Physicians' Assessment of Computerized Prescribing

Daniela Zalman, Majed Odeh, Arie Oliven

Dept. of Internal Medicine B, Bnai Zion Medical Center, Technion Faculty of Medicine, Haifa

Prescription errors are a major source of preventable adverse drug events. Computerized prescribing (CP) which screens physicians' order for mistakes, drug-allergy, drug-disease, drug-laboratory and drug-drug interactions can prevent many of these errors and improve quality of care. However, computerized systems are often time-consuming, difficult to handle, and may create their own mistakes.

Following the introduction of CP on an internal medicine ward, we administered a questionnaire to evaluate physicians' opinions about the new system. The survey assessed computer literacy, ease of using CP, effects on time management, opinion of users regarding error prevention, and usefulness of the information provided. Opinions were generally favorable; most users felt that CP makes their work more accurate, reduces errors, is easy to learn and to use, and provides important and useful information. Physicians were most critical of equipment failure and drugs and dosages not included in the CP program, a result of rapid development of the system.

Errors resulting from the use of CP were considered minimal. Comparison of physicians, with and without previous experience with computer work, as well as local and foreign graduates, revealed minor differences. But once physicians learn to work with a well-organized CP system and computerized work stations, they appreciate the order, safety and knowledge they provide.

High Dose Endobronchial Brachy - Therapy for Malignant Airway Obstruction

Alex Yarmolovsky, Alan Katz, Eyal Fenig, G. Fink, Daniel Bendayan, Aaron Sulkes, Mordechai R. Kramer

Institutes of Pulmonology and Oncology, Rabin Medical Center, Beilinson Campus, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University

Brachytherapy is especially suitable for palliative treatment of endobronchial tumors adjacent to internal organs that might be damaged by intensive external beam radiation, but are easily accessed with a flexible bronchoscope. This treatment is mostly palliative.

30 patients underwent such palliative high-dose endobronchial brachytherapy to alleviate malignant airway obstruction. With the aid of a flexible fiberoptic bronchoscope an endobronchial catheter was inserted adjacent to the tumor and treatment delivered using a 192Ir remote afterloader for 5-10 min, in 2 or 3 sessions.

There was symptomatic improvement in 26 (86%) and objective improvement in 27 (90%). 1 patient died of hemoptysis.

Autologous Chondrocyte Transplantation - from Science Fiction to Routine Clinical Practice

Dror Robinson, Hana Ash, David Aviezer, Gabriel Agar, Nahum Halperin, Zvi Nevo

Dept. of Clinical Biochemistry, Sackler Medical School, Tel Aviv University, Ramat Aviv; Dept. of Orthopedic Surgery, Assaf Harofeh Medical Center, Zerifin; and CTI Ltd., Science Park, Kiriat Weizmann, Nes Ziona

Adult articular cartilage lacks the capacity for self-repair. The limiting factor appears to be the inability of chondrocytes to proliferate while embedded in the extracellular matrix typical of hyaline cartilage. Cartilage defects larger than 1 cm² change articular biomechanics and lead to eventual osteoarth-ritis and joint destruction.

During the past decade, several competing techniques have evolved to stimulate articular cartilage repair. Small lesions can be successfully treated by either micro-fracture or osteochondral cylinder grafting. The latter technique allows immediate weight bearing but leads to damage of previously uninvolved areas of articular cartilage, which limits its application to lesions of less than 2 cm².

When the damaged area is more extensive, grafting of autologous chondrocytes should be considered. First a diagnostic arthroscopy is performed to assess the damaged area and a small cartilage biopsy is taken. 6 weeks later, arthrotomy and chondrocyte transplantation are performed. In the interval, the antologous chondrocytes have expanded by 2 to 3 orders of magnitude. Our experience to date includes 10 cases with follow-up of 6 months to 5 years. Preoperative complaints of crepitation and locking disappear. There is functional improvement and pain reduction of approximately 50%. This procedure, currently limited to patients under 55 years of age with limited damage to an articular surface, for the first time allows reconstruction of damaged articular areas without resorting to allografts.

Cannabis Has Dangerous Implications for Mental Health 

Emi Shufman, Eliezer Witztum

Jerusalem Institute for Treatment of Substance Abuse, Kfar Shaul Mental Health Center, Jerusalem and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Accepting and forgiving attitudes to the use of cannabis in its various forms, such as marijuana or hashish, are not justified, as they may result in dangerous mental health consequences.

A theoretical framework for this opinion is provided, including information on the various forms of cannabis available. Case studies presented exemplify possible complications resulting from use of cannabis or its derivatives.

Pulmonary Involvement in Osler- Weber-Rendu Syndrome 

Efrat Bron-Harlev, Benjamin Zeevi, Ben-Zion Garty

Dept. of Medicine B and Cardiac Catheterization Unit, Schneider Children's Medical Center, Petah Tikva

Hereditary hemorrhagic telangiectasia (Osler-Weber-Ren-du syndrome) is a group of autosomal dominant diseases with variable penetration, characterized by vascular malformations. Recently hereditary hemorrhagic telangiectasia has been found to be a phenotypic expression of mutations in genes located on chromosomes 9 and 12, and possibly of other genes located on other chromosomes.

We describe 2 patients with hereditary hemorrhagic telangiectasia and pulmonary involvement who presented with repeated complaints of dyspnea and cyanosis and were diagnosed as having long-standing asthma. Both were treated with therapeutic catheterization and embolization with good clinical outcomes.

SYME Amputation for Foot Infections in Diabetics 

Michael Michailevich, Ehud Lebel, Menachem Itzchaki

Dept. of Orthopedics, Shaare Zedek Medical Center, Jerusalem

Syme ankle disarticulation for foot infections in diabetics with concomitant peripheral vascular disease is often unsuccessful. The need for re-amputation usually results from recurrent infection or ischemia of the posterior heel flap. We present 5 such cases of deep foot infections in diabetics who underwent Syme amputation after failure of local debridement. All patients needed reamputation in 4-18 days for ischemia of the flap.

Cilazapril for Essential Hypertension Treated in the Community 

Reuven Zimlichman

Dept. of Medicine and Hypertension Institute, Wolfson Medical Center and Sackler Faculty of Medicine, Tel Aviv University

In a multicenter study in community clinics, 413 patients with mild to moderate essential hypertension were treated with cilazapril (Vasocase), 2.5 mg daily. Patients had either been untreated or had developed side-effects from previous antihypertensive treatment. When response was inadequate the dose was either increased to 5 mg or another antihypertensive medication was added, or both.

Treatment significantly reduced systolic and diastolic blood pressures. Pulse rate decreased significantly from the second month of treatment onwards. At the end of the 3rd month of treatment blood pressure was normalized or had decreased by more than 10 mmHg in 91.9% of patients. Physicians' evaluations revealed improvement in 62%; patients' self-evaluations suggested improvement in 61%. Efficacy was equal in all age groups and in both obese and nonobese patients. Antihypertensive response was superior in those with normal renal function. Side-effects were rare and similar to those reported in the literature.

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.

Prioritizing Suspected Diagnosis of Both Brain and Abdominalinjuries: Is it a Problem?

Leon Levi, Moshe Michaelson

Dept. of Neurosurgery and Trauma Unit, Rambam Medical Center, Haifa

Current guidelines for management of suspected head and abdominal injuries are based on retrospective studies like that of Wisner & al, Following a recent review in this journal by Y. Kluger & al, which was based on non-Israeli data, we decided to define the current status at our trauma center.

We compare our data of 18 months of hospital admissions for acute trauma in which head CTs were done with those of 5 articles advocating specific protocols for decisions in pre-laparotomy diagnosis.

In the 861 cumulated cases, compared with the 800 of Wisner & al, craniotomy was required in 15% vs 7% (p<0.05); laparotomy was much less frequent, 2.7% vs 12.9% (p<0.05). The chance of finding a case requiring both craniotomy and laparotomy was 1 in 300.

As the clinical condition of multiple trauma involving the head and abdomen is becoming less frequent and includes diverse situations, a comprehensive algorithm might be inaccurate. Good clinical judgment of the clinician and teamwork are therefor preferable.

Management of Compound High Energy Injuries of the Limbs 

A. Lerner, I. Weisz, G. Nierenberg, D. Horer, H. Stein

Dept. of Orthopedic Surgery A, Rambam Medical Center, and Technion Medical Faculty, Haifa

We treated 49 patients with high energy injuries of the limbs between 1.1.94-31.12.97. They had sustained 61 fractures, 50 of which were open; 14 had bilateral injuries, and 3 had lost a limb. All fractures were stabilized on arrival with an A-O tubular external fixator. Soft tissue loss was covered by a combination of split skin graft and tissue flaps following repeated surgical debridement.

After 10 days, or when all soft tissue defects were covered, the cantilever external fixation frame was exchanged for a hybrid ring which provided three-dimensional stability and allowed early full weight bearing and joint mobilization. The hybrid ring frame did not interfere with the care of soft tissue injuries. Furthermore, it kept the risk of developing deep infections to a bare minimum. At follow-up after a median of 20 months, 1 patient had developed osteomyelitis but all had returned to independent function.

Microlaparoscopy in Diagnostic and Operative Gynecologic Procedures 

Dov Dicker, Shmuel Nitke, Itai Bar-Hava, Raul Orvieto, Zion Ben-Rafael, Arie Dekel

Depts. of Obstetrics and Gynecology, Rabin Medical Center, Beilinson and Golda Campuses, Petah Tikva; and Sackler School of Medicine, Tel Aviv University

A recent further development in laparoscopic surgery is microlaparoscoopy. The technique is identical to standard 10 mm laparoscopy except for the use of small, 2 mm scopes and trocars. We used this technique in 19 patients treated from June 1998 to February 1999.

The advantages of microlaparoscopy are: smaller incisions, less risk of damage to pelvic organs and less postoperative pain. However, the use of microlaparoscopy for operative procedures is limited to simple operations due to the limited field of vision. We urge our colleagues to consider microlaparoscopy whenever diagnostic laparoscopy is needed.

Cortical Blindness Following Coronary Angiography 

Addie Ron, Simcha Meisel, Myra Shapiro-Feinberg,Herman O. Klein

Depts. of Medicine, Cardiology and Diagnostic Imaging,Meir Medical Center, Kfar Saba

Cortical blindness has been occasionally reported as a complication after cerebral angiography, but is rare after coronary angiography. The contrast agent is believed to be responsible for the sudden development of blindness. Although the exact mechanism is unknown, it appears that the contrast agent disrupts the blood brain barrier, mostly in the occipital areas.

We report a 77-year-old man who suddenly developed transient, bilateral cortical blindness 4 hours after coronary angiography. Using contrast enhancement, the CT scan showed typical, symmetrical involvement of both occipital lobes. There were no other neurological deficits. Vision and CT findings returned to normal within 48 hours.

Causes of Blindness in Israel 

Y. Hod, Y. Corcia, Y. Yassur, O. Geyer

Depts. of Ophthalmology, Carmel Medical Center, Haifa and Rabin Medical Center, Petah Tikva; Israel Ministry of Labor and Social Affairs, Jerusalem; and Rehabilitation Services Administration, Services for the Blind

Of the world population, 38 million are blind and another 110 million are visually impaired. Even in the developed countries there are 3.5 million who are blind.

This study of blindness in Israel is based on the National Blind Registry. At the end of 1998, 15,937 were registered as blind, 0.3% of the total population; 776 (5%) of them were 18 years old or younger; 6,426 (40%) 18-65 years old; and 8,735 (55%) 65 years or older.

The leading causes of blindness in Israel are glaucoma (2,074, 13%), macular degeneration (1,954, 12%) and diabetes mellitus (1,680, 11%). Since glaucoma and diabetes, and to a lesser extent glaucoma, respond to treatment, blindness could have been avoided in most cases. National screening programs for early diagnosis and treatment of these diseases would reduce prevalence of the newly blind.

Early Detection of Glaucoma by a Mobile Unit

S. Kurtz, M. Goldenfeld, S. Melamed

Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer

Glaucoma, the third leading cause of blindness in the western world, is characterized by painless, gradual loss of visual fields which may lead to severe visual impairment or even blindness. In 4 years of operation of a mobile glaucoma unit for screening and early diagnosis of glaucoma, 10,037 subjects aged 18-95 years were screened (4504 women, 45%); 55% were under 50 years (Graph 1).

Ocular hypertension was diagnosed in 8.0%; primary open angle glaucoma (POAG) in 0.8%, with 2/3 already under treatment, the rest newly diagnosed. Pseudo-exfoliative glaucoma was diagnosed in 0.2%; only 2 cases had closed angle glaucoma; 91% of those screened were normal (Fig. 4; age stratification, Graph 3).

POAG increased with age, from 0.2% in those under 40 years to 10% in those over 80; POAG was more common in men, but OHT was similar in both sexes (6.0% vs. 5.3%). There was no correlation between incidence of POAG and place of work except in the Sorek Nuclear Center (1.9% vs. 0.8%, p=0.11). Other conditions significantly more frequent in POAG than normals were diabetes mellitus (x 2.5), systemic hypertension (x 4), myopia (x 2) and history of intraocular surgery (x 6).