy for children with JRA. An initial response can be expected in most patients after 9 weeks of treatment, and full clinical remission occurs after a mean of 14 months.

Extensive Liver Resection: a Series of 72 Cases

Moshe Hashmonai, Doron Kopelman, Ahmed Assalia, Yoram Klein, Hani Bahus, Alex Beny, Yaakov Baruch

Depts. of Surgery B, Oncology and Unit for Liver Diseases, Rambam Medical Center and Technion Faculty of Medicine, Haifa

Partial liver resection is the treatment of choice for various liver diseases, including primary and secondary (metastatic) malignancies, benign tumors, cysts, abscesses, trauma, etc. Improved knowledge of hepatic anatomy and physiology, improved diagnostic techniques and more developed peri-operative treatment have reduced postoperative morbidity and mortality to acceptable levels.

We present a series of 72 liver resections, the majority of which were liver lobectomies or more extensive procedures performed during 1982-1997. The percentage of postoperative complications, which ranged from 1.3% to 19.4%, and mortality (8.3%; 6/72) are comparable to those of other large series in the world literature. We believe that better appreciation of the surgical potential of Israel by our medical community will improve our therapeutic approach to various liver diseases.

Optic Glioma in Children with Type 1 Neurofibromatosis

M. Ben-Arush, H. Goldberg, A. Kuten, J. Guilbord, R. El-Hassid

Pediatric Hematology-Oncology Unit, The Northern Israel Oncology Center, and Division of Neurosurgery, Rambam Medical Center; and Technion School of Medicine, Haifa

During the period 1985-95 we treated 5 girls and 13 boys with optic glioma associated with Type 1 neurofibromatosis (median age 3 years, range 2-10 years). 6 were treated with radiotherapy alone, 1 with surgery and radiation therapy and 1 with chemotherapy in order to postpone irradiation to an older age; 1 is being followed with no therapy. All children are alive, 2-10 years from diagnosis (mean follow-up time 5.4 years). 3 had improvement of vision following therapy and in 4 visual ability stabilized, including the child being followed without treatment. In 1 vision deteriorated despite therapy.

Abnormal Liver Function Tests in the Primary Care Setting

Shlomo Vinker, Sasson Nakar, Emanuel Nir, Eitan Hyam, Michael A. Weingarten

Dept. of Family Medicine, Rabin Medical Center, Sackler Faculty of Medicine; Tel Aviv University; and General Sick Fund, Central District

Results of laboratory tests ordered during a primary care encounter may reveal findings of abnormal liver function tests, including elevated liver enzymes, hyperbilirubinemia, hypoalbuminemia or abnormal coagulation tests. The object of this study was to describe the spectrum of these liver function test (LFT) abnormalities in primary care.

Results of all laboratory tests ordered during 10 months in an urban primary care clinic were retrospectively reviewed and the medical charts of patients with abnormal LFTs were studied. In 217/1088 (20%) of the tests at least 1 LFT abnormality was found in 156 patients. New diagnoses were made in 104 patients. The main diagnostic groups were: non-alcoholic fatty liver changes, Gilbert's disease, acute infectious hepatitis, alcoholic liver disease and cirrhosis and hepatotoxic drug injury. In 60 patients the physician classified the abnormality as negligible and not associated with significant disease. However, an abnormal test that had been ordered for evaluation of a specific complaint, was indeed likely to represent significant disease (X²=29.5, p<0.001). We conclude that finding abnormalities in liver function tests is common in the primary care clinic but does not often indicate significant liver disease.