תוצאת חיפוש

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.

Popliteal Vascular Trauma

R. Avrahami, M. Haddad, B. Watemberg, E. Stelman, A. Koren, J. Dahn, A. Zelikovski

Dept. of Vascular Surgery, Rabin Medical Center (Beilinson Campus), Petah Tikva

6 cases of popliteal vascular trauma are presented, 3 due to posterior dislocation of the knee and 3 due to crush injury. The patients were referred from another hospital and some had undergone unnecessary angiography when ischemia was present, leading to delay in surgery. All patients presented with distal ischemia and underwent reconstructive surgery; 2 subsequently underwent below-knee amputation because of irreversible ischemia and sepsis.

Urgent operation for popliteal vascular trauma is necessary whenever there is ischemia and intraoperative angiography may be necessary. There should be reconstruction of the artery and vein when there is concomitant venous damage, and fasciotomy and debridement are important. The harmful potential of occult popliteal vascular injuries and their ostensible mild presentation present a challengfor the emergency room surgeon.

Early Results with Threaded Spinal Cage Fusion Systems

Ely Ashkenazi, Stephen T. Onesti

Neurosurgery Depts. of Hadassah-University Hospital, Jerusalem and Montefiore Medical Center, New York

Lumbar interbody fusion is a surgical technique used to treat symptomatic lumbar disc disease. Low back disorders are the most common of the musculoskeletal disorders causing a tremendous burden of disability. One of the causes of low back pain and radiculopathy is spinal instability, which can be treated by spinal fusion. In the past year, threaded cage systems have become available for segmental lumbar fusion for degenerative disc disease. These systems offer several biomechanical advantages over traditional lumbar fusion and instrumentation techniques, and are better tolerated.

From December 1996 until June 1997 we operated and fused spines of 17 patients, using 2 different fusion systems (anterior and posterior approaches). We present our early results.

Geriatric Rehabilitation in Israel: Assessment of Needs and In-Patient Services

J. Gindin, M.A. Clarfield, Z. Haklai, P. Zedaka, J. Brodesky, M. Davis

Geriatric Division, Kaplan-Hartzfeld Hospitals, Rehovot; Geriatric Wing, and Health Information and Computer Service, Israel Ministry of Health; Central Bureau of Statistics, Prime Minister's Office; Brookdale Institute, Jerusalem; and Health of the Elderly, Israel Center for Disease Control

Geriatric rehabilitation (GR) in Israel, which has not been thoroughly investigated, was examined by a subcommittee of the Committee on Health of the Elderly, in the Israel Center for Disease Control.

The needs of the elderly population for rehabilitational services were assessed and the existing services reviewed. A survey of GR beds, their geographic distribution, and the number of patients over 65 after CVA and hip fracture (the 2 main causes for GR need) was carried out. Data were gathered from records of the Ministry of Health and the Central Bureau of Statistics.

In 1994 there were 1,503 beds for active, long-term geriatric care in general and geriatric hospitals: 751 beds were assigned to rehabilitative geriatrics, and the rest to skilled-nursing geriatrics. A high concentration of beds was found in the geographical center of the country, in contrast to a small number in the periphery. Approximately 10,100 patients were hospitalized that year in rehabilitative geriatric and skilled-nursing wards.

There was considerable variation between services, as expressed in the wide range in average duration of hospitalization (from 12-269 days). Most of the beds for GR and skilled-nursing care beds were mixed in the geriatric wards together in the wards.

Limited services and public needs have led to the development of services outside the licensed and regulated settings, a process which has not yet been investigated. About 6,700 older patients were hospitalized during 1994 with a primary diagnosis of CVA. It has been estimated that 4,000 of them needed GR. 2,624 older patients died that year of CVA.

The increase in CVA prevalence between 1987 and 1994 was far greater than the increase in morbidity, in both the general and older populations. Nearly 4,000 elderly patients with a primary diagnosis of hip fracture, most of whom needed rehabilitation, were hospitalized in 1994. The total number of older patients who needed GR following CVA or hip fracture that year was set at 8,000. However, this figure is up to 30% lower than the actual rates, since the those 2 diagnoses include only 70% of total GR needs.

It is impossible to obtain a comprehensive picture of GR in Israel based only on currently available data. The subcommittee outlined areas to be thoroughly examined in-depth, including services and needs, as well as GR tools and processes and how to maintain the achievements of rehabilitation after discharge.

Parturient Compliance in Intra-Partum Epidural Analgesia

Eyal Sheiner, Ilana Shoham-Vardi, Moshe Mazor, Reli Hershkowitz, Miriam Katz

Obstetrics and Gynecology Depts., and Epidemiology and Health Services Evaluation Dept., Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba

The relationship between parturients' sociodemographic characteristics and the tendency of the medical staff to offer and of the parturients to accept intrapartum epidural analgesia, was investigated. 97 Jewish parturients were interviewed during January 1996. Multiple logistic regression analysis was used to evaluate the statistical significance of the results. 10 parturients (10.3%) asked for intrapartum epidural analgesia, and while 46 (47.4%) were offered it, only 22 (22.7%) accepted. Epidural analgesia was mostly offered to, and accepted by: low birth-order parturients (1st-3rd delivery), those belonging to the upper middle class, and to parturients with higher compliance with prenatal diagnostic tests. There was no significant association between the tendency of the medical staff to offer epidural analgesia to secular as compared to traditional parturients.

We conclude that the use of intrapartum epidural analgesia is related to various maternal sociodemographic characteristics. If the low compliance with epidural analgesia is related to prejudice and unfounded fears, we recommend that the benefits of this type of analgesia be explained before birth in the antenatal clinics.

Acute Appendicitis during Pregnancy

Eldad Silberstein, Tali Silberstein, Gad Shaked, Miriam Katz, Moshe Mazor, Itzhac Levi

Dept. of Surgery C, Divisions of Obstetrics and Gynecology, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Acute appendicitis is the most common surgical problem in pregnancy, when it is difficult to diagnose early because of the physiological changes of pregnancy. We studied the problem in the Negev population and present the main issues in diagnosis and management. Between 1988-96, 26 women were operated on for acute appendicitis during pregnancy (1/3297 deliveries), 3 by laparoscopy. In 13 there was a histopathological confirmation of the diagnosis. Clinical diagnosis was more accurate in the first trimester of pregnancy than in the second or third (p=0.073). Premature delivery rate was higher in both confirmed and unconfirmed acute appendicitis than in other pregnancies (p<0.00001), but without significant differences between the 2 groups with appendicitis. Other indexes of maternal and perinatal morbidity did not differ either.

Alternative Medicine in a Kibbutz Community

D. Hermoni, M. Kafman, E. Kitai

Dept. of Family Medicine, Rappaport Faculty of Medicine, The Technion, Haifa and Family Medicine Dept., Sackler Faculty of Medicine, Tel Aviv University

Interest in, and use of alternative medicine has increased in the past few years in Israel. Still, little is known about the extent to which it is utilized, the more common treatments, patterns of use, and its influence on the conventional primary care system. We surveyed a kibbutz community to determine prevalence and patterns of use of alternative medicine and satisfaction with the outcome. The entire kibbutz population was asked to fill out a questionnaire (parents answered for their children). They were questioned as to their use of alternative medicine in the previous 5 years, types and dates of treatment, duration of treatment, and whether it had helped.

Of 1044 subjects, 830 responded (79.5%). 16.4% had used alternative medicine at least once in the previous 5 years. Of these, more than a 1/4 were treated by 2 or more types of alternative therapy. About 2/3 of those responding were women. Most had muscle-skeletal (36%), upper respiratory and/or atopic problems (19.3%). The most common treatments were homeopathy (31%) and acupuncture (20%). In approximately 2/3, the treatment was considered helpful, and either solved the problems or gave long-lasting improvement. 70% of those who used alternative medicine were treated within the previous 15 months and about 40% within the previous 3 months. The use of alternative medicine is increasing and it is now includein standard medical services. Most of those who used alternative therapy felt is hadhelped.
 

Osteoid Osteoma of the Hand: a Rare Location

Nahum Rosenberg, Shalom Stahl

Dept. of Orthopedics A, and Hand Surgery Unit, Rambam Medical Center, Haifa

Osteoid osteoma is a benign bone tumor. It is rare in the hand where it may cause local swelling and pain. Marginal resection is almost always curative, without residual functional disability. Because it is rare in this location, osteoid osteoma is not usually considered in the differential diagnosis of painful lesions of the hand, which may delay treatment. Osteoid osteoma in the hand has characteristic clinical, roentgenologic and scintigraphic features. Early diagnosis of this lesion may be improved by recognition of these features. An algorithm for decision-making that may help is proposed. We describe our experience in 3 cases involving, respectively, the capitate bone, a proximal, and a distal phalanx, in which cases marginal resection was curative.

Pains and Pleasures of a Family Physician: 10 Years of Caring for a Family

Andre Matalon

Family Medicine Dept., Tel Aviv University and Kupat Cholim Klalit, Machoz Dan, Petah Tikva

One of the major characteristics of family medicine is the duration of the doctor-patient relationship over a continuum of time. Physician and family contribute to establishing a relationship that is both therapeutic and gratifying. This mutual bond and involvement was called by Balint "a mutual investment company," in which understanding and trust grow over the years. This paper deals with these contributions and investments, and the positive and negative emotions evoked in the family physician by the patient and family. After 20 years of caring for the family presented, it was possible to address more specifically the analysis of the pains and pleasures of this continuity of care, and the sources of the complex bonding between the family and the family physician.

Combinations of Vasoactive Agents by Penile Injection for Erectile Dysfunction

E. Segenreich, S. Israilov, J. Shmueli, D. Simon, J. Baniel, P. Livne

Andrology Unit, Institute of Urology, Rabin Medical Center (Beilinson Campus), Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University

In the past 15 years there has been continuous increase in the use of injections into the corpora cavernosa of different vasoactive drugs for treatment of erectile dysfunction (ED). However, some of these drugs are very expensive, are not available everywhere, and have side effects. We therefore compared the success rate of the most widely used compounds, papaverine and regitine, in 452 patients (age range 26-85) with different types of ED. Each patient received in the clinic injections of papaverine, 6-25 mg, and regitine, 0.05-1.5 mg. When maximal rigidity of the penis (MRP) was >80%, we instructed the patient to self-inject the drug at home, 5-30 minutes before coitus. If after 3 injections MRP was not >80%, prostaglandin E1 (PGE1) in an average dose of 10-25 mcg was added. If there was no response, papaverin+regitine+PGE1 were given in higher dosage, and atropine sulfate, 0.02+0.06 mg, was added if necessary.

Of 452 patients, 305 (67.4%) had MRP >80% after 3 injections of papaverine plus regitine. The other patients received PGE1 in addition. This was helpful in 61 patients (41.5%), while 55 (63.9%) required papaverine + regitine + prostin in higher doses. Of these, only 31 received papaverine + regitine + PGE1 + atropine sulfate. Of these, 20 (64.5%) reached MRP >80%, and 11 (2.4%) MRP <60. For these 11 patients, we recommended a penile prosthesis. Thus in 67.4% of the 452 patients, papaverine + regitine injections were effective; in 41.5%, PGE1; in 63.9%, papaverine + regitine + prostin + atropine sulfate. Only 11 (2.4%) did not react to intracorporeal injection.

This progressive method of treatment enabled us to select the optimal dosage and combinations of compounds in 441/452 patients (97.5%) according to the severity of their dysfunction. During follow-up of 6 months, spontaneous erections without injection were achieved in 115 (26.0%).

Islet Autoantibody Assays in Type I Diabetes can Replace ICA Test

Daniel Lazar, Naomi Weintrob, Natalia Abramov, Sara Assa, Konstantin Bloch, Regina Ofan, Hadassa Ben-Zaken, Pnina Vardi

Institute for Pediatric Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva and Felsenstein Medical Research Center, Tel Aviv University

Islet cell antibodies (ICA) continue to serve as the basis of the principal serological test for definition of active autoimmunity of beta-cells. Its disadvantages are the need for human pancreatic tissue and difficulty in obtaining quantitative results. In the past decade biochemically-defined beta-cell antigens were described, leading to the development of sensitive and specific autoantibody assays, to predict insulin-dependent diabetes mellitus (IDDM). We examined the value of combined biochemically-based serological assays, such as autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA) and ICA512 (ICA512A) to replace the traditional ICA assay.

Blood samples of 114 newly diagnosed IDDM patients, aged 12‏5 yrs (range 2 months - 29 years) were tested for ICA (indirect immunofluorescence), IAA, GADA and ICA512A (radiobinding assay). The latter 2 assays were performed using recombinant human [35S]-labeled antigen produced by in vitro transcription/translation. We found that fewer sera scored positive for ICA and/or IAA (80.7%, 92/114) than for 1 or more of IAA, GAD, or ICA512 (88.6%, 101/114). We conclude that combined testing for IAA, GAD and ICA512 can replace the traditional ICA/IAA test to predict IDDM and is helpful in the differential diagnosis of insulin-dependent and noninsulin-dependent diabetes.

Community-Acquired Pneumonia in the Elderly: Guidelines for Hospitalization

Jacob Feldman, Abraham Yarezky, Carola Vigder

Geriatric. Dept., Meir Hospital, Kfar Saba and Sakler Faculty of Medicine, Tel Aviv University

A prospective study was carried out among elderly patients with community-acquired pneumonia to determine if there are any specific features that could help in deciding whether to hospitalize, or to treat in the community. We concluded that there is no correlation between clinical presentation of pneumonia and outcome, except for impairment of consciousness. Laboratory data showed a correlation between oxygen saturation in arterial blood, levels of hemoglobin and albumin, and outcome. Sputum culture was not helpful in deciding about diagnosis and treatment, which remain empiric. These patients should be treated at home if conditions permit. Recommendations are made for improving such conditions.

Emergency Stenting for Acute Left Main Coronary Artery Closure during Cardiac Catheterization

Alberto Hendler, Oren Agranat

Catheterization Laboratory, Rama Marpeh Hospital, Petah Tikva

We report a case of acute closure of the left main coronary artery, a rare complication of diagnostic cardiac catheterization, treated by emergency stenting prior to aorto-coronary by-pass surgery. We suggest encroachment of the Judkins catheter into a calcified left main ostium, with dissection and acute thrombosis of this segment, as the possible mechanism.

Clinically, the patient's condition deteriorated to cardiogenic shock and loss of consciousness. Remarkably, there was no angiographic evidence of significant left main coronary artery disease, besides the presence of calcification in the proximal part of the left coronary system and ventricularization of coronary pressure at the time of engagement. We chose to slide quickly the angioplasty guidewire through the left main coronary artery, which allowed prompt mechanical recanalization and rapid restoration of coronary flow, with dramatic clinical and hemodynamic improvement. This relatively simple procedure allowed stenting the left main artery after brief predilation, and the patient came to by-pass surgery in excellent condition. The rationale for surgery in this case was the need for complete coronary revascularization because of significant 3-vessel coronary artery disease.

Evaluation of a Local Infant Formula Enriched with Polyunsaturated Fatty Acids

Zvi Weizman, Elena Brutman, Drora Leader, Chaim Zegerman

Pediatric Gastroenterology Dept. and Nutrition Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev and Soroka Medical Center, Beer Sheba;

and Ma'abarot Products Industry, Kibbutz Ma'abarot

Polyunsaturated fatty acids (PUFA) are vital for the normal development of the brain and the eye retina in infancy. Breast milk contains significant amounts of PUFA, and compensates for their low production in infancy. Only recently a few companies with worldwide product distribution have started to enrich infant formula with PUFA. We evaluated the safety and clinical efficacy of a locally made PUFA-enriched infant formula, produced for the first time in Israel.

50 normal, full term infants participated in a prospective, randomized double-blind study. Half received a regular whey-predominant infant formula (Materna Plus), and the other half a PUFA-enriched formula (Materna Premium), both produced in Israel, for 30 days. Evaluation included physical examination, growth parameters, stool analysis, daily parental questionnaires regarding infant behavior and defecation, and developmental assessment.

There were no significant differences on comparing growth parameters, infant behavior, attacks of restlessness, gas severity, or stool characteristics in the 2 groups. There were no side effects or abnormal stool findings in either group, and no differences in developmental assessment at 3 months of age.

We conclude that the locally-produced PUFA-enriched infant formula is safe and clinically efficient. We assume that the lack of any effect on developmental indices is due to the relatively short exposure to the PUFA-enriched diet. Nevertheless, based on the recent literature, there is no doubt that PUFA supplementation isvital in improving infant brain and eye development.

Conversion Total Hip Replaceafter Failed Internal Fixation of Intertrochantric Fracture

M. Kligman, M. Roffman

Dept. of Orthopedic Surgery, Carmel Medical Center, Haifa

Between 1933-1995, 16 patients underwent conversion-total hip replacement after internal fixation of an intertrochanteric fracture failed. Clinical results were unsatisfactory compared to primary total hip replacement. There was a high incidence of intra- and postoperative complications, including femoral fracture, wound infection, and aseptic loosening. This study should increase the surgeon's awareness of the difficulties encountered in conversion of failed intertrochanteric fractures to total hip replacement.