שי מרקו, אלעד לרון, משה מזור

החטיבה למיילדות וגינקולוגיה, מרכז רפואי אוניברסיטאי סורוקה, הפקולטה למדעי הבריאות, אוניברסיטת בן-גוריון בנגב, באר-שבע

שיררומות רחם הן שאתות טבות ממקור של שריר חלק ומהוות גורם שכיח לדימום רחמי לא חד.

הן נפרדות מרירית הרחם, אך אינן עטופות קופסית סיבית. הטיפולים המוצעים כיום לחולות בשרירומות, כגון כריתת רחם, כריתת השרירומת עצמה וטיפולים נוספים אחרים, הם בעלי חסרונות. תיסחוף עורק הרחם באמצעות צינתור הוא טיפול חדש שהוצע על ידי Ravina וחב' ב- 1994. תיסחוף עורק הרחם הוא שיטה לא ניתוחית ומהווה כיום נקודת מיפנה בחשיבה הגינקולוגית ובטיפול בנשים עם שרירומות רחם תסמיניות המעוניינות לשמר את יכולת הפוריות שלהן. בשיטה זו מתבצע צינתור עורק הרחם וחסימת זרימת הדם לעבר השרירומות המסופקות על ידו. בסקירה זו מובאת סקירת המחקרים ותוצאותיהם בתחום חדש זה.

Atrophic Gastritis Presenting with Pulmonary Embolism

Muhammad A. Abdul-Ghani, Rima Feldman, Moshe Shai, Jacob Varkel

Dept. of Medicine C, Western Galilee Hospital, Naharia

Atrophic gastritis is an autoimmune gastropathy in which there is destruction of gastric parietal cells. This results in intrinsic factor deficiency and disturbance in vitamin B12 absorption. Its clinical manifestationa are therefore the consequences of B12 deficiency and include anemia and neurological defect. In addition, lack of B12 results in metabolic changes, including disturbances of methionine metabolism and accumulation of homocysteine.

In recent years, there has been increasing evidence suggesting that hyperhomocysteinemia is a risk factor for thrombo-embolic disease. We describe a 51-year-old man with atrophic gastritis, severe B12 deficiency and hyperhomocystein-emia. The initial clinical manifestation was pulmonary embolism, without either anemia or neurological signs. B12 deficiency should therefore be considered in patients being investigated for hypercoagulability.

Benign Paroxysmal Positional Vertigo: Diagnostic Pitfalls 

C.R. Gordon, O. Zur, R. Furas, E. Kott, N. Gadoth

Depts. of Neurology and of Physical Therapy, Meir General Hospital, Kfar Saba, and Sackler Faculty of Medicine, Tel Aviv University

Benign paroxysmal positional vertigo (BPPV) is a common but often unrecognized cause of treatable vertigo. Possible causes of misdiagnosis of BPPV were studied by review of the records of 191 patients referred to our neurology clinic; 36 were identified as having BPPV not previously diagnosed. On referral the patients carried the following diagnoses: unspecified dizziness/vertigo (33%), transient ischemic attacks (28%), cervicogenic vertigo (19%), psychogenic dizziness/vertigo (11%), and others (8%).

The paroxysmal nature of the vertigo and position-precipitating factors were not spontaneously reported by 31%. Atypical, even bizarre, symptoms including dizzy sensations were reported by 19%, and neck pain and headache were cardinal symptoms that accompanied vertigo.

The Dix-Hallpike maneuver, which is essential for the diagnosis of BPPV, was not performed in any of the patients prior to referral. 30 (83%) experienced complete resolution of signs and symptoms after the first physical treatment session.

We conclude that non-paroxysmal, non-positional vertigo does not rule out BPPV. Atypical and even bizarre complaints of dizziness, as well as neck pain and headache could be cardinal symptoms of BPPV. The Dix-Hallpike maneuver is mandatory in those complaining of dizziness and vertigo.

Carbon Dioxide Gas Embolism during Laparascopic Cholecystectomy

Anat Laver-Segal, Miguel Iuchtman, Paltiel Weiner

Depts. of Anesthesiology, Surgery A and Medicine A, Hillel Yaffe Medical Center, Hadera and Rappaport Medical School, The Technion, Haifa

A case of carbon dioxide gas embolism during laparascopic cholecystetomy is presented. Prompt diagnosis and immediate treatment resulted in positive outcome. Laparascopic cholecystectomy is nowadays one of the most common operations for cholecystectomy and certainly the most frequent endoscopic surgical procedure. It is usually safe and effective. However, a number of serious complications have been reported during the procedure.

Gas embolism is one of the complications that may occur during the initial gas insufflation or during dissection of the gall bladder. Symptoms are mainly related to the speed and the amount of gas that reaches the venous system. Early recognition and prompt treatment are required to prevent severe morbidity or even fatal outcome.

Transesophageal echocardiography has detected many unsuspected cases of gas embolism. However, capnograph monitoring of end-tidal CO₂, routinely used in everyday anesthesia, is highly reliable in alerting to the possibility of gas embolism and also in confirming its occurrence.

In cases of suspected gas embolism close collaboration between anesthetist and surgeon is required.

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.

Transarterial Oil Chemoembolization for Hepatocellular Carcinoma 

Izhar Levy, Anthony Verstandig, Talia Sasson, Dana Wolf, Ilia Krichon, Eugin Libson, Pinchas Levensart, Orit Papo, Oded Yurim, Ahmed Id, Daniel Shouval

Division of Medicine, Liver Unit and Invasive Radiology, Radiology, Pathology and Surgery Depts., Hadassah University Hospital, Ein Kerem, Jerusalem

Hepatocellular carcinoma (HCC) is a common malignancy with a grave prognosis. Most patients have both the malignant tumor as well as hepatic cirrhosis. Liver transplantation or hepatectomy are considered the only curative procedures, but can be applied in fewer than 10% of patients. In recent decades the most common treatments of HCC are transarterial chemoembolization with oil (TOCE) and percutaneous ethanol injection (PEI). We summarize our retrospective study of 100 patients (mean age 64) 3‏ treated by TE.

In 271 procedures between 1989-1998, in 16 patients hepatectomy was combined with TOCE and in 8 PEI was combined with TOCE, while the rest were treated by TOCE alone. Tumor mass was reduced in 36% of those treated by TOCE (tumor volume reduced 24-75%). Alpha-feto protein (AFP) was reduced 25-90% in 20/32 of those with elevated AFP levels. Median survival for the 100 in the entire group was 19 months (10.9 months in those with conservative treatment). Median survival in the 57 in Okuda stage 1 and the 43 in stages 2 or 3 was 30.1 months and 10.9 months, respectively (p<0.0001). Of the 57 in stage 1, 16 underwent hepatectomy in addition to TOCE and 41 were treated only by TOCE (median survival 15 and 26 months, respectively, p not significant).

Comparing Okuda 1 patients treated by TOCE only with the natural history of the disease and historical controls (Okuda 1 patients treated conservatively in 1984) median survival was 26 and 10 months respectively (p<0.001). The side effects of TOCE were relatively mild. There was 1 fatality (3 days after treatment), and quality of life was maintained. Despite progress in the treatment of HCC by TOCE, PEI, and liver transplantation, long-term survival has remained unsatisfactory.

Thromboembolism in Orthopedic Trauma

A. Khoury, R. Mosheiff, M. Liebergall

Orthopedic Surgery Dept., Hadassah University Hospital and Hebrew University - Hadassah Medical School, Jerusalem

Trauma increases risk of thromboembolic complications. Thus, in pelvic fractures and spinal injuries the incidence of deep vein thrombosis (DVT) is about 35-60%. Half occur in the pelvic veins and are the most likely to result in pulmonary embolism. While symptomatic pulmonary embolism occurs in 2-10% of patients, more have silent pulmonary embolism. 0.5-2% of pulmonary embolisms are fatal. In lower extremity trauma the incidence of DVT is about 58%, with 18% of them in the proximal veins. Thromboembolic complications are the prime cause of morbidity and mortality among trauma patients, yet they can be prevented efficiently and cost-effectively. The arsenal of prophylactic agents includes heparin, low molecular weight heparin, and mechanical devices including inferior vena cava filters.

Multiple Organ Damage due to Cholesterol Embolization

Ido Wolf, Meir Mouallem

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

Cholesterol crystal embolization can affect multiple organ systems and mimic other systemic diseases. We describe a 65-year-old woman who had renal failure, diarrhea, transient ischemic attacks and purple toes due to spontaneous cholesterol crystal embolization.

Knowledge, Attitudes and Training of Family Physicians with Regard to Addiction to Illicit Drugs

Aya Peleg, Roni Peleg, Pesach Shvartzman

Health Promotion and Disease Prevention Unit, and Dept. of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Substance abuse is one of the most serious problems in Israel. Recent studies show the situation is getting worse. The deleterious outcomes of psychoactive substance abuse include crime, car accidents, physical and mental illness, violence and work injuries.

48 family physicians in the Negev completed a questionnaire which included training, diagnostic and treatment skills, attitudes, knowledge and need for training in this field. 38 family physicians (81%) had had no training, most (96%) indicated the importance of such training. 34 (71%) said that their medical skills could not cope with the problems of addiction, and 29 (64.5%) claimed that the quality of care of addict patients is reduced because of lack of knowledge and diagnostic skills. These findings support the conclusion that efforts should be invested in training family physicians in the field of psychoactive drugs, licit and illicit.

ד. זלצר, י. שפירא, ש. ברלינר

מח' לרפואה פנימית ד' והיחידה לטיפול בנוגדי קרישה, מרכז רפואי סוראסקי תל-אביב והפקולטה לרפואה סאקלר, אוניברסיטת תל- אביב

Accidental Severance of a Venous Catheter: Diagnostic and Therapeutic Approach

Harel Gilutz, Aharon Gavriel, Shmuel Yurfest

Cardiology, Heart and Lung, and Vascular Surgery Depts., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

The most common invasive procedure performed in hospitals ithe insertion of a vascular access device. This procedure has the rare complication ofcatheter emboli. Accidental cutting of a peripheral catheter, the use of duplex ultrasound to locate the cut and the extraction of the catheter through a venesection is described. If peripheral extraction fails, percutaneous extraction or thoracotomy should be tried, in that order. The immediate precautions have an impact on the final results.

Ambulatory Oral Procedures on Low-Dose Aspirin

Ronen Gaspar, Leon Ardekian, Benyamin Brenner, Micha Peled, Dov Laufer

Dept. of Oral and Maxillofacial Surgery, and Thrombosis and Hemostasis Unit, Rambam Medical Center, Haifa

Discontinuation of long-term, low-dose aspirin prior to ambulatory oral surgical procedures was assessed in a blind, controlled prospective study. 50 patients on low-dose aspirin who needed dental extractions, periodontal surgery, or other ambulatory oral surgery were randomly divided into test and control groups. The control patients stopped taking aspirin a week before operation, but in the test group aspirin was continued. Before, during and after surgery bleeding time was tested. Although bleeding time was significantly longer when aspirin was continued, in both groups it was within normal limits. Intraoperative hemorrhage was more frequent in those taking aspirin. Hemostasis control posed no problem and there were no postoperative complications in either group. It is concluded that discontinuing low-dose aspirin prior to elective oral surgery is not justified.

Second Degree A-V Block in Graves© Disease

Yoram Singer, Pesach Shvartzman

Dept. of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Cardiac tachyarrhythmias are common in thyrotoxicosis. We report an uncommon case of a 53-year-old woman with Grave's disease who developed second degree A-V block while euthyroid on propylthiouracil. The most likely mechanism is an autoimmune response causing infiltration of the cardiac conduction pathways.

Influence of Warning Labels on Medicines and Physicians' Orders on Patient Behavior

Yehuda Limony, Pesah Shwarzman

Child Health Center of Kupat Holim Klalit, Kiryat Gat and Dept. of Family Medicine, Ben-Gurion University of the Negev, Beer Sheba

Compliance of 40 mothers with a warning label, "for external use," on a medicine package was checked in a survey in a primary care clinic for children. We also checked parents' attitudes to giving a medicine to their child when instructions given by the physician or by a friend contradicted the printed warning on the label. All mothers who were told that the medicine was recommended by their physicians accepted the recommendation without hesitation. Another group included 20 mothers who were told that the medicine was recommended by a friend. 9 of 20 mothers in this group refused to use the medicine. Talking with the nurse about the potential risk of medicine in general, some mothers, after second thought, refused to give the medicine to their child. At the end, 65% of recommendations made by a friend were rejected by mothers as compared to only 15% of the physicians' recommendations.

35 of 40 mothers (87%) understood the meaning of the warning label, but only 13 (32%) had noticed it at all. We conclude that patients may accept their physicians' recommendation to use a medicine despite a contradictory warning label much more readily than when it was recommended by a friend. Therefore, any intervention program intended to promote a more cautious use of medicines should include not only the explanations of the various warning labels but should also promote a change in the patient's behavior to a more active search for warning labels.

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.