אדוארד כליף (1), שלום שטהל (2)

(1) המח' לאורתופדיה א', מרכז רפואי רמב"ם, (2) היח' לכירורגיה של היד, מרכז רפואי רמב"ם והפקולטה לרפואה של הטכניון, חיפה

שברים בבסיס עצם הטפח החמישית בכף היד אינם שכיחים. הסיבות להתהוותם הן בדרך כלל נפילה על יד מושטת או פגיעה בעקבות חבטת אגרוף. הגישות הטיפוליות הן שמרניות וניתוחיות. בספרות אין הסכמה לגבי הגישה הטיפולית המיטבית. במעקב אחר 14 חולים עם שברים בבסיס עצם הטפח החמישית שנותחו תוך יום ועד ארבעה ימים מהפציעה, נמצא איחוי מלא בכל השברים, טווח תנועות תקין במיפרקי הזרת והיעדר שינויים ניווניים במיפרק הקרפו-מטאקרפי החמישי במהלך שלוש שנים ומעלה ממועד הפציעה.

המטרה במאמר היא לסקור את ניסיוננו בטיפול ניתוחי מיידי בשברים בבסיס עצם הטפח החמישית, תוך שימת דגש על המצב האנטומי הייחודי של המיפרק הקרפו-מטאקרפי ועצם הטפח של הזרת וההשלכה התיפקודית שיש לכך על החולה, וכן סקירת הספרות המשמעותית לנושא.

יהונתן שרעבי, אהוד גרוסמן

המח' לרפואה פנימית ד', מרכז רפואי שיבא, תל-השומר והפקולטה לרפואה סאקלר, אוניברסיטת תל-אביב

יתר-לחץ-דם (יל"ד) היא מחלה שכיחה ושיעור נע בין 10% בקרב צעירים ועד 50% במבוגרים מעל גיל 65. על אף העדויות המוצקות בדבר התועלת בגילוי המחלה וטיפול בה, שיעורי האיבחון עדיין נמוכים אף יותר. כיום, ההנחיות לאיבחון וטיפול ביל"ד מתבססות על מדידות במרפאה, אולם ייתכן שתנאי זה תורם לקושי בהגעה לשליטה נאותה במחלה בקרב הציבור. בנוסף, בשל האופי המשתנה של לחץ הדם, ערכי לחץ הדם שנמדדו במירפאה אינם משקפים בהכרח את לחץ הדם האופייני לחולה.

אחד האמצעים היכולים להפחית את הצורך במדידת לחץ-הדם במירפאה, הוא שימוש במכשיר מדידת לחץ-דם עצמי (לד"ע) בביתו של הנבדק. ואכן, בשנים האחרונות, אנו עדים לשימוש גובר והולך במכשירים אלו, ובמקביל – לפירסומן של עבודות אודות יעילותם של מכשירי המדידה, תקפותן של המדידות הביתיות ומשמעותן של התוצאות. עד לאחרונה, לא היו כללים ברורים לניתוח ופירוש התוצאות. השנה, התכנסה ועדה בין-לאומית, שבחנה סוגיות אלו ופירסמה הנחיות קליניות ראשוניות אודות השימוש במכשירי מדידת לחץ-דם ביתיים באיבחון וטיפול ביל"ד. בסקירה זו, נדווח על עבודות מרכזיות בנושא, נציג את ההנחיות ונמליץ על אופן יישומן בהתמודדות היומיומית עם האיבחון והטיפול ביל"ד.

י' אליס, מ' יניב, א' לוגר

המח' לאורתופדיה ב' והמח' לאורתופדיה לילדים ביה"ח לילדים דנה, מרכז רפואי סוראסקי תל-אביב והפקולטה לרפואה סאקלר, אוניברסיטת תל-אביב

איחוי עצמות שורש כף-הרגל (tarsal coalition) (אעש"כ) הוא מום מלידה, המתבטא בחיבור שתיים או יותר מעצמות שורש כף-הרגל, הפרעה זו היא הסיבה השכיחה ביותר להתהוות תיסמונת כף-רגל שטוחה עוויתית. התיסמונת כוללת כאב באזור הקרסול והעקב, עיוות נוקשה של כף הרגל במנח וולגוס ועווית (spasm) של השרירים הפרונאליים. בחלק גדול מהחולים הצעירים מהווה אעש"כ סיבה שכיחה לתחושה של נקעים נישנים.

בן-עמי סלע

המכון לכימיה פתולוגית, מרכז רפואי שיבא, תל השומר, החוג לביוכימיה קלינית, הפקולטה לרפואה סאקלר, אוניברסיטת תל-אביב

הגילויים התכופים המתפרסמים לאחרונה על תאי הגזע (stem cells) מעוררים התרגשות של ממש. דורות שלמים התחנכו על העקרונות הקלאסיים של הביולוגיה ההתפתחותית, לפיהם ייעודם של תאים נקבע ונחתם בשלבים עובריים מוקדמים. על פי גישה מסורתית זו, תאים מוגבלים לרקמות ולאברי המוצא שלהם; לדוגמה, תאי גזע המאטופויאטיים הממוקמים בלשד-העצם, הם המקור לתאי דם שונים, אולם תאי גזע אותרו גם במעי, בבלוטות הרבייה, בעור ואף במוח. כיום מתברר והולך, שתאים בוגרים יכולים להיות מתוכנתים מחדש ולבטא גנים האופייניים למיגוון תאים שונים בתכלית שעברו התמיינות (differentiation) בכל אחת משורות התאים (lineage) העובריות: האנדודרמית, המזודרמית והאקטודרמית. התנאי ההכרחי ל"שינוי זהותו" של תא הגזע, הוא נדידתו לריקמת היעד הזרה, שם הוא קולט אותות כימיים ועובר התמרה לזהות תאית חדשה. גמישות (plasticity) מפתיעה זו של תאים בוגרים משמעותה, שגם לאחר התמיינותם, עשויים תאים מסויימים לשנות את ייעודם. בסקירה זו, מובאות דוגמאות אחדות להדגמת המהפך הבלתי-צפוי בזהותם של תאים.

Inflammatory Bowel Disease and Osteoporosis: an Evidence-Based Connection

Eyal Meltzer, Eran Dolev,

Department of Internal Medicine E, Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv, Israel

Inflammatory bowel diseases (IBD) often have chronic or remittent course. Control of symptoms and disease activity often requires the administration of glucocorticoids.

Osteoporosis is a frequent finding in patients with IBD. The evidence-based connection between the two conditions relies on a relatively limited number of cross-sectional and longitudinal studies. The cause of this connection has not been defined completely. Probably, both the chronic inflammation and the steroid therapy contribute to the osteopenia, through an increase in bone resorption without a compensatory increase in bone formation. There is little data regarding the efficacy of therapeutic interventions for the prevention of osteoporosis in patients with IBD. Recently, guidelines for the evaluation and treatment of osteoporosis and IBD have been published. There is need for further research on the relation between these conditions and on the efficacy of current therapy for this unique population.

Male Genital Self Mutilation - A Cause of Hematuria

P. Schwartzman, Z. Viner

Department of Familyu Medicine, Community Health Section, Ben-Gurion University, The Negev, Beer-Sheva, Israel

Pathological self-mutilation is defined as a deliberate destruction of body tissue without conscious intent. It is sometimes associated with several pathologies such as mental disorders and mental retardation.

We report a non-psychotic male, with borderline mental retardation who practiced sporadic moderate genital self-mutilations as a masturbation technique and presented as a case of recurrent gross hematuria.

Diagnosis and Therapy in Acute Stroke: A Rehabilitation Center Viewpoint

M. Motin, J. Streifler, A. Tsur, H. Ring

Neurological Rehabilitation Dept., Loewenstein Rehabilitation Center, Ra'anana; Neurological Unit, Rabin Medical Center, Golda Campus, Petah Tikva and Sackler School of Medicine, Tel Aviv University, Ramat Aviv

The extent of the diagnostic work-up of patients with acute stroke was evaluated in 101 patients admitted for rehabilitation during a 4-month period in 1997. This included specific blood tests and neuro- and cardiac imaging, and compared the extent of work-up in a community hospital versus a rehabilitation center. Comparisons were also made with similar investigations 10 and 20 years earlier.

Results demonstrated that the trend to admit younger stroke patients (<50 years) to neurological (as opposed to medical) departments observed between 1977-1987 persisted in 1997.

The use of CT scan increased dramatically from 1977 to 1987 (19% vs 78%), and in 1997 was actually 100% The use of carotid duplex and echocardiography increased steadily during the 3 decades reaching 26% and 28% respectively. Tests for thrombophilia were seldom done. However, in neurological departments it was done in about 50% of the younger stroke patients. In neurology departments carotid duplex was done 2 to 3 times more often than in medical departments.

During rehabilitation imaging tests were done once or more in almost half the patients. The results and those of additional blood tests, have led to modification of antithrombotic treatment in 14% of the younger group and 4% of the older group.

We have clearly shown that while stroke work-up has become more comprehensive in recent years, there is still much to do in this field. Stroke units or teams in our general hospitals will increase stroke awareness, improve work-up and hasten definitive treatment.
 

Secondary Bone Grafting in Cleft Lip and Palate

M. Peled, D. Aisenbud, D. Goldstein, A. Rachmiel, D. Laufer

Maxillofacial and Oral Surgery Dept. and Cleft-Palate Clinic, Rambam Medical Center; and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Results of reconstruction of residual alveolar bone defects in 52 patients operated between 1990-1998 were evaluated clinically and radiographically in a retrospective study.

Ages ranged between 9-37; 30 were males. The donor site of bone grafts in all was particulate cancellous marrow from the anterior iliac crest. 32 had unilateral clefts and 20 bilateral. Total cleft sites treated was 72.

Best results were achieved when bone grafting was carried out prior to the eruption of the canine tooth. The cleft space was closed and oro-nasal fistulas were eliminated in 42 (80%). Success rates in unilateral and bilateral cases were significantly different.

High-Dose Chemotherapy and Autologous Stem Cell Trans-Plantation for Refractory and Relapsing Hodgkin's Disease

A. Avigdor, I. Hardan, O. Shpilberg, P. Raanani, I. Grotto, I. Ben-Bassat

Hematology Institute and Hemato-oncology Unit, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

High dose chemotherapy and autologous stem cell transplantation are widely used in relapsed and primary refractory Hodgkin's disease. We transplanted 42 patients with Hodgkin's disease between 1990-1998. Median follow-up was 31 months (range 1-102). 29 (69%) were transplanted after relapse and 13 (31%) were refractory to first line therapy. Median age at transplantation was 29 years (range 19-58) and 23 (55%) were males.

All were treated with the BEAM protocol (carmustine, etoposide, cytarabine and melphelan). 18 who were in remission received radiotherapy following transplantation. The source of the stem cells was bone marrow in 17% and peripheral blood in 83%. At initial diagnosis: 57% had stage III-IV disease and B symptoms were present in 52%. 75% were treated with MOPP, ABVD or with related versions. Radiotherapy followed in 52%. Prior to transplantation, 45% of the relapsed group were in the advanced stage. 33% and 12% of all patients had lung and bone involvement, respectively.

The complete remission rate was 86% for the 2 groups. 2 (5%) died from transplant-related complications and MDS/AML developed in 2 (5%) after transplantation. The 3-year overall survival (OS) and disease-free survival (DFS) were 68% and 60%, respectively. The 3-year OS for the relapsed group was 64% compared with 76% for the refractory group, and the 3-year DFS for the relapsed group was 60% vs. 42% for the refractory group (neither difference significant). Radiotherapy following transplantation did not have a beneficial effect on DFS. No prognostic factors for outcome of transplantation were found, most probably due to the limited number of patients and the high variability of disease characteristics.

We conclude that high dose chemotherapy and autologous stem cell transplantation are effective and relatively safe for relapsed or primary refractory Hodgkin's disease. The DFS at 3 years was longer for those transplanted after relapse than those with primary refractory disease, but not significantly. Patients with primary refractory disease can be salvaged with high dose chemotherapy.

Testicular Cancer: Self-Awareness and Testicular Self-Examination in Soldiers and Military Physicians

Thomas Tichler, Rony Weitzen, Aharon Feinstone, Raoul Orvieto, Marian Moskovitz, Adam Singer

Depts. of Oncology and Medicine B, Sheba Medical Center, Tel Hashomer; Medical Corps, Israel Defence Forces; Gynecology Dept., Hasharon Medical Center, Petah Tikvah; and Medical Dept. B, Fleaman Hospital, Haifa

Testicular cancer is the most common malignancy in young men. To evaluate knowledge and awareness of that cancer, and of the practice of testicular self-examination (TSE), we developed a questionnaire which was distributed to 717 male soldiers and 200 of their military physicians.

21% of the soldiers had received some explanation of the importance of TSE, but only 16% were actually instructed how to perform TSE, and only 2% practiced it regularly. 24% had never examined their testicles before, 185 only rarely, and 6% often. With increased age, TSE frequency increased, but previous education, type of military unit, and ethnic origin had no affect. 99% of military physicians had been taught how to examine breasts, but only 70% had been taught routine testicular examination. 22% performed it, but 27% never did. 84% had never taught their soldiers the importance of TSE, although 51% taught female soldiers breast self-examination.

There was a significant lack of awareness of the importance of regular practice of TSE among both soldiers and their army physicians.

Mortality in Fractures of the Hip 

Y. Titiun, Z. Eshkol, Z. Horesh, M. Soudry

Dept. of Orthopedic Surgery, Beilinson Campus, Rabin Medical Center, Petah Tikva

Prevalence of hip fractures is increasing world-wide, as the mean age of populations increases. Despite advances in anesthesia, nursing care, and surgical techniques, hip fractures remain a significant cause of morbidity and mortality in the elderly.

We operated on 65 cases of hip fractures from 1995 to the end of 1997: average age was 82.9, 72% were women, average waiting time for operation was 1.6 days, perioperative mortality was 3.5% and postoperative mortality 26.2%.

Scaphoid Fractures in Children  

Shalom Stahl

Hand Surgery Unit, Rambam Medical Center and Rappaport Faculty of Medicine, Israel Institute of Technology, Haifa

The scaphoid is the most common carpal bone fractured in adults. In children the fracture is distinctly uncommon. We present our experience with 23 children treated between 1987-1998, 19 of them with fractures in the distal third of the wrist; there were 11 avulsions, 4 waist fractures, and 12 were undisplaced. The mechanism of injury was a direct blow or a fall onto the outstretched hand. Immobilization in a plaster cast led to union in all except 1 case.

Based on our experience and study of the literature, it is evident that scaphoid fractures, although uncommon, do occur. Thorough clinical and radiological examination of children with a forearm or wrist injury is important in detecting such fractures.

Spontaneous Bilateral Ectopic Pregnancy 

David Rabinerson, B. Kaplan, Zion Ben Rafael, Arie Dekel

Dept. of Gynecology, Beilinson Medical Center, Golda Campus, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University

Bilateral, spontaneous ectopic pregnancy is rare (1 in 125-1580 ectopic pregnancies). We describe a 30-year-old, unmarried woman with no predisposing factors for ectopic pregnancy who presented in hypovolemic shock, in the 7th week of gestation, complaining of abdominal pain. On immediate laparoscopy there were found blood and clots in the abdominal cavity, a left ampullar pregnancy (5 cm in diameter), and there was active bleeding from the fimbria of the right tube. Bilateral salpingectomy was performed and she received 3 units of packed red cells. She was discharged in good condition 3 days later. The pathologic diagnosis was pregnancy in each tube. This case emphasizes the need for thorough sonographic and laparoscopic observation in order not to miss the presence of bilateral ectopic pregnancy.

Hemophagocytic Syndrome

I. Morag, M. Goldman, T. Bistrizer, C. Kaplinsky

Pediatric Division, Assaf Harofeh Medical Center, Zerifin and Pediatric Hematology-Oncology Dept., Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Hemophagocytic syndrome is a rare, fulminant disease characterized by generalized histiocytic proliferation associated with phagocytosis of erythrocytes, platelets, and to a lesser extent, of white blood cells. We report a 2-year-old boy admitted with high fever and irritability, with a rash, marked hepatomegaly and generalized lymphadenopathy. Liver function tests were abnormal and there was thrombocytopenia and hyperlipidemia. Bone marrow aspiration revealed hemophagocytosis. Despite intensive treatment with steroids, intravenous immunoglobulin and cytotoxic drugs, he died within 10 weeks.

Referrals and Self-Referrals to an Emergency Department

Sasson Nakar, Shlomo Vinker, Yaacov Or, Mordechai Schadel, Yosi Niego, Gavriel Plotkin

Central District of General Sick Fund and Family Medicine Dept., Sackler Faculty of Medicine, Tel Aviv University, and Emergency Dept., Kaplan Medical Center, Rehovot (Affiliated with Hebrew University-Hadassah Faculty of Medicine, Jerusalem)

The Israeli health system has been undergoing major changes in recent years. Considerations of cost containment have led sick funds to open new out-of-hours services in the community to reduce visits to hospital emergency departments.

Referred and self-referred visits to our emergency department during a 1-month period were studied. Patients after trauma or whose visits resulted in hospitalization were excluded. Of the 505 encounters 56.3% were of women; the average age was 52.5±19.3 years (range 18-96). 57.4% visits were during working hours of primary care clinics ("working hours"), while the others were "out-of-hours" visits. Only 52.7% had a referral letter, 75% of them from the family physician. The quality of the handwriting in 46% was good, in 44% fair and the remaining 10% were illegible. A specific clinical question was asked in only 16% of the letters. A third of "working-hours" visits were self- referrals, rising to 64% in "out-of-hours" visits (p<0.001).

The most common diagnoses in discharge letters were: chest or abdominal pain, asthma, back pain, headache, nephrolithiasis and upper respiratory tract infection. The rate of self-referrals was relatively high throughout the day. Cost-containment efforts did not seem to eliminate self-referrals with "primary care" problems. The quality of referral letters should be improved both with regard to format and content.