תוצאת חיפוש

מיכאל אהרנפלד¹, פנינה לנגביץ², יהודה שינפלד³

מחלקות לרפואה פנימית ג¹, ו² ו- ב³ והיחידה למחלות מיפרקים, המרכז הרפואי שיבא, תל-השומר

Limited Percutaneous Surgical Drainage in Severe Neonatal Necrotizing Enterocolitis in Low Birth Weight Prematures

Robert Finaly, Zahavi Cohen, Vadim Kapuller, Agneta Golan, Edna Kurtzbart, Abraham Mares

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

The usual treatment of complicated neonatal necrotizing enterocolitis (NEC) is resection of the necrotic bowel, lavage of the peritoneal cavity and diversion enterostomy. Low-birth-weight premature neonates with this condition are in special danger if general anesthesia and full exploratory surgery is contemplated.

A relatively simple alternate procedure is percutaneous insertion under local anesthesia of a soft abdominal drain, most often in the right lower quadrant. The procedure is done in the neonatal intensive care unit without moving the whole set-up to the operating room.

4 such cases have been treated within the past year. 3 were discharged home as they did not require additional surgical treatment, not having developed intestinal stenosis or obstruction. 1 recovered from the acute episode, but succumbed to a severe intraventricular hemorrhage and respiratory failure 7 days after the procedure.

Our limited but most gratifying experience, in addition to similar experience of others, encourages us to recommend this simple surgical approach in the very sick low-birth-weight premature with fulminant NEC.

Information Provided for Informed Consent in Clinical Trials

Avishay Sella

Genitourinary Medical Oncology Unit, Dept. of Oncology, Rabin Medical Center (Beilinson Campus), Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University

The Helsinki Declaration contains recommendations guiding physicians who conduct clinical trials. One is that the requirement for informed consent is essential for approval of a trial. An important component of the informed consent doctrine is that all data required for the participant's decision must be provided. We analyze data of a therapeutic trial, and define 12 data components outlined in, or directly derived from the Helsinki Declaration.

61 instances of informed consent for therapeutic clinical trials from various fields of medicine, from 1994 to 1997, were analyzed. In each the presence of the 12 components was evaluated.

The data demonstrated that there were only 5 components cited in most cases of informed consent: trial objectives, methods, treatment plan, risks, and the option of withdrawing. Benefit to the participant was mentioned in half the cases, while only limited information was provided about other components such as life-threatening and unpredictable risks, and alternative treatment.

Examples of informed consent from 1997 showed statistical improvement since 1994 in the data concerning trial objectives, methods, risks and alternative therapy. Informed consent documents of international multicenter trials compared with local trials showed statistical improvement in the data components of the trial objectives, methods, and risks, including those of potentially life-threatening and unpredictable risks, and alternative therapy. Analysis of informed consent showed that not all components required for a comprehensive decision regarding participation in a clinical trial are included. These data emphasize the need to design a structured informed consent protocol in which all the required data components are specifically outlined for potential participants.

Laparoscopic Treatment of Small Bowel Obstruction Caused by Adhesions

S. Kyzer, Y. Aloni, I. Charuzi

Surgery Unit B, Wolfson Medical Center, Holon

We describe our experience in 14 patients operated on for small bowel obstruction, who underwent laparoscopic adhesiolysis. In 13 (93%) the obstruction was relieved and only 1 case required conversion to open operation. Bowel activity usually resumed within 24-48 hours, and there were no remarkable intraoperative and postoperative complications. During follow-up none developed recurrent obstruction.

Our experience demonstrates that laparoscopic adhesiolysis is a valid therapeutic option. Additional experience is needed to determine which types of cases are suitable for the procedure.

Combined Sclerotherapy and Surgery for Huge Cervical Lymphangioma

Zvi Steiner, Asher Pressman, Jorge Mogilner

Dept. of Pediatric Surgery, B'nei Zion Medical Center and Faculty of Medicine, Technion Institute of Technology, Haifa

Lymphangioma is a benign developmental anomaly of the lymphatic system located in about 40% of cases in the neck and usually completely resectable. In some cases it invades adjacent structures such as the larynx, pharynx, or tongue. In such cases it is almost impossible to resect completely, as this would endanger vital structures.

We describe a baby born with a huge cervical lymphangioma which invaded the tongue, larynx, pharynx and other cervical structures. He was treated with bleomycin and aethoxysklerol. The sclerotherapy shrank the lymphangioma considerably and it became resectable. At 2 years of age the cosmetic result is good and vital function, such as swallowing and facial expression, are preserved.

Smoking and Incidence of Lung Cancer, 1981-1995

Orna Baron-Epel, Helena Andreev, Micha Barchana, Manfred S. Green

Israel Center for Disease Control, Ministry of Health, Tel Hashomer, Israel; Cancer Registry, Ministry of Health, Jerusalem, and Dept. of Epidemiology and Preventive Medicine, Faculty of Medicine, Tel Aviv University

Smoking is the dominant risk factor for lung cancer. We compared trends in smoking with those of the incidence of lung cancer in Israel. The proportion of smokers has declined during the past 20 years; the decrease is greater in men than in women, and more marked in the elderly. Since 1980 the age-adjusted incidence of lung cancer in Jewish men has decreased slightly, but in women it has remained constant. Among Arab men there was an increase in age-adjusted incidence of lung cancer and since 1986 it has been higher than in Jewish men.

The largest decrease in lung cancer incidence was among Jewish men aged 75 and over. This may be explained by data on the age of smoking cessation in the population. It was observed that the main decrease in smoking occurred among men over the age of 55 in the past 20 years, which correlates with the decline in lung cancer observed in the older age group. Lung cancer rates in Israel are lower than in other western countries despite the similar prevalence of smoking, for unknown reasons.

Attentional Characteristics of Developmental Right Hemi-Sphere Syndrome

Yael E. Landau, Varda Gross-Tsur

Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem

Developmental right hemisphere syndrome (DRHS) is characterized by emotional and interpersonal difficulties, attention deficit hyperactivity disorder (ADHD), visuo-spatial handicaps, subtle left body neurologic signs and failure in nonverbal academic domains, especially arithmetic. Concurrence of ADHD and DRHS is not surprising because research has implicated dysfunction of the right hemisphere in both syndromes. Furthermore, the right hemisphere has more brain areas devoted to attentional processing, making it more important and more vulnerable in attentional problems.

We describe the clinical parameters of DRHS as exemplified by 2 cases, a boy and a girl, both 13 years old. They participated in a study group in which attention and speed of performance were assessed in children with DRHS and were compared to children with ADHD and to a control group. A tendency to overfocusing, difficulty in inhibition, perseverative behaviors, stereotypy, and slowness and absence of hyperactivity characterized the DRHS group. These behaviors led us to hypothesize that the attentional symptoms in DRHS define a specific subgroup of ADHD which requires a different therapeutic approach.

High Alkaline Phosphatase in Subacute Thyroiditis

Rami Kantor, Rachel Pauzner, Elena Pali, Zvi Farfel

Dept. of Internal Medicine E, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Subacute thyroiditis may be hard to diagnose, therefore patients are sometimes misdiagnosed and subjected to unnecessary work-up. We report a 37-year-old man with subacute thyroiditis and a high concentration of serum alkaline phosphatase. After aspirin treatment there was clinical improvement and decrease in rapid ESR, and in high serum thyroxin and alkaline phosphatase. The increased alkaline phosphatase, seen in as many as 50% of patients, is of hepatic origin, and is not caused by high serum thyroxin. Awareness of this relationship may help in diagnosis and may prevent unnecessary diagnostic procedures, which may be invasive.

Neurological Manifestations of Non A-G Viral Hepatitis

Rifaat Safadi, Yaron River, Yosef S. Haviv, Yaron Ilan

Liver Unit, Division of Medicine and Neurology Dept., Hadassah University Hospital, Jerusalem

Guillain-Barre and other neurologic syndromes rarely occur as complications of viral hepatitis (A, B and C). Other neurologic syndromes have also been reported in serologically defined viral hepatitis, including mononeuritis, auditory neuritis, and seizures. Chronic hepatitis B and mononeuritis multiplex are found together in 31-54% of patients with periarteritis nodosa. The mechanisms of these associations are unknown, but may include direct cytotoxicity of the virus or immune-mediated damage. Vasculitis of the vasa nervorum plays an intermediate role, at least in some cases. We describe a 36-year-old man with acute non A-G hepatitis complicated by Guillain-Barre syndrome. The neurological manifestation resolved completely without specific therapy within 6 days, as the hepatitis resolved.

Knowledge and Practice of Primary Care Physicians Relating to Streptococcal Pharyngitis

S. Leshem, H. Tabenkin, E. Dan, A. Tamir

Family Medicine Dept., Emek Medical Center and Northern District of Kupat Holim; and Northern Branch of Specialization Institute, Faculty of Life Sciences, Ben-Gurion University of the Negev, Beer Sheba

Knowledge and practice of primary care physicians as to diagnosis and treatment of group A, b-hemolytic streptococcal pharyngitis, and the degree to which they agreed with the medical literature and current clinical guidelines were examined. The study was conducted in a group of 195 general physicians, pediatricians, and family medicine specialists and residents. The data were collected using questionnaires which included personal information and questions relating to b-hemolytic streptococcal pharyngitis and were analyzed by chi-square and t-tests, and logistic regression, as appropriate. A new dependent variable, good clinical practice (GCP), was defined as the total number of correct answers to the questions in the questionnaire. 147 of the 195 eligible physicians returned completed questionnaires, a compliance rate of 76%.

96.6% cited pV as the drug of choice at a daily dosage of 1 g (43.7%) or 2 g (25.4%), for 10 days (90%). 133 physicians (90%) stated that the goal of penicillin therapy for beta-hemolytic streptococcal pharyngitis is to prevent late complications. 116 physicians (82%) cited rheumatic fever as a complication of group A beta-hemolytic streptococcal pharyngitis, preventable by appropriate antibiotic therapy. However, only 84 (59%) cited glomerulonephritis as a preventable complication.

When the knowledge and attitudes of the respondents was analyzed in terms of the new variable, GCP, a significant association (p<0.001) was found between physicians’ attitudes and variables such as where they had studied medicine, and work seniority. Those with less seniority and or medical graduates of the Americas demonstrated greater knowledge and better clinical judgment than their more senior colleagues and graduates of European and Asian medical schools. Most primary care physicians in northern Israel treat group A b-hemolytic streptococcal pharyngitis as recommended in the medical literature.

The level of medical studies in Israel and the Americas and the quality of training of residents in family medicine and pediatrics, have a positive influence on the degree of knowledge of as common a subject as b-hemolytic streptococcal pharyngitis. Emphasis should be placed on continuing medical education among primary care physicians, particularly veteran general physicians and those who studied in European or Asian medical schools.

Influenza Surveillance through Sentinel Reporting Clinics

T. Shohat, N. Versano, A. Kiro, G. Golan, E. Mendelson, M. Weingarten

For the Influenza Surveillance Network: Israel Center for Disease Control, Israel National Laboratory for Influenza and Central Virology Laboratory; Netka Child Health Center and Dept. of Family Medicine, Rabin Medical Center, Beilinson Campus, Petah Tikva

In a joint effort of the Israel Center for Disease Control, the National Center for Influenza in the Central Virology Laboratory, together with a group of collaborating pediatricians and family physicians, a network for influenza surveillance was established in the winter of 1996-97. Nose and throat swabs were obtained from 571 patients with flu-like illness. 133 (23%) were positive for influenza virus. Both influenza A(H3N2) and B were isolated, predominantly influenza B during the beginning of the season. Both circulating strains were antigenically similar to those included in the vaccine for 1996-1997. Patients from whom influenza virus was isolated were significantly more likely to suffer from cough and myalgia in comparison with patients whose cultures were negative (p=0.02 and 0.003. respectively). Results of the first year of surveillance indicate that sentinel reporting clinics are useful for timely detection and identification of the viral strains circulating in the community, thus allowing prompt intervention in preventing the spread of influenza. Conclusions from the first year of the study were drawn and applied in the winter of 1997-1998.

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.

Proper use of Pressurized Hand-Held Inhalers in Patients with Chronic Airway Obstruction 

Shabtai Varsano, Ilana Jacoby, Mila Garenkin

Asthma Care and Education Unit, Dept. of Pulmonary Medicine, and Epidemiology Unit, Meir General Hospital, Sapir Medical Center, Kfar Saba; and Sackler School of Medicine, Tel Aviv University

Inhaling drugs via hand-held inhalers in recommended for those with chronic obstructive airway disease (COPD). Approximately 8%-9% of Israel's population use hand-held inhalers, many of them pressurized. Skill in using them and ability of chronic users to learn their proper use have not been assessed.

During 1993 and 1994 we studied 200 patients with bronchial asthma or COPD who regularly used a pressurized hand-held inhaler (PI), but were not trained to use it in our out-patient pulmonary clinic. Only a third were found to be skilled in its use. About half were completely unable to use it properly, and 17% used it in a suboptimal way. Remarkably, only 40% had been taught anything with regard to its use. About 75% of the suboptimal users significantly improved their skill in its use immediately after receiving a single individual teaching and corrective demonstration session. While 15% failed to learn the proper use of the PI, many of those who improved immediately after a single teaching session retained the learned skills for months.

We conclude that the physician who recommends the use of a PI is responsible for the patient's being taught its proper use in a demonstration session. Skill in its use should be reassessed periodically during the entire treatment period.

The Fate of Gallstones "Dropped" during Laparoscopy

Menashe Barzilai, Arie Bitterman, Dorit Schlag-Eisenberg, Nathan Peled

Depts. of Radiology and Surgery B, Carmel Medical Center, Haifa

Laparoscopic cholecystectomy is considered the procedure of choice for removing symptomatic, stone-containing gallbladders. It is estimated that in 30-40% of these operations stone(s) spill into the peritoneal cavity. It was assumed that these "dropped stones" are harmless and are dissolved and absorbed spontaneously. We present a 70-year-old woman in whom such a stone, dropped during laparoscopy, led to formation of an intraperitoneal abscess.

Ultrasonographic Imaging of Superior Sagittal Thrombosis

Ilan Shelef, Avi Cohen, Yehiel Barki

Depts. of Radiology and Neurosurgery, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Ultrasonographic findings of superior sagittal sinus thrombosis include dilated and hyperechoic sinus (direct imaging of the thrombus). No flow should be demonstrated by the various Doppler techniques. In the deeper sinuses, if the thrombus can not be visualized after a negative Doppler study, MR imaging is recommended. Recanalization and reflow can be demonstrated on follow-up study.