תוצאת חיפוש

Acute Appendicitis during Pregnancy

Eldad Silberstein, Tali Silberstein, Gad Shaked, Miriam Katz, Moshe Mazor, Itzhac Levi

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

Acute appendicitis is the most common surgical problem in pregnancy, when it is difficult to diagnose early because of the physiological changes of pregnancy. We studied the problem in the Negev population and present the main issues in diagnosis and management. Between 1988-96, 26 women were operated on for acute appendicitis during pregnancy (1/3297 deliveries), 3 by laparoscopy. In 13 there was a histopathological confirmation of the diagnosis. Clinical diagnosis was more accurate in the first trimester of pregnancy than in the second or third (p=0.073). Premature delivery rate was higher in both confirmed and unconfirmed acute appendicitis than in other pregnancies (p<0.00001), but without significant differences between the 2 groups with appendicitis. Other indexes of maternal and perinatal morbidity did not differ either.

Parturient Compliance in Intra-Partum Epidural Analgesia

Eyal Sheiner, Ilana Shoham-Vardi, Moshe Mazor, Reli Hershkowitz, Miriam Katz

Obstetrics and Gynecology Depts., and Epidemiology and Health Services Evaluation Dept., Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba

The relationship between parturients' sociodemographic characteristics and the tendency of the medical staff to offer and of the parturients to accept intrapartum epidural analgesia, was investigated. 97 Jewish parturients were interviewed during January 1996. Multiple logistic regression analysis was used to evaluate the statistical significance of the results. 10 parturients (10.3%) asked for intrapartum epidural analgesia, and while 46 (47.4%) were offered it, only 22 (22.7%) accepted. Epidural analgesia was mostly offered to, and accepted by: low birth-order parturients (1st-3rd delivery), those belonging to the upper middle class, and to parturients with higher compliance with prenatal diagnostic tests. There was no significant association between the tendency of the medical staff to offer epidural analgesia to secular as compared to traditional parturients.

We conclude that the use of intrapartum epidural analgesia is related to various maternal sociodemographic characteristics. If the low compliance with epidural analgesia is related to prejudice and unfounded fears, we recommend that the benefits of this type of analgesia be explained before birth in the antenatal clinics.

Geriatric Rehabilitation in Israel: Assessment of Needs and In-Patient Services

J. Gindin, M.A. Clarfield, Z. Haklai, P. Zedaka, J. Brodesky, M. Davis

Geriatric Division, Kaplan-Hartzfeld Hospitals, Rehovot; Geriatric Wing, and Health Information and Computer Service, Israel Ministry of Health; Central Bureau of Statistics, Prime Minister's Office; Brookdale Institute, Jerusalem; and Health of the Elderly, Israel Center for Disease Control

Geriatric rehabilitation (GR) in Israel, which has not been thoroughly investigated, was examined by a subcommittee of the Committee on Health of the Elderly, in the Israel Center for Disease Control.

The needs of the elderly population for rehabilitational services were assessed and the existing services reviewed. A survey of GR beds, their geographic distribution, and the number of patients over 65 after CVA and hip fracture (the 2 main causes for GR need) was carried out. Data were gathered from records of the Ministry of Health and the Central Bureau of Statistics.

In 1994 there were 1,503 beds for active, long-term geriatric care in general and geriatric hospitals: 751 beds were assigned to rehabilitative geriatrics, and the rest to skilled-nursing geriatrics. A high concentration of beds was found in the geographical center of the country, in contrast to a small number in the periphery. Approximately 10,100 patients were hospitalized that year in rehabilitative geriatric and skilled-nursing wards.

There was considerable variation between services, as expressed in the wide range in average duration of hospitalization (from 12-269 days). Most of the beds for GR and skilled-nursing care beds were mixed in the geriatric wards together in the wards.

Limited services and public needs have led to the development of services outside the licensed and regulated settings, a process which has not yet been investigated. About 6,700 older patients were hospitalized during 1994 with a primary diagnosis of CVA. It has been estimated that 4,000 of them needed GR. 2,624 older patients died that year of CVA.

The increase in CVA prevalence between 1987 and 1994 was far greater than the increase in morbidity, in both the general and older populations. Nearly 4,000 elderly patients with a primary diagnosis of hip fracture, most of whom needed rehabilitation, were hospitalized in 1994. The total number of older patients who needed GR following CVA or hip fracture that year was set at 8,000. However, this figure is up to 30% lower than the actual rates, since the those 2 diagnoses include only 70% of total GR needs.

It is impossible to obtain a comprehensive picture of GR in Israel based only on currently available data. The subcommittee outlined areas to be thoroughly examined in-depth, including services and needs, as well as GR tools and processes and how to maintain the achievements of rehabilitation after discharge.

Massive Pulmonary Embolism

Ron Ben Abraham, Eran Segal, Dov Freimark, Elinor Goshen, Hanoch Hod, Jacob Lavee, Zvi Ziskind, Azriel Perel

Depts. of Anesthesiology and Intensive Care, Cardiology, Nuclear Medicine and Cardiac Surgery, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Pulmonary embolism is a common event in hospitalized patients. In some cases it presents with hemodynamic collapse, indicating massive obliteration of the pulmonary vasculature and has a very grim prognosis; 2/3 of such patients die within 2 hours of onset of symptoms. We describe our experience in 13 patients with massive pulmonary embolism. An aggressive diagnostic and therapeutic approach, utilizing sophisticated imaging techniques, thrombolytic therapy and surgery, led to the survival of 8 of the patients. Our experience supports an aggressive approach in these seriously ill patients.

Splenic Artery Aneurysm

M. Shimonov, M. Nobel, M. Kunichevski, E. Antebi

Depts. of Surgery A and Pathology, Rabin Medical Center, Petah Tikva

Splenic artery aneurysm is an uncommon form of vascular disease of unknown etiology. Its clinical importance is due to its high mortality, especially in pregnancy, when maternal mortality is 70% and fetal mortality 95%. Most cases of splenic artery aneurysm are asymptomatic and are diagnosed incidentally. We present a woman with incidentally diagnosed splenic artery aneurysm in whom the splenic artery and its aneurysm were resected.

Familial Occurrence of Ebstein Anomaly

Ruti Margalit-Stashefski, Avraham Lorber, Eyal Margalit

Family Practice Unit, Kupat Holim Klalit, Haifa, Pediatric Cardiology Unit, Rambam Hospital, Haifa and Ophthalmology Dept., Hadassah--University Hospital, Jerusalem

Ebstein anomaly is a rare congenital disease which affects location, structure and mobility of the tricuspid valve, and right atrium and ventricle. Although most cases are sporadic, familial occurrence has been reported. We report 2 brothers born with Ebstein anomaly. The parents were first degree cousins and there were 8 other children. 2 daughters were born with other congenital heart anomalies, 1 with ventricular septal defect and the other with severe pulmonary artery stenosis. We suggest that in some families, Ebstein anomaly is an autosomal dominant disease with different expression in the sexes.

Islet Autoantibody Assays in Type I Diabetes can Replace ICA Test

Daniel Lazar, Naomi Weintrob, Natalia Abramov, Sara Assa, Konstantin Bloch, Regina Ofan, Hadassa Ben-Zaken, Pnina Vardi

Institute for Pediatric Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva and Felsenstein Medical Research Center, Tel Aviv University

Islet cell antibodies (ICA) continue to serve as the basis of the principal serological test for definition of active autoimmunity of beta-cells. Its disadvantages are the need for human pancreatic tissue and difficulty in obtaining quantitative results. In the past decade biochemically-defined beta-cell antigens were described, leading to the development of sensitive and specific autoantibody assays, to predict insulin-dependent diabetes mellitus (IDDM). We examined the value of combined biochemically-based serological assays, such as autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA) and ICA512 (ICA512A) to replace the traditional ICA assay.

Blood samples of 114 newly diagnosed IDDM patients, aged 12‏5 yrs (range 2 months - 29 years) were tested for ICA (indirect immunofluorescence), IAA, GADA and ICA512A (radiobinding assay). The latter 2 assays were performed using recombinant human [35S]-labeled antigen produced by in vitro transcription/translation. We found that fewer sera scored positive for ICA and/or IAA (80.7%, 92/114) than for 1 or more of IAA, GAD, or ICA512 (88.6%, 101/114). We conclude that combined testing for IAA, GAD and ICA512 can replace the traditional ICA/IAA test to predict IDDM and is helpful in the differential diagnosis of insulin-dependent and noninsulin-dependent diabetes.

Combinations of Vasoactive Agents by Penile Injection for Erectile Dysfunction

E. Segenreich, S. Israilov, J. Shmueli, D. Simon, J. Baniel, P. Livne

Andrology Unit, Institute of Urology, Rabin Medical Center (Beilinson Campus), Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University

In the past 15 years there has been continuous increase in the use of injections into the corpora cavernosa of different vasoactive drugs for treatment of erectile dysfunction (ED). However, some of these drugs are very expensive, are not available everywhere, and have side effects. We therefore compared the success rate of the most widely used compounds, papaverine and regitine, in 452 patients (age range 26-85) with different types of ED. Each patient received in the clinic injections of papaverine, 6-25 mg, and regitine, 0.05-1.5 mg. When maximal rigidity of the penis (MRP) was >80%, we instructed the patient to self-inject the drug at home, 5-30 minutes before coitus. If after 3 injections MRP was not >80%, prostaglandin E1 (PGE1) in an average dose of 10-25 mcg was added. If there was no response, papaverin+regitine+PGE1 were given in higher dosage, and atropine sulfate, 0.02+0.06 mg, was added if necessary.

Of 452 patients, 305 (67.4%) had MRP >80% after 3 injections of papaverine plus regitine. The other patients received PGE1 in addition. This was helpful in 61 patients (41.5%), while 55 (63.9%) required papaverine + regitine + prostin in higher doses. Of these, only 31 received papaverine + regitine + PGE1 + atropine sulfate. Of these, 20 (64.5%) reached MRP >80%, and 11 (2.4%) MRP <60. For these 11 patients, we recommended a penile prosthesis. Thus in 67.4% of the 452 patients, papaverine + regitine injections were effective; in 41.5%, PGE1; in 63.9%, papaverine + regitine + prostin + atropine sulfate. Only 11 (2.4%) did not react to intracorporeal injection.

This progressive method of treatment enabled us to select the optimal dosage and combinations of compounds in 441/452 patients (97.5%) according to the severity of their dysfunction. During follow-up of 6 months, spontaneous erections without injection were achieved in 115 (26.0%).

Changes in Structure and Process Components of Trauma Care in Emergedepartments

Rephael Joseph Heruti, Ron Ben-Abraham, Yanir Abramovitch, Michael Stein, Joshua Shemer, Baruch Marganit

Trauma Control, Israeli Center for Disease Control (ICDC), Israel Ministry of Health and Sackler School of Medicine, Tel Aviv University

In recent years there have been tremendous efforts to improve primary trauma care. The Ministry of Health and other authorities have invested in new trauma facilities in various hospitals. A nationwide survey with regard to structure and function of emergency departments was carried out. Compared to a similar survey conducted in 1992, significant progress in quality and quantity of equipment at various emergency departments was demonstrated. However, there are still differences between various hospitals. A drive to standardize trauma care will undoubtedly contribute to improvement in care of the injured.

Taxol as Second-Line Therapy in Recurrent Breast and Ovarian Cancer

R. Borovik, M. Steiner, J. Atad, B. Sneiderman, T. Rosenberg, S. Palti

Oncology Depts., Lin Medical Center and Carmel Medical Center, Haifa

Results of chemotherapy with Taxol (paclitaxel) in 55 patients with recurrent breast and ovarian cancer were reviewed. Taxol was given as a 3-hour infusion, every 3 weeks, on an outpatient basis. There was complete or partial response in 8 patients (23%) with breast cancer and 10 (50%) with ovarian cancer. Performance status and previous response to adriamycin were important prognostic factors. Toxicity was manageable. Treatment had to be stopped for hypersensitivity reactions in only 2 patients. Taxol given in an ambulatory clinic is safe and effective.

Chemical Synovectomy in Arthritis by Intra-Articular Injection of Osmic Acid

D. Markovits, M. Rozenbaum, I. Rosner, E. Rottenstriech

Dept. of Medicine A, Carmel Hospital; Rheumatology Unit, Bnai Zion Hospital; and Zevulun Medical Clinic, Haifa

18 patients suffering from persistent synovitis despite medical therapy were treated with an intra-articular injection of osmic acid. After 1 year of follow-up, 68% had good results and there were no complications nor detectable radiographic evidence of disease progression. Because osmic acid is almost as effective as surgical synovectomy and is cheap and easy to administer, it can be recommended as the first choice for treatment of corticosteroid-resistant arthritis in the early stages of the disease.

Acute Hyperparathyroidism Caused by Hemorrhage into a Parathyroid Adenoma

I.E. Priel, Rama Katz, E. Dolev

Depts. of Medicine E and Radiology, Wolfson Medical Center, Holon and Sackler School of Medicine, Tel Aviv University

Acute hyperparathyroidism is a rare and dangerous condition. It is supposed to result from transformation of a mild chronic form into an acute and stormy illness. The causes and the mechanism of such a transformation are usually unknown. A case of acute hyperparathyroidism is presented in which hemorrhage into a parathyroid adenoma was recognized and diagnosed as the immediate cause of the transformation from the mild long-standing form of the disease into the severe acute form.

Living-Related Liver Transplantation

N. Bar-Nathan, Z. Shapira, E. Shaharabani, A. Yussim, Y. Ben-Ari, T. Sheinfeld, I. Zehavi, R. Shapira, G. Dinari, Z. Ben-Ari, R. Tur-Kaspa, E. Mor

Dept. of Transplantation and Liver Institute, Rabin Medical Center (Beilinson Campus), and Pediatric Intensive Care and Pediatric Gastroenterology Units, Schneider Children's Medical Center, Petah Tikva

Our experience with living-related liver transplantation is described. In 2 boys and 1 girl, aged 4-4.5 years with acute, fulminating hepatitis A, the presence of very severe jaundice (bilirubin levels > 18 mg%) associated with severe coagulopathy (INR>10) and encephalopathy indicated the need for urgent liver transplantation. In all 3 cases the left lateral hepatic segment of a matched blood type parent was transplanted. None of the donors suffered a serious complication postoperatively and all returned to full activity in 6-16 weeks. The post-transplantation course was uneventful in 1 child, but in the other 2 there was hepatic arterial thrombosis in 1 at 1 day and in the other at 8 days post-transplantation. Early detection of arterial thrombosis by Doppler sonography permitted salvage of the 2 hepatic grafts after thrombectomy and re-anastomosis. In 1 of these 2 children an anastomotic biliary stricture was found 2 months after transplantation. It was corrected at surgery and a percutaneous stent was inserted. All 3 children are alive with normal graft function at 2, 7 and 8 months post-transplantation, respectively. This initial experience indicates that living-related liver transplantation is feasible in Israel. The technique might help to solve our severe organ shortage for children awaiting liver transplantation.

Primary Care Physicians in Israel Compared with European Countries

P. Shvartzman, R. Gross, H. Tabenkin, D. Yuval, M. Grinshtein, B. Wienka

Dept. of Family Medicine, Ben-Gurion University of the Negev, Beer Sheba;

Brookdale Institute, Jerusalem; and Nivel Institute, Maastricht, the Netherlands

This study compares Israeli primary care physicians with those of European countries. In Israel a larger proportion of those in primary care are women. The Israeli physicians see many patients a day, but almost never make home visits. They also report for work the fewest hours a day, but spend 21 hours a month in continuous medical education. (more than Europeans?) The Israeli primary care physician scores high in screening for breast cancer and blood cholesterol level, but very low in the fields of minor surgery and alcohol and smoking prevention, contraception, nutrition counseling and normal pregnancy follow-up. Residency training and education may be inadequate, and more emphasis has to be put on the health system and recognizing environmental influences.

Cardiac Failure following Sting of Yellow Scorpion in an Adult

C. Kristal, I.Y. Shemesh, Y. Mishal, A. Bourvin

Intensive Care Unit, Dept. of Anesthesia and Medical Dept., Barzilai Medical Center, Ashkelon

3 men, aged 18, 29, and 47 had severe cardiovascular disturbances following the sting of the yellow scorpion (Leiurus quinquestriatus hebraeus), which is considered the most dangerous scorpion in Israel. Cardiovascular complications are common in children after scorpion sting, but are rare in adults. Pulmonary edema developed in 1 of those being reported and hypertension and arrhythmias in the other 2. Severe deterioration in left ventricle function was confirmed by echocardiographic measurement of diminished ejection fraction. All patients recovered completely. This is the first report of severe cardiac involvement in adults following scorpion sting. We therefor recommend that even adults who develop cardiac symptoms after scorpion sting, particularly those with chronic cardiac disease, be monitored and treated in an intensive care unit.