Israel Hospital Pharmaceutical Services: A National Survey 

S. Livny, A. Hammerman, S. Shani, J. Shemer

Hiliel Yaffe Medical Center, Hadera; Israel Center for Technology Assessment in Health Care; Gertner Institute, Tel HaShomer; Dept. of Internal Medicine, Sheba Medical Center, Tel HaShomer; and Sackler School of Medicine, Tel Aviv University

Results of a 1996 survey of hospital pharmaceutical services in Israel are presented. A questionnaire was mailed to 46 pharmacy directors in Israel hospitals of which a total of 33 were returned (72%).

The main services provided at hospital pharmacies are production of pharmaceuticals and inventory management. The pharmacy directors estimated that more then half of their pharmacists' time was spent on technical work that did not need their academic, professional knowledge. In Israel general hospitals there are on the average 1.23 full time pharmacist positions per 100 hospital beds and 1.09 positions for other pharmacy employees.

A similar survey carried out in the United States showed an average of 7.4 pharmacists per 100 hospital beds. Pharmacists there have broad clinical roles which, in general Israeli pharmacists do not have.

Computer systems are used in our pharmacies mainly for inventory management. About half of the directors did not think that the location, structure and furnishings of their pharmacy were appropriate for its role.

Under current conditions, Israel hospital pharmacies are not organized to provide pharmaceutical services beyond inventory management and pharmaceutical production. Appropriate budgets and personnel are required to develop clinical pharmacy services at Israel hospitals. This would lead to improved quality of drug treatment and cost-containment and would allow pharmacists to exploit their knowledge, skills and training that under the current system, are only partially utilized.

Use of Civilian Emergency Departments by Israel Defense Force Soldiers 

A.D. Cohen, A. Porath, R. Bessorai, A. Shulman, Y. Snir

Medical Corps, Israel Defense Forces; Depts. of Medicine F and Orthopedics and Emergency Dept., Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Many physicians, civilian as well as in military, feel that some referrals of soldiers to civilian emergency departments are inappropriate and that soldiers should receive medical attention within their military units. We therefore evaluated referrals of soldiers to our emergency department.

707 referral letters from military physicians and the corresponding emergency room discharge letters were evaluated. Most soldiers were referred for mild trauma (45.0%) or miscellaneous diseases (52.9%); 22 (3.1%) were hospitalized.

It appears that some military physicians use the civilian hospital emergency department as a surrogate for an out-patient specialty clinic and for x-ray and laboratory services. This is in contrast to the designated functions of the emergency department which are to provide emergency and trauma services and to evaluate the need for hospitalization of referred patients.

Trends in Epidemiology of Hepatitis in the Israel Defense Forces 

Michael Gdalevich, David Gillis, Daniel Mimouni, Itamar Grotto, Ofer Shpilberg

Institute of Military Medicine, Medical Corps, Israel Defense Forces

During the 50's and 60's there were large scale epidemics of hepatitis A every 3-4 years in the Israel Defense Forces. During these epidemics the annual incidence exceeded 10/1000 soldiers at risk. There has been a highly significant decrease in rates during the past 30 years. The average annual incidence of clinically identified viral hepatitis A decreased from an average of 6/1000 during the 60's to 2.5/1000 during the 70's. The decrease coincided with the introduction in the 1970's of wide-scale post-exposure prophylaxis with immune serum globulin (ISG). The incidence was further significantly reduced to 0.5-1.0/1000 with the introduction of pre-exposure prophylaxis with ISG, starting in 1978 (p<0.001).

Other factors probably played a role in accelerating the decline in morbidity, such as improvement in personal hygiene and sanitation facilities, and in waste disposal and other aspects of military environmental health.

These improvements were probably more pronounced in the civilian sector, leading to decreased exposure of children to the virus and consequently a higher proportion of seronegatives at induction. Increase in the proportion of recruits without natural immunity to the virus poses greater risk, both in terms of personal morbidity as well as military operational ability. This risk, combined with problems of ISG use and availability, has propelled hepatitis A prevention policy towards the use of the new inactivated vaccines.

Decompression Sickness in Divers Treated at the Israel Naval Medical Institute 

A. Gil, A. Shupak, H. Lavon, Y. Adir

Israel Naval Medical Institute, Israel Defense Forces, Haifa

Clinical characteristics of 125 divers treated for decompression sickness (DCS) in the hyperbaric multiplace chambers of this Institute during 1992-1997 were analyzed retrospectively. In 62 (51%) the diagnosis was DCS Type I (joint pain or skin involvement) and in 60 (49%) DCS Type II (neurological, inner ear or pulmonary disease). Risk factors for the evolution of DCS were depth and duration of the dives involving accidents, violation of recommendations of the decompression tables, and repeated dives.

Results were available for 112 of the 125 patients. 54 of them (48%) recovered completely, and another 54 recovered partially; 4 did not respond to treatment. Inner ear DCS was less responsive to hyperbaric oxygen treatment (p=0.0001). There was significant improvement of neurological function in those with severe neurological injury (p=0.0001). Rapid diagnosis and transportation of divers with DCS to a hyperbaric chamber is of crucial importance.

Israel Naval Medical Institute: 20 Years of Applied Research, and Future Goals 

Ran Arieli, Avi Shupak

Israel Naval Medical Institute, Medical Corps, Israel Defense Forces

The Israel Naval Medical Institute (INMI) is unique as a research center located in a naval base and having close inter-relations with naval underwater units. It is ideal for applied research, and for mutual exchange of needs and of ideas and instructions.

Factors making this institute so suitable for applied research include: direct personal communication with combat divers, professional naval divers, submariners, civilian recreational divers and professional civilian divers, as well as naval vessel crews prone to seasickness; hyperbaric oxygen therapy is administered in cooperation with a large neighboring hospital.

Close spatial and personal relations with an academic institution (the Technion, with its Faculties of Medicine, Biology and Biophysics) provide a basis for cooperative research which expands research capabilities, and allows access to extensive expertise, instrumentation and equipment. Close ties with physicians who served at the INMI in the past also bring them into this research community.

During their specialization, physicians may spend up to 6 months working with us on a research project. Undergraduate, graduate and post-graduate students may complete their research at our institute with the agreement of their parent academic institutions.

Much of the research can be released to the international community. However, some is classified, serves only internal needs or is not of public interest. The number of published papers has stabilized since 1991 at about 16 a year.

Studies of gas exchange and oxygen toxicity originate mainly in the Hyperbaric Research Unit, research on motion sickness in the Motion Sickness and Human Performance Laboratory, and work on hyperbaric and diving medicine in the Clinical Section of the INMI.
 

Medical Support During The Sinai War Of Attrition (1968-1970): A 30-Year Perspective 

Z. Gimmon, J. Adler

Dept. of General Surgery, Hadassah-Hebrew University Medical Center, Ein Kerem, Jerusalem and Medical Section, Israteam, Lod

The War of Attrition between Israel and Egypt along the Suez Canal line lasted 23 months (9/1968-8/1970), during which the Israel Defense Forces (IDF) were mostly in fixed fortifications. A few of the important principles of field medical support, which became cornerstones of IDF procedure, were established during that war. These included use of armored vehicles for evacuation under artillery fire, as well as emergency treatment, physiological stabilization, and maintenance of the wounded until evacuation.

The latter objectives were achieved by stationing medical officers and paramedics within the fortifications, where they remained with the troops. A field surgical hospital was established in Refidim which had a trained surgical staff and a well-equipped emergency department. It included an operating theater and post-op recovery facilities for proper surgical care until evacuation to hospitals in the rear.

Tables showing the number of casualties throughout 1 year of the War of Attrition are presented. Better personal shielding by helmets and body shields decreased the number and severity of head and thoraco-abdominal injuries. The relative large number of those who died-of-wounds was due to the proximity of medical facilities, so that treatment could be administered within the fortifications. Otherwise, many more would have been included among the killed-in-action.

Acipimox as a Secondary Hypolipidemia in Combined Hypertriglyceridemia and Hyperlipidemia

D. Yeshurun, H. Hamood, N. Morad, J. Naschitz

Hyperlipidemia Clinic, Dept. of Medicine A, Bnai-Zion Medical Center, and Rappaport Faculty of Medicine, Technion, Haifa

32 patients with hypertriglyceridemia, excessive hypertri- glyceridemia, and combined hyperlipidemia, were treated with the nicotinic acid derivative acipimox (Olbetam). First line treatment with bezafibrate, or statins in some with combined hyperlipidemia, had failed. In 10 acipimox was discontinued due to side effects or absence of clinical response. The other 22 completed 6 months of treatment with no side effects.

Acipimox caused a significant 54% decrease in triglyceride levels, a 23% decrease in total cholesterol, and a 12% increase in HDL-cholesterol. LDL-cholesterol was difficult to calculate because of the high triglyceride levels, so no results are presented.

Although acipimox was much better tolerated than nicotinic acid, it also had side effects, but fewer. Acipimox can therefor be used as a second-line drug, mainly in those with combined hyperlipidemia and hypertriglyceridemia.

Ethnicity and Emergency Department Visits in the Negev

Shahar Livnat, Eyal Almog, Gad Rabinowitch, Yoram Snir

Dept. of Emergency Medicine, Soroka University Medical Center and Dept. of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer Sheba

The population of the Negev consists mainly of Jews and Bedouin, who have very different life styles. Patients of both ethnic groups use our emergency department exclusively, providing a unique opportunity to study comparative patient habits.

In gathering and processing the information we used Data Mining technology, which allows search for unique patterns in large data bases. We examined demographic data on some 64,000 emergency department visits during 1997-8, mostly medical and surgical cases, but not trauma cases. Many more were by Bedouin than Jews, and between the ages of 25 and 44, more by women than men. There were changes in trends in comparison with an arrival survey conducted some 11 years before.

Etoposide and Cisplatin for Non-Small Cell Lung Cancer 

David B. Geffen, Sofia Man, Yoram Cohen*

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

Etoposide and cisplatin (EP) has been the standard therapy for non-small cell lung cancer (NSCLC) at many cancer centers for over a decade. We analyzed our experience with EP in NSCLC to provide a baseline for comparison with new drugs. From 1986 through 1994, 46 of our patients with NSCLC received EP as first-line chemotherapy. Radiation therapy was administered to 25 of them, including 20 who received it immediately before or concomitantly with chemotherapy. Toxicity was mild and included only 1 episode of neutropenic fever and 1 case of reversible renal failure.

Overall response was 22%. In 3, response was complete (pathologically documented in 2 of them) and in 7 partial. Median survival in locally advanced (stage III) and metastatic disease (stage IV and recurrent) were 12 months and 7 months, respectively. 2 patients are alive and free of disease more than 6 years after diagnosis.

Our results are consistent with other published studies of EP in NSCLC. EP provides modest benefit in locally advanced NSCLC, with minimal toxicity.

Jules E. Harris Chair in Oncology.

Smoking by an Israeli Hospital Staff, its Attitude to Smoking in Hospitals and to “Smoke-Free” Hospitals

Shabtai Varsano, Giora Hevion, Mila Garenkin

Depts. of Pulmonary Medicine, Asthma Care-Education Unit, Hospital Management Office, and Epidemiology and Medical Data Unit; Meir General Hospital, Sapir Medical Center, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University

Smoking within hospitals is common in general hospitals in Israel. It has a strong negative educational impact, has a negative image and curing its ill effects help keep our hospitals busy. An anonymous questionnaire was answered by 128 members of our hospital staff (28%). Their distribution, according to occupation and sex was representative of the rest of our hospital staff.

19% of our workers are smokers, a much lower proportion than in our general adult population. The proportion was highest among maintenance (40%) and sanitary-help staff (36%). 23% of nurses and 15% of physicians were smokers. This situation is better than that among Italian or Japanese medical staff, but much worse than among North American medical staff.

75% of our workers who smoke declared that they smoke outside the room in which they work. 66% and 72% of the staff believe that hospital workers and visitors, respectively, should smoke outside hospital buildings. Only 19% of all workers do not believe that a "smoke-free hospital" is attainable. 34% believe that a "smoke-free hospital" is achievable, and 47% said that it is perhaps achievable. 86% of all the workers, and 41% of the smokers, expect the hospital director to implement an effective policy of enforcing the law limiting smoking within hospitals (and other public buildings) in Israel. 60% are willing to contribute actively to this effort.

We believe these results strongly suggest that the time is ripe for implementation of the "smoke-free hospital" in Israel. This requires a strong and effective central policy, like that in the USA. We suggest measures that the Israel Ministry of Health take measures to successfully implement this policy.

Incidence of Insulin Dependent Diabetes in Youth in Israel 

Israel IDDM Registry Study Group

Recent reports from different countries have shown an increasing incidence of insulin-dependent diabetes mellitus (IDDM, type I diabetes). In Israel, several surveys of the incidence of IDDM have been conducted. During 1996, a national juvenile diabetes register was founded by specialists in endocrinology, and the Israel Center for Disease Control (ICDC).

This is the first report of the national incidence of IDDM in the 0-17 year age group in Israel. New cases of juvenile diabetes were reported using an anonymous form. The ICDC was responsible for data collection, control and statistical analyses.

During 1997, 162 new cases of diabetes mellitus were reported in the age group 0-17, 154 of them diagnosed as IDDM. The annual incidence in the total population of Israel in 1997 was 7.7/100,000. Age-specific incidence was 7.3/100,000 in boys and 8.1 in girls. A family history of IDDM was found in 14.3% of the cases. Incidence was higher for Jews (9.2/100,000) than Arabs (3.6/100,000). Among Jews, children whose fathers were born in Yemen had the highest incidence and those born to fathers born in Israel the lowest incidence.

IDDM incidence rates for 1997 are higher than reported in previous surveys. It will be possible to draw conclusions regarding possible trends in incidence from data to be gathered in the next few years.

Cost-Effectiveness of Imaging Procedures in Knee Injuries 

Moshe Leshno, Hagai Amir, Dalia Leshno

School of Business Administration, Hebrew University of Jerusalem; Dept. of Orthopedics, Tel Aviv Medical Center; Israel Defense Forces, and Faculty of Management, Tel Aviv University

It is clear to experts in the health care industry that with regard to medical decision-making, considering costs of medical devices is not a good index, but it is highly important to include medical aspects. This approach guarantees an advance and an appropriate method.

We present a cost-effectiveness analysis to target the optimal strategy of how to use medical diagnostic devices in cases of knee injuries. Today, one of the more common medical emergency referrals seen worldwide is in the area of orthopedics, knee injuries in particular. They can harm soft tissue, bone tissue, or both simultaneously. The diagnosis of soft tissue injury is difficult at best. Among the devices helping the clinician make an accurate diagnosis are MRI and ultrasound (US).

We conclude that US is superior to MRI in this condition. This is especially true when the orthopedic examination leads to the suggestion of arthroscopy. The results were not modified, and a sensitive study of the parameters that influence the decision- making process was undertaken. Decision-makers should not consider medical outcome alone, but should take into account the costs. A clinical study should validate the assumption on which this study was based.

Brief Preoperative Radiotherapy reduces Local Recurrences and Improves Survival in Rectal Cancer

T. Peretz, Z. Weshler,* Y. Goldberg, A.L. Durst, H.R. Freund

Depts. of Surgery and Oncology, Hadassah University Hospitals, and Hebrew University-Hadassah Medical School, Ein Kerem and Mt. Scopus, Jerusalem

Locoregional recurrence of rectal cancer ranges between 20%-50% following apparently radical surgery. Radiation has the potential of reducing this high rate of recurrence and residual disease. A retrospective analysis of 78 patients with locally advanced, biopsy proven, adenocarcinoma of the rectum treated between 1980-1987 was conducted. 28 (36%) were treated by surgery alone (surgery); 29 (37%) by surgery and postoperative radiotherapy (post-op); and 21 (27%) by surgery and preoperative radiotherapy (pre-op). 41 were females and 37 males. The median age was 62 years (range 25-90).

All tumors were resectable. 42 patients (54%) underwent abdomino-perineal resection and 36 (46%) anterior resection patients [8 Dukes B₁ (10%); 37 B₂ (47%); 2 C₁ (3%); 31 C₂ (40%]. Local recurrences were verified by transanal or ultrasound guided needle biopsy.

The 5-year actuarial survival rates by the Kaplan-Meier method for 75 evaluated patients was 55%. Overall 5-year actuarial survival was significantly higher (p=0.001) in pre-op radiotherapy (95%) compared to surgery alone (45%), or surgery with postoperative radiotherapy (32%). The data were significant (p=0.006) for patients with stage B tumors, but not stage C. This trend of improved survival held also at 8-year follow-up (80% pre-op; 32% post-op; 27% surgery). The 5-year actuarial local control was significantly better (p=0.03) for the pre-op irradiated patients (22%), compared with surgery only (56%) and post-op radiotherapy (38%). Local control was better (p=0.02) for Dukes B tumors in the preoperative group, but not Dukes C tumors.

Actuarial 5-year survival of those without distant metastases was 87% for pre-op patients, 62% for surgery alone and 48% for post-op radiotherapy. As all patients were clinically classified as advanced rectal tumors, tumor downstaging by preoperative radiotherapy seems to be paramount for local control. Improved local control translates into a siginificant advantage in overall actuarial survival.

*DECEASED.

Sport-Related Maxillofacial Fractures

Yitzhak Shoshani, Navot Givol, Shlomo Taicher

Dept. of Oral and Maxillofacial Surgery, Sheba Medical Center, Tel Hashomer and Faculty of Dental Medicine, Tel Aviv University

The records of 537 patients with 750 maxillofaciafractures were reviewed and analyzed. 55 (10.2%) had sport-related injuries and the rest were due to othercauses. The sport-related group was predominantly male (ratio 9:1) with a mean age of 24.5 years. The mandible was most commonly injured (52.5%), followed by the zygomatic complex (32.8%). The incidence of complicated mid-facial fractures was only 2.8%, and of comminuted fractures 9%. This distribution of injuries is most likely due to the relatively low-energy of trauma associated with many sport activities. The relatively low mean age of the patients, most of whom had full dentition, allowed for conservative treatment of most of the mandibular fractures, using closed reduction.

Injuries were caused by 11 different sports. The highest incidence was soccer (45%), followed by skating (15%), basketball (9%) and horse-riding (9%). Contact sports were the cause of injuries in 72.2%, with the highest incidence of trauma due to impact with another player (60%). Better protection of the oral and maxillofacial region is needed, especially during high-contact sport.