אדם מור ויוסף מקורי

המחלקה לרפואה פנימית ב', בית-חולים מאיר, כפר סבא

תיסמונת יתר-אאוזינופילית ראשונית (תי"א), היא מצב המאופיין ביצירה קבועה ומוגברת של אאוזינופילים. לקביעת אבחנה זו צריכים להתקיים שלושה תנאים: מספר אאוזינופילים בדם ההיקפי הגדול מ-1,500 תאים לממ"ק למשך תקופה של שישה חודשים לפחות, העדר אטיולוגיה אחרת המסבירה את האאוזינופיליה וכן סימנים ותסמינים המעידים על מעורבות איברים מישנית לאואזינופיליה. ההסתמנות הקלינית של תי"א מגוונת ביותר. הביטוי הראשון יכול להיות פתאומי כתוצאה ממעורבות הלב ומערכת העצבים, או הדרגתי וכללי: עייפות, שיעול, קוצר-נשימה, כאבי-שרירים, חום והזעות. המספר הממוצע של כלל הליקוציטים נע בין 9,000 ל-25,000 תאים לממ"ק, כאשר מתוכם כ-30% עד 70% הם אאוזינופילים.

Choice of Infusion Site - Differences in the References of Nurses, Residents and Patients

Ido Weinberg, Ben Gross, Herbert Freund

Department of Surgery, Hadassah University Hospital Mount Scopus and Hebrew University - Hadassah Medical School, Jerusalem

Insertion of an intravenous (IV) line is a common and routine procedure in hospitalized patients. The literature recommends not to insert an IV line in a limb fold, but other than that there are no guidelines regarding optimal locations for the IV line. In this study we attempted to elucidate whether there are other possible preferences and guidelines for choosing the location of an IV line. We studied four groups: patients at the time of hospitalization, hospitalized patients, nurses and surgical interns on a surgical ward. We found that 91.8% of the patients request to take part in choosing the location of their IV line. Moreover, we found that most patients have a hand preference for the IV, whereas, the ward staff has little location preference. Despite these findings, we discovered that, in practice, most patients were not asked to participate in the decision making process regarding their IV line location. Analysis of the results showed that there is a need to include the patient's preference in choosing the location for the IV line, whenever possible. If the patient doesn't have a preference, the IV line should be inserted in the non-dominant hand or the hand in the bed which is more accessible to the medical & nursing staff.

Colonic Pseudo-Obstruction (Ogilvie Syndrome) Following Cesarean Section

Ido Solt, Peter Jakobi

Dept. of Obstetrics and Gynecology, Rambam Medical Center and Technion Faculty of Medicine, Israel Institute of Technology, Haifa

Acute colonic pseudo-obstruction, or Ogilvie syndrome can be a major surgical complication. Ogilvie syndrome, unlike adynamic ileus, is usually not self-limiting and may cause ischemic necrosis and colonic perforation, with a mortality rate as high as 50 percent. Ogilvie syndrome represents a diagnostic and therapeutic challenge that deserves a multidisciplinary approach. We present a case report and a literature review of the syndrome.

האתיקה הרפואית, כבר מימיה הראשונים, מטילה על הרופא אחריות לטובת החולה. בזמננו, ממשיכים הקודים לתמוך במסורת זו, וקובעים מחויבות להגיש טיפול יעיל ומצפוני לטובת החולה מעבר לשיקול דעת הרופא עצמו, על הצהרת ג'נבה (1948) "בריאות החולה שלי היא חשיבותי הראשונה". בין היסודות של כללי ההתנהגות האתית מצויה מחד גיסא מחויבות של הרופא להגיש לחולה מידע שיעזור לו לקבל החלטות, ומאידך גיסא הצורך לשמור על הסודיות כדי למנוע פגיעה בחולה על ידי הציבור. נשאלת השאלה, האם ההתפתחויות בכלי התקשורת והאינטרנט משרתות את החולה או פוגעות בו.

נתן רוז'נסקי, אברהם בן-שושן

מח' לרפואת נשים ויולדות, ביה"ח הדסה, עיןכרם, הפקולטה לרפואה של האוניברסיטה העברית, ירושלים

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.

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.

Nerve Palsies Following Prolonged Use of Limb Tourniquets

G. Volpin, R. Said, W. Simri, B. Grimberg, M. Daniel

Depts. of Orthopedic Surgery and Neurology, Western Galilee Hospital, Nahariya

Nerve paralysis following the use of tourniquets, regular or pneumatic, for limb surgery is rare. We describe a 19-year-old male soldier who had tourniquets applied for 3 1/4 hours to his arm and both legs due to penetrating injuries. As a result, he suffered palsy of the radial nerve and both common peroneal nerves. Nerve palsy in such cases has not been described in the literature. It is not clear whether the cause is direct mechanical pressure on the nerve, nerve ischemia, or a combination of both.

We recommend that tourniquets should not be used continuously for more than 2 hours. If evacuation of the injured is delayed, the medical team should consider loosening tourniquets for short intervals or changing for a pressure bandage. This is providing the patient's condition is stable and bleeding does not start again on release of the tourniquet.

Brucellosis Presenting as Acute Abdomen

Nathan Kaufman, Noga Reichman, Edith Flatau

Dept. of Medicine B, HaEmek Medical Center, Afula

Usually symptoms of brucellosis are nonspecific and characterized by a wide range of complaints. Although the disease in Israel is almost exclusively food borne (caused by Brucella melitensis in unpasteurized goat milk products) so the main route of infection is the gastrointestinal tract, but gastrointestinal complications are rare, and only sporadic cases of ileitis or colitis have been described.

We present a 43-year-old woman with an acute abdomen, probably due to diverticulitis. It was diagnosed only after blood cultures were positive for Brucella melitensis. We believe that its protean manifestations should be consin addition to the other bizarre presentations of this disease, important in our region.

Self-Limited Lymphadenopathy Mimicking Lymphoma or Lupus

I. Solt, N. Gatas, Y. Cohen, D. Rimon

Medical Dept. B and Pathology Dept., Western Galilee Regional Hospital, Naharia and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Kikuchi-Fujimoto disease in a self-limited lymphadenopathy that can be confused histologically and clinically with lymphoma or systemic lupus erythematosus. It was diagnosed in a 37-year-old woman presenting with fever, cervical, submandibular and axillary lymphadenopathy, weight loss and recurrent urinary tract infections. Lymph node biopsy was consistent with the diagnosis of a histiocytic necrotizing lymphadenitis. Early diagnosis of Kikuchi-Fujimoto disease can prevent harmful treatment.

Spontaneous Internal Jugular Vein Thrombosis Complicating Chronic Pulmonary Disease

Nir Hilzenrat, Edit Liberty, Luna Avnon

Depts. of Medicine B and E, and Pulmonary Disease Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba

Spontaneous internal jugular thrombosis is a rare vascular disorder. It usually occurs as a result of external pressure due to a tumor, infection or as a result of damage to the vessel wall after trauma or central venous catheterization. We report a 35-year-old woman who suffered from severe pulmonary hypertension due to chronic cystic lung disease. She was admitted due to sudden, severe, right-sided neck pain. Internal jugular occlusion by a thrombus was demonstrated by ultrasound and CT-scans but no apparent cause was found. We postulated that the important factors in the development of her thrombosis were stasis due to pulmonary hypertension and high blood viscosity.

Multiple Angiodysplastic Lesions of the Colon - a Therapeutic Challenge

Nir Hilzenrat, Edit Liberty

Division of Gastroenterology and Dept. of Medicine E, Soroka Medical Center and Ben-Gurion University, Beer Sheba

Colonic angiodysplasia is one of the most frequent causes of recurrent lower gastrointestinal tract bleeding, mainly in the elderly. In 50% of patients multiple angiodysplastic lesions were reported when they were the cause of rectal bleeding. Bleeding from angiodysplasia is more severe and less responsive to treatment in those with coagulation disorders. A 74-year-old woman with an artificial mitral valve who was treated with coumadine is reported. A few years after operation she began to develop severe recurrent rectal bleeding because of multiple angiodysplastic lesions along the right colon, proven by colonoscopy. She was frequently hospitalized for blood transfusions; endoscopic treatment was not feasible and the surgical risk of colectomy was very high. Treatwith estrogen and progesterone significantly decreased recurrent episodes of bleeding.

Purpura - an Unusual Presentation of Takayasu Arteritis

N. Reichman, N. Kaufman, R. Mader, E. Flatau

Dept. of Medicine B and Rheumatic Disease Unit, HaEmek Hospital, Afula and Rappaport Faculty of Medicine, The Technion, Haifa

Takayasu arteritis is an uncommon vasculitis, often referred to as aortic arch syndrome. It is most prevalent in young women. Physical findings such as the combination of pulseless arms and carotid bruits suggest the diagnosis. Associated skin manifestations such as pyoderma gangrenosum and erythema nodosum have been described. We present a 27-year-old woman with diffuse purpuric eruption and Takayasu arteritis. This appears to be the first description of such an association.

Motor Vehicle Accidents And Eye Injuries

J. Pikkel, Y. Gelfand, E. Mezer, B. Miller

Dept. of Ophthalmology, Rambam Medical Center and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

The medical records of 24,632 patients treated in our surgical emergency service over a 3-year period were reviewed to determine the frequency and characteristics of ocular trauma caused by motor vehicle accidents (MVA). MVA-related injuries accounted for 13.9% of all visits to the service and involved 1106 of the patients (33%), of whom 77% were young males. At least 1 pathological finding was found in 858 (77.6%) and 169 (15.2%) were admitted. 16 patients sustained very severe ocular injuries which resulted in poor vision.