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Biomedical subjects

Ram M Spira

Publications and source records attributed to Ram M Spira.

9 recordsLinked to original sources
PubMed2006

Surgeon and hospital leadership during terrorist-related multiple-casualty events: a coup d'état.

HYPOTHESIS: During terrorist-related multiple-casualty events (TMCEs), the role of the surgeon expands beyond providing traditional trauma care. DESIGN: Survey and expert opinion poll. SETTING: Interviews (structured, open/closed questions) conducted in 14 Israeli hospitals. PARTICIPANTS: Sixty hospital physicians selected for their experience in TMCEs. MAIN OUTCOME MEASURES: Identification of key staff members and their roles during TMCEs and development of recommendations for hospital management. RESULTS: During TMCEs, hospitals are comanaged by a physician hospital administrator and a clinical medical director (usually a surgeon) responsible for prioritization of patient care. Primary triage is often performed by a general surgeon experienced in trauma. Trauma specialists supervise other physicians providing patient care. Key staff members to recruit to the hospital at event onset include the chiefs of surgery and anesthesiology, attending surgeons and anesthesiologists, critical care physicians, and radiologists. Paramedics stationed in-hospital as emergency medical services liaisons improve communication between the field and the hospital. Operating room and intensive care unit (ICU) management remain unchanged. Controversies exist regarding continuation of planned and ongoing elective surgery and ICU triage despite use of the postanesthesia care unit as an extension of the ICU. CONCLUSIONS: During TMCEs, surgeons fill pivotal roles in hospital command and control and hands-on clinical care. Anesthesiology services and ICUs are relied on heavily for provision of patient care and should be included in information flow and decision making. Operating room and ICU management should remain unchanged since the care of patients who are already in these locations at the time disaster strikes is a subject of controversy with ethical implications.

General Surgery↗
PubMed2004

Clinical profile of breast cancer in Arab and Jewish women in the Jerusalem area.

BACKGROUND: The clinical profile of breast cancer may vary among different ethnic groups living in the same country and therefore affect the yield of a breast cancer screening program. The present study attempts to better characterize the breast cancer clinical profile of Arab women compared with Jewish women in the greater Jerusalem area with a future aim of establishing a comprehensive and effective screening program for this population. METHODS: Retrospective chart review was conducted and the following covariates were correlated with survival: ethnicity, age at diagnosis, and American Joint Committee on Cancer (TNM) stage at diagnosis. RESULTS: A total of 312 women were operated on for breast cancer between 1994 and 1999; 51% were Ashkenazi Jews (AJ), 26% were Sephardic Jews (SJ), 21% were Palestinian Arabs (PA), and 2% patients did not fit into those ethnic groups. The mean age at diagnosis was 51.5 years for the PA group, 53.4 +/- 1.5 for the SJ group, and 55.9 years for the AJ group (P <0.03 PA versus AJ). The tumor size (mean +/- SEM) was 38.8 +/- 3.7 mm, 31.1 +/- 2.4 mm, and 24.5 +/- 1.6 mm for the PA, SJ, and AJ groups, respectively (P = 0.03 for PA versus SJ and P <0.001 for PA versus AJ). Five-year overall survival was 77 %, 72%, and 58% for the AJ, SJ, and PA groups, respectively (P = 0.02); and 5-year disease-free survival was 72%, 51%, and 50% for the AJ, SJ, and PA groups, respectively (P = 0.03, AJ versus SJ). CONCLUSIONS: Our data demonstrate younger age and larger primary tumor size for the Arab patients compared with the Jewish patients. These findings were associated with lower 5-year survival and disease-free survival of the Arab patients.

Adult↗
PubMed2003

Laparoscopy for adhesions.

Intestinal and abdominal adhesions may be responsible for a variety of clinical conditions, including chronic recurrent small-bowel obstruction, acute small-bowel obstruction, closed-loop bowel obstruction and, debatably, abdominal or pelvic pain. Experience in laparoscopic surgery has increased at a rapid pace, thus adhesions are no longer considered a contraindication to treatment of these conditions. In recent years, numerous publications have reported the feasibility, safety, and favorable outcome of laparoscopic intervention in various adhesion-related conditions. As adhesions are the most common cause of recurrent or acute bowel obstruction, this review will focus on the laparoscopic management of these conditions and outline the technical considerations, indications, contraindications, and results.

Abdominal Pain↗
PubMed2003

[Screening mammography for early diagnosis of breast cancer: facts, controversies, and the implementation in Israel].

BACKGROUND: Breast cancer is the leading cancer among Israeli women. Mammography is the most widely used tool for early diagnosis of breast cancer. Eight published randomized controlled trials followed nearly 500,000 women over 7 to 18 years. Most trials found that screening mammography decreases breast cancer mortality by 20 to 40%. A recent study examined the methodology of the randomized clinical trials and found that most trials were flawed in the methodology of data collection and analysis in a way that might have influenced the results of those trials. PURPOSE: To review the studies, clarify the issues, and reach a conclusion regarding the utility of screening mammography in reducing breast cancer-related mortality in Israel. METHODS: A review of the world literature, and analyses of the Israeli data. RESULTS: Seven out of eight published randomized controlled trials found a significant decrease in breast cancer mortality among women who underwent screening mammography. A meta-analysis of the trials also supports the utility of screening mammography in decreasing breast cancer mortality. The criticism over the methodology of these trials does not necessarily invalidate their conclusions. CONCLUSIONS: The data indicate that screening mammography does indeed assist in early diagnosis, and most published studies show a significant reduction in breast cancer-related mortality in the screened population. Due to the high incidence of breast cancer in the Israel, especially among young women, the national screening program should continue. Moreover, consideration should be given to expanding it to women starting at age 45, instead of 50, as is practiced today.

Adult↗
PubMed2003

Comparison of bursting pressure of abdominal wall defects repaired by three conventional techniques.

Still debated are the appropriate techniques for the repair of abdominal wall defects and the methods used to measure their strength. Although tension has been used in many studies to test wound strength, bursting pressure reflects more accurately the pathophysiology of wound dehiscence. The aim of the current study was to evaluate three different techniques for closure of abdominal wall defects using a new and more accurate device for bursting pressure measurements. Full thickness abdominal wall defects measuring 2 cm2 were created in 43 anesthetized rats randomly assigned to three groups: simple primary closure (n = 15), Mayo repair (n = 14), and primary closure reinforced with a mesh (n = 14). Thirty days after surgery, the rats were sacrificed. The abdominal wall was fully excised and placed over a bursting chamber made of a metal cylinder connected to a carbon dioxide source with a control valve and a manometer. Gas was gradually released while the pressure was recorded until bursting occurred. Disruption of all closures occurred at the point where the suture itself penetrated the tissue. The average bursting pressure was 1383 +/- 299 mm Hg for the primary closure group, 1200 +/- 409 mm Hg for the mesh reinforcement group, and 1607 +/- 337 mm Hg for the imbrication repair (Mayo) group (P < 0.03). The data suggests an advantage for the Mayo repair over the other two repairs. The bursting chamber tested is a new and more reliable method to study techniques and conditions influencing the strength of abdominal wall closure.

Abdominal Wall↗
PubMed2002

Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis.

BACKGROUND: The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients. METHODS: The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999. RESULTS: The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 plus minus 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury. CONCLUSIONS: The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.

Acute Disease↗
PubMed2002

Retroperitoneoscopic lumbar sympathectomy.

We present a series of 27 consecutive unselected patients who underwent 29 retroperitoneoscopic lumbar sympathectomies. There were 21 male patients and six female patients, with a mean age of 45 years (RANGE, 21 to 28 years). Twenty-two patients had ischemia of the lower limb, and five patients had severe reflex sympathetic dystrophy. The retroperitoneal space was developed with a balloon trocar inserted through a small incision in the flank. Additional trocars used for endoscopic instruments. The sympathetic chain from the ganglia second lumbar vertebrae to the fourth lumbar vertebrae was resected. The procedure was successfully accomplished in all the patients without any operative or postoperative complications. The mean operative time Was 136 minutes, and the mean hospital stay was 1.4 days. All the patients had significant improvement of pain or dystrophic changes. Retroperitoneoscopic lumbar sympathectomy successfully combines the advantages of minimally invasive surgery with the effectiveness of the open procedure.

Female↗
PubMedDate not supplied

Intraoperative palpation for clinically suspicious axillary sentinel lymph nodes reduces the false-negative rate of sentinel lymph node biopsy in breast cancer.

Axillary sentinel lymph node biopsy (SLNB) is widely used to identify the first lymph node draining breast tumors. When the sentinel lymph node is free of metastasis, axillary dissection is avoided because the rest of the nodes are expected to be negative as well. A false-negative rate of 5% is considered acceptable. In the case of a false-negative SLNB, adjuvant local and systemic treatments might be suboptimal. We assessed the effect of intraoperative axillary palpation for clinically suspicious lymph nodes that are not otherwise detected by radioactive tracer or blue dye on the false-negative rate of SLNB in breast cancer patients. Our prospective database of patients having surgery for primary invasive breast cancer and who had a SLNB from 2000 to 2004 was reviewed. Only patients with clinically negative nodes preoperatively were included. The procedure included preoperative injection of radiotracer, with dye injection as backup, and intraoperative palpation of the axilla for suspicious lymph nodes that were not radioactive or blue. Of the 290 patients, 89 (30.7%) had sentinel node involvement by tumor. Seven patients had clinically suspicious nodes identified solely by palpation and not by tracer, in addition to sentinel lymph nodes detected by tracer. In five of the seven patients, the nodes harbored metastasis. In four of these five patients (4.5% of the 89 patients with axillary involvement), the palpable nodes were the only ones involved. A generous axillary incision and systematic palpation of the axilla reduces the false-negative rate and should be a part of the SLNB procedure.

Breast Neoplasms↗