תוצאת חיפוש

Israel's ATLS Program: Summary and Outlook

Ron Ben Abraham, Michael Stein, Yoram Kluger, Gideon Paret, Avraham Rivkind, Joshua Shemer

Medical Dept., Israel Defense Forces and Israel Trauma Society

In recent years a vigorous effort has been made to improve quality of primary trauma care in Israel. Advanced trauma life support courses (ATLS) were given to physicians throughout the country, regardless of their specialties. In 7 years 4229 physicians participated in 202 courses with an average success rate of 76%. In the future, issues such as mandatory vs. voluntary training, language barriers, and continuous decline of knowledge should be addressed if momentum is to be maintained.

Recurrent Tuberculosis in a Psychiatric Hospital

A. Zeenreich, B. Gochstein, A. Grinshpoon, M. Miron, J. Rosenman, I. Ben-Dov

Pulmonary and Radiology Institutes, Chaim Sheba Medical Center, Tel Hashomer and Tel Aviv University; Israel Ministry of Health; and Gan Meged Hospital

During 1987-1996, 39 of 720 patients hospitalized (most for severe schizophrenia) were diagnosed as having active pulmonary tuberculosis (5.4%, 975 per 105 per year). In 1992-1993, after a cluster of 5 cases was found, all patients were screened by PPD skin test and chest X-ray and 16 more cases were identified. Diagnosis was confirmed bacteriologically in only 10 of them but there were typical radiological findings in the others. 39 were treated with a multi-drug regimen. In addition, 333 exposed patients and 21% who had converted their skin tests were given isoniazid preventive therapy. A small increase in levels of liver enzymes was common, but significant abnormality (over 4 times the upper limit of normal) was found in only 7 patients, in whom therapy was therefor stopped or changed. During a follow-up period of 4 years, 2 more developed tuberculosis and 33 converted their PPD reactivity status. We conclude that an outbreak of tuberculosis in a psychiatric hospital can be controlled with a relatively low rate of side-effects by using systematic diagnostic and therapeutic measures. However, single step screening is not sufficient. Routine screening of all new patients, a high index of suspicion and contact investigation are needed.

Propofol Anesthesia for Craniotomy in Patients who are Awake

Ron Ben Abraham, Noah Lieberman, Zvi Ram, Sylvia Klempner, Azriel Perel

Depts. of Anesthesia and Intensive Care and of Neurosurgery, Chaim Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University

During craniotomy, the patient's cooperation is needed during procedures in which continuous neurological examination and mapping of crucial regions close to the area to be resected area are required. We report our experience in 9 patients who underwent such procedures under intravenous propofol as the main sedating agent. This short-acting hypnotic was administered prior to and during the painful stages of the procedure. Patients were fully asleep when the skull was opened and the dural flap raised or excised. During the rest of the operation patients were lightly sedated but remained responsive and cooperative. This enabled precise intra-operative mapping of the brain and surgery-related neurological deficits were avoided. Respiratory depression or hemodynamic compromise were not encountered. All patients were comfortable during the operation and there were no additional neurological deficits after operation. We believe that propofol should be the main sedating agent used for these procedures.

Pelvic Lytic Lesion and Osteoporosis-Related Fractures

Yaron Weisel, Ehud Rath, Nissim Ohana, Dan Atar

Orthopedic Dept., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Insufficiency fractures of the pelvis may be overlooked as a cause of hip or groin pain. These fractures occur in the elderly, usually those with pronounced osteopenia of the pelvis. Predisposing factors include corticosteroids, local irradiation and postmenopausal osteoporosis. These fractures are difficult to detect clinically and plain radiographs and other studies may be misleading, delaying diagnosis and treatment. A 65-year-old woman had left groin and hip pain for 2 months with no history of trauma. Plain radiographs showed lytic lesions in the left pubic rami. Bone scan revealed increased uptake in that region, suggesting metastatic bone disease. Computed tomography and magnetic resonance imaging demonstrated fractures in the left superior and inferior pubic rami, with callus formation with no involvement of soft tissues. Quantitative computed tomography indicated low calcium concentration, below fracture threshold. The diagnosis of insufficiency fractures of the pelvis was confirmed by the favorable clinical and radiographic outcome. It is therefore important to be familiar with the appearance and location of these fractures.

Intra-Osseous Ganglion of Scaphoid and Lunate Bones

M. Kligman, M. Roffman

Dept. of Surgery, Carmel Medical Center, Haifa

We present a patient with intra-osseous ganglion of the left scaphoid and lunate bone. These were excised and a bone graft inserted. 1 year after operation the patient was free of pain, without limitation of wrist motion. Intra-osseous ganglion of the carpal bone is not common and lunate and scaphoid intra-osseous ganglion has rarely been reported. Awareness of this condition may lead to earlier diagnosis and treatment, with satisfactory outcome.

Progression of Diabetic Retinopathy after Cataract Extraction

Y. Raniel, Y. Teichner, Z. Friedman

Annette and Aron Rozin Dept. of Ophthalmology, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

A prospective study of the effect of cataract extraction with intraocular lens implantation on the course of diabetic retinopathy (DR) in 44 patients (59 eyes) was carried out. It showed that in the 1-3 years following surgery, there was progression of DR (including development of newly formed retinopathy) in 35% of the patients (28.8% of eyes). Progression was more marked in patients with pre-operative bilateral DR compared to those without bilateral DR (77% and 16% respectively). Insulin dependence did not play a role in progression. Final visual acuity was better in patients without pre-operative DR, as well as in eyes without progressive retinopathy.

Onchocerca in Israel

A. Pressman, Y. Kandelis, Y. Bachar, G. Mogilner

Depts. of Pediatric Surgery and Pathology, Bnei-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

The parasite Onchocerca volvulus is well-known in its endemic areas in South and Central America and West Africa. It is transmitted to man by simulium flies and causes systemic infection with skin, lymphatic and ophthalmic manifestations and can cause blindness (river blindness). Treatment with Ivermectin is effective but sometimes there is need for surgical intervention to prevent or treat complications. We describe an 11-year-old girl, a new immigrant from Ethiopia, who had a firm mass in her left thigh, caused by Onchocerca volvulus. It was completely excised. This is a very rare condition in Israel, which must be considered in patients coming from endemic areas.

Local Treatment of Purulent Chronic Otitis Media with Ciprofloxacin

Ludwig Podoshin, Alexander Brodzki, Milo Fradis, Jacob Ben-David, Josef Larboni, Isaac Srugo

Dept. of Otolaryngology, Head and Neck Surgery, Microbiology Unit and Dept. of Pharmacology, Bnai-Zion Medical Center, and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

We evaluated the efficacy of ciprofloxacin eardrops compared to tobramycin and to a placebo in the treatment of chronic suppurative otitis media. 60 ears were randomly assigned to treatment for 3 weeks with ciprofloxacin, tobramycin or placebo eardrops. The organism most commonly isolated from the ear discharge was Pseudomonas aeruginosa. The clinical responses were 78.9% and 72.2%, respectively, in the ciprofloxacin and tobramycin groups, while it was only 41.2% in the placebo group. Treatment with ciprofloxacin eardrops seemed to be at least as efficient as treatment with tobramycin. Considering the lack of ototoxicity of ciprofloxacin, this treatment may be best for chronic otitis media.

Six Cases of Acute Rheumatic Fever in One Year

George Habib, Ramiz Abu-Ahmad

Rheumatology Clinic and Dept. of Medicine, Nazareth Hospital; and Medical Dept. B, Carmel Medical Center, Haifa

During 1995, 6 cases of acute rheumatic fever were diagnosed here. Taking into account differences in total admissions, this appears to represent an increase over 1994. Most of the cases were males, with average age at diagnosis 19.5 years. All were of low socioeconomic status. 50% had cardiac involvement, and 1 needed treatment with corticosteroids. Most had pharyngeal symptoms prior to the acute attack, and 1 patient had 2 prior episodes of rheumatic fever. A thorough epidemiological study should be done in the Nazareth area to assess the real incidence of acute rheumatic fever, and to determine whether there is a true increase in incidence.

Central Cord Syndrome in the Elderly Who Fall: a Diagnostic Trap

A. Adunsky, H. Semo, S. Levenkrohn

Geriatric Rehabilitation Dept., Chaim Sheba Medical Center, Tel Hashomer

Acute post-traumatic spinal injury is common and usually poses no diagnostic difficulties. Following a low-energy fall, the onset of acute central cord syndrome in the elderly is not common and is frequently misdiagnosed. Men aged 60 and 81, and a woman aged 75 are described, in whom central cord syndrome was overlooked. Awareness of this condition is important to avoid incorrect diagnosis and hazardous management.

Balance Disturbances in Children with Middle Ear Effusions

Avishay Golz, Batia Angel-Yeger, Henri Zvi Joachims, Aviram Netzer, S. Parush

Dept. of Otolaryngology and Head and Neck Surgery, Rambam Medical Center and Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Vertigo and dizziness are not common complaints in childhood, but probably present more often than has been thought. These symptoms, caused mainly by otitis media (OM) and middle ear effusion (MEE), are 2 of the most common diseases in children, and until recently had long been neglected in the literature and in practice. We determined objectively the incidence of balance-related symptoms in children with long-lasting MEE, and resolution following insertion of ventilation tubes (VT). 36 children, aged 4-9 years, were studied using electronystagmography (ENG) and the Bruininks-Oseretsky tests for motor proficiency, before and after ventilation of the middle ear. Results were compared to those in 74 healthy children with no history of middle ear disease. Abnormal ENG findings were found in 58%, and 71% had low Bruininks-Oseretsky (BO) test scores. The ENG was abnormal in only 3 of the controls, 1 of whom also had low BO test scores. The symptoms and signs of balance disturbances resolved in 96% following VT insertion. These results indicate that balance-related symptoms often encountered in young children may result from chronic MEE, and that they resolve following evacuation of the effusion and ventilation of the middle ear.

Bromocriptine for Refractory Rheumatoid Arthritis

Reuven Mader

Rheumatic Disease Unit, HaEmek Medical Center, Afula

In recent years prolactin (PRL) has emerged as an important immunomodulator in various autoimmune disorders. Bromocriptine (BRC) is a dopamine agonist that suppresses secretion of PRL. Good clinical response to BRC has been reported in patients with psoriatic arthritis, Reiter's syndrome, and systemic lupus erythematosus. 5 mg of BRC at bedtime were given to 5 patients (aged 35-50) with refractory rheumatic arthritis (RA) who had failed to respond to previous treatment with at least 2 disease-modifying antirheumatic drugs. Patients were assessed at 4-6 week intervals for 6 months. 3 showed more than 25% improvement in the number of tender and swollen joints at 12 weeks of treatment. However, in only 2 of them was improvement maintained till the end of the 6 months. There were no changes in other measures of disease activity. 1 patient dropped out of the study due to acute exacerbation of her disease 4 weeks after initiation of BRC and required intra-articular injections of corticosteroid. The remaining patient did not show any significant clinical changes. No correlation was found between serum PRL levels and disease activity over time. It is suggested that some patients with refractory RA might improve with BRC. Its use in larger doses in larger groups of patients may help elucidate its role in the treatment of RA.

The Parapharyngeal Space: Tumors and Surgical Approaches

E. Raveh, R. Sadov, B. Nageris, R. Feinmesser

Dept. of Otolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva

The potential parapharyngeal space contains the great vessels of the neck, cranial nerves IX-XII, the sympathetic chain and lymph nodes. Surgical access is difficult and the infrequency of tumors in it make surgery of this part of the head and neck a challenge. 8 women and 2 men (mean age 54.7, range 31-70 years) with tumors of the parapharyngeal space operated on during the past 6 years are presented. The most common surgical approach was the cervical submandibular, used in 6 of our patients with relative ease and minimal complications. Tumors of deep lobe parotid origin should be operated through a transparotid approach. Large benign or malignant tumors have a better prognosis when the transcervical transmandibular approach is used, providing wider access.

Postoperative Ulnar Nerve Palsy of the Elbow

Shalom Stahl, Doron Norman, Chaim Zinman

Hand Surgery Unit and Dept. of Orthopedic Surgery B, Rambam Medical Center and Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Ulnar nerve neuropathy of the elbow is a recognized complication of surgery involving general anesthesia. In 13 patients, aged 21-76 years, ulnar nerve palsy developed at various times and of varying degrees of severity during the postoperative period. Diagnosis was based on clinical and electrophysiological findings. 3 patients had subclinical entrapment of the ulnar nerve. All were treated conservatively by rest, splinting and physical therapy: 10 improved slowly with time and 3 were operated on, but only 1 recovered fully. Preventive measures, such as proper positioning on the operative table, use of elbow pads, avoiding adduction of the arm, pronation of the forearm and prolonged elbow flexion, may reduce the incidence of ulnar nerve palsy. Unfortunately, treatment of established lesions has yielded mixed results.

Sunscreen Use in an Urban Negev Population

Pesach Shvartzman

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

The use of sunscreen in the Negev population was assessed. The study population included 1458 subjects, mean age 35.5‏±14.2 years, half born in Israel and 25% in East Europe. Two-thirds were exposed to the sun 1-2 hours a day and 13% 4 hours a day or more. Only about 15% used sunscreen while shopping, 69% used it at the beach, and less than half applied it to children being sent to school. Sunscreen use was greater in women (p<0.000001), especially those with sensitive skin (p<0.0001) and red hair (p<0.0001). No significant association was found with age, education or country of birth.