עמוד בית
יום ד, 27.01.21

מאי 1999

1 במאי
בנימין זאבי, גלית בר-מור ומיכאל ברנט

1000 Cardiac Catheterizations in Congenital Heart Disease


Benjamin Zeevi, Galit Bar-Mor, Michael Berant


Cardiac Catheterization Unit, Schneider Children's Medical Center, and Sackler School of Medicine, Tel Aviv University


Over the past 15 years, percutaneous therapeutic cardiac catheterization has become increasingly important in the treatment of congenital heart disease. We describe our experience in 1000 such catheterizations between 1993-1997. 55% were in 1-12-year-olds; only 20% were in patients younger than 1 year old and 11.3% were in adults with congenital heart defects. In about 50% it was at least a second cardiac catheterization. Overall, there were 425 therapeutic cardiac catheterizations, increasing from 33% in the first 200 procedures, to 63% in the last 200.

We performed 30 different types of therapeutic catheterizations: 23.3% were valvular dilations, 21.4% vessel angioplasties, 36.9% closure procedures, 9.2% electrophysiological procedures, and 9.2% miscellaneous. In 31.3% of therapeutic catheterizations we used 12 new procedures. Minor complications occurred in 8.5% and major in 0.6%; most complications were successfully treated or were self-limited and there was no residual damage.

In this report the current role of each type of major catheterization is discussed on the basis of our experience. Further development of technology for lesions not amenable to currently available transcatheter methods, and longer follow-up for current techniques will consolidate the role of therapeutic cardiac catheterization in congenital heart disease.

אירנה ציקונוב וישראל פוסטמן

Monocytic Ehrlichiosis - An Emerging Pathogen


Irena Zikonov, Israel Potasman


Dept. of Internal Medicine A and Infectious Disease Unit, B'nai Zion Medical Center and Technion Faculty of Medicine, Haifa


Ehrlichiosis is an emerging zoonotic disease transmitted to man by ticks. Its clinical features include fever, headache, myalgia, nausea and rash. The diagnosis requires a high index of suspicion; the disease has a specific serology, and has never been reported in Israel.

We describe a 52-year-old man hospitalized with fever, a diffuse rash, arthralgia and epididymitis. Skin biopsy disclosed necrotizing small vessel disease consistent with periarteritis nodosa. Acute phase serum titer for E. chaffeensis was 1:256. Fever promptly subsided following ciprofloxacin.

אבישי סלע

Information Provided for Informed Consent in Clinical Trials


Avishay Sella


Genitourinary Medical Oncology Unit, Dept. of Oncology, Rabin Medical Center (Beilinson Campus), Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University


The Helsinki Declaration contains recommendations guiding physicians who conduct clinical trials. One is that the requirement for informed consent is essential for approval of a trial. An important component of the informed consent doctrine is that all data required for the participant's decision must be provided. We analyze data of a therapeutic trial, and define 12 data components outlined in, or directly derived from the Helsinki Declaration.


61 instances of informed consent for therapeutic clinical trials from various fields of medicine, from 1994 to 1997, were analyzed. In each the presence of the 12 components was evaluated.

The data demonstrated that there were only 5 components cited in most cases of informed consent: trial objectives, methods, treatment plan, risks, and the option of withdrawing. Benefit to the participant was mentioned in half the cases, while only limited information was provided about other components such as life-threatening and unpredictable risks, and alternative treatment.

Examples of informed consent from 1997 showed statistical improvement since 1994 in the data concerning trial objectives, methods, risks and alternative therapy. Informed consent documents of international multicenter trials compared with local trials showed statistical improvement in the data components of the trial objectives, methods, and risks, including those of potentially life-threatening and unpredictable risks, and alternative therapy. Analysis of informed consent showed that not all components required for a comprehensive decision regarding participation in a clinical trial are included. These data emphasize the need to design a structured informed consent protocol in which all the required data components are specifically outlined for potential participants.

ניר שהם ויחיאל שויד

Conservative Approach in Abdominal Trauma in Childhood


Nir Shoham, Yechiel Sweed


Dept. of Ophthalmology, HaEmek Medical Center, Afula and Dept. of Pediatric Surgery, Nahariya Medical Center


To determine the results of the conservative approach in the treatment of pediatric abdominal trauma, we retrospectively analyzed data from the files of 95 cases of abdominal trauma in children during a 5-year period.


51 patients (54%) had isolated abdominal injury, while 44 (46%) had multiple trauma. The most common causes of injury were road accidents and falls from heights (74%). CT scans were performed in 61 (64%) with positive results in 90%. Ultrasonography was done in 22 (23%) and was positive in 55%.


The spleen was the most vulnerable intra-abdominal organ (33 patients, 35%), as well as the organ most severely damaged. Other injured organs were: liver (30 cases), kidney (16), stomach (2), large blood vessels (2), and pancreas, duodenum and diaphragm (1 case each).

83 patients (87%) were treated conservatively, while 11 were operated on for penetrating abdominal trauma (3 cases), hemodynamic instability (3), positive DPL (3), and Scale 4 splenic injury and free intra-abdominal air on CT scan (1 case each). Early and late complications were mild.


It is concluded that CT is an efficient and reliable imaging method for diagnosis and staging of severity of injury in blunt abdominal trauma. Nonoperative management of solid organ injuries under careful observation in a pediatric trauma center is safe and appropriate. Most Scale 4 splenic injuries can be treated successfully without surgical intervention. Using this conservative approach there were no late complications.

גדעון פרת, רון בן אברהם, סוזנה ברמן, אמיר ורדי, רן הראל, יוסי מניסטרסקי וזוהר ברזילי

Prognostic Implications in Pediatric Head Injuries


Gideon Paret, Ron Ben Abraham, Susana Berman, Amir Vardi, Rami Harel, Yossi Manisterski, Zohar Barzilay


Depts. of Pediatric Intensive Care and of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University


An unselected series of 200 consecutive cases of major head trauma in children aged 6 months to 16 years, seen during 4 years, was studied. Injuries were due to road accidents (40%), falls (30.5%) and other causes (29.5%), and were assessed clinically and by cranial CT.


On admission the Glasgow Coma Score ranged from 4.72-11.65 and in addition to pupillary responses and brain stem reflexes, was a significant predictor of outcome. Brain edema, midline shift, intracranial hemorrhage and also hyperglycemia, hypokalemia and coagulopathy, were associated with poor outcome. While 17% died, 53% were discharged in good functional condition.


Early identification of clinical features related to prognosis can help the caring team provide maximal support for patient and family.

שלמה קייזר, יואלה אלוני ואילן חרוזי

Laparoscopic Treatment of Small Bowel Obstruction Caused by Adhesions


S. Kyzer, Y. Aloni, I. Charuzi


Surgery Unit B, Wolfson Medical Center, Holon


We describe our experience in 14 patients operated on for small bowel obstruction, who underwent laparoscopic adhesiolysis. In 13 (93%) the obstruction was relieved and only 1 case required conversion to open operation. Bowel activity usually resumed within 24-48 hours, and there were no remarkable intraoperative and postoperative complications. During follow-up none developed recurrent obstruction.


Our experience demonstrates that laparoscopic adhesiolysis is a valid therapeutic option. Additional experience is needed to determine which types of cases are suitable for the procedure.

ענת אנגל, ירון בר-דיין, יצחק אנגלברג ויאיר לוי

Malignant Nodular Hidradenoma (Sweat Gland Tumor)


Anat Engel, Yaron Bar-Dayan, Santiago Engelberg, Yair Levi


Depts. of Medicine B, Pathology, and Disease Research Unit, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University


Malignanhidradenoma is a very rare tumor that originates from sweat glands. We present a 61-year-old man with an ulcerated tumor in his right flank, 4 cm in diameter, that was excised with a wide free margin. Histopathologic study showed an ill-defined, epithelial neoformation, formed by lobules of clear polygonal cells in the deep dermis and subcutaneous tissue, diagnosed as malignant nodular hidradenoma.


1.5 years after excision there was enlargement of the right axillary and inguinal lymph nodes, which showed metastatic, adnexal neoplastic cells. Axillary resection and superficial dissection of the right inguinal nodes were performed. After 3 months the tumor had spread to other lymph nodes and acute obstructive renal failure required insertion of a pig-tail catheter into the right ureter. Radiotherapy was followed by chemo-therapy, but he died from end-stage metastatic disease in multi-organ failure.

מאיר מועלם, אברהם אדונסקי, חיים סמו ומרק דולגופיאט

Polyneuropathy in Critical Illness


M. Mouallem, A. Adunsky, H. Semo, M. Dolgopiat


Depts. of Medicine E, Geriatrics, and Neurological Rehabilitation, Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University


Critical illness polyneuropathy developed in 8 patients aged 22-84 years in our intensive care units. This acute polyneuropathy, predominantly axonal and motor, develops in the setting of the systemic inflammatory response syndrome and multi-organ failure. It is found in about 50% of patients treated in intensive care units for more than 2 weeks. In those who survive, neurological and functional recovery is the rule.

15 במאי
חנה ארד, חנה גבע, ואלרי רוזין, רות קיבריק ויצחק קרש

Home Palliative Care of Terminal Cancer Patients, with Family Feedback


Hana Arad, Hana Geva, Valery Rosin, Ruth Kibrik, Isaac Kersz


Home Care Unit of Kupat Holim Haklalit, HaEmek Medical Center, Afula and Quality Improvement Unit, Rambam Medical Center, Haifa


Palliative care of terminal cancer patients is one of the tasks of our Home Care Unit. Increasing hospitalization costs have brought forward the decision to treat them at home, assuming that they would prefer to return and die in their natural surroundings, among family.


Most of our patients are aged, recent immigrants from the Soviet Union, of low socioeconomic status; most live with their close families. Our care model combines social, cultural, economic, medical and nursing aspects. More patients choose to die at home, and that is where costs are minimal. Care management and characteristics of 44 terminal cancer patients, who died between January and October 1996, are described. Living with a family was not required for treatment at home. Length of care by the unit ranged from 1-48 weeks, with an average of 8.5 and a median of 6. 55% of patients were hospitalized, most (58%) for 5-9 days for noncancerous diseases, and then discharged home. 54% died at home, a third were hospitalized for 2-17 days before death. Compared to the average length of stay in palliative care oncology wards, 1044 days and more than NIS 500,000 were saved.


A telephone survey examined families' satisfaction with various components of care. 92% were satisfied with the home treatment. 79%-82% felt that the nurse and doctor of the team met their needs and expectations. Half the families were satisfied with the treatment of pain. Families in which treatment was 24 weeks or more were generally less satisfied than those with shorter treatment at home. We learned that an early entry into treatment is necessary; hospital referral criteria should consider to a greater extent the coping ability of families; nursing aid hours should be increased and professional emotional support added; additional pain control methods should be used. All these would strengthen families, improve quality of care, and contribute to additional savings by decreasing hospital stay.

גליה סואן-גואסרו ואשר ברזילי

Interactive Effects of Perinatal Co-Infection with Hepatitis B and HIV Viruses


Galia Soen-Grisaru, Asher Barzilai


Pediatric Infectious Disease Unit, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University


We report the case study of a 1-year-old girl who was perinatally infected with both hepatitis B (HBV) and HIV viruses. The clinical presentation and treatment are described. We examined the interaction between the 2 viruses and the possible effects of the interaction on the development of each virus and on treatment. Our findings demonstrate that combined HIV and HBV infections intensified deterioration, as the HBV liver disease aggravated the HIV infection. The medication of choice was Lamivudine, since it prevents the transcription of both viruses.

שרהלי גלסר וויטה בראל

Depression Scale for Research in and Identification of Postpartum Depression


Saralee Glasser, Vita Barell


Health Services Research Unit, Ministry of Health, Sheba Medical Center, Tel Hashomer


Postpartum depression (PPD) is a relatively frequent and serious condition, with negative consequences for the mother, her infant, and the family. From research and clinical experience in many countries, it has been found that PPD can be identified early, and women at risk for developing PPD can be identified before delivery in the framework of primary health care service. The Edinburgh Postnatal Depression Scale (EPDS) has been found valid for this purpose, both in the original English version, and in translation to numerous languages. The Hebrew translation of the EPDS is presented, and it is recommended that Israeli researchers use the same translation to facilitate accumulation of knowledge regarding the epidemiology of PPD and intervention strategies in various Israeli population groups, and for comparison with data from other countries.

אורנה לוינסון, שמואל אורן, חנה יגיל, מרינה ספוג'ניקוב, אלכסנדר וקסלר, רוזנה בלוק ויורם יגיל

ACE Gene Polymorphism in a Diabetic Cohort and Diabetic Nephropathy


Orna Levinson, Shmuel Oren, Chana Yagil, Marina Sapojnikov, Alexander Wechsler, Rosanna Bloch, Yoram Yagil


Laboratory for Molecular Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba and Barzilai Medical Center, Ashkelon


The renin-angiotensin system is thought to play an important role in the pathophysiology of kidney disease in diabetes. Previous studies have shown a possible association between the D allele of the angiotensin converting enzyme (ACE) gene, known to be associated with higher circulating levels of ACE, and increased risk of developing nephropathy in NIDDM. The present study investigated the distribution of ACE gene genotypes in the general population and patients with NIDDM, the association between the D allele and diabetic nephropathy, and the association between the ACE genotype and involvement of other target organs in NIDDM. The ACE genotype (insertion/deletion I/D) was determined in all subjects, subsequently divided into 3 groups based on their polymorphism (DD, DI and II). The presence of nephropathy was defined by an albumin-creatinine ratio of 30 mg/g or greater (mean of 2 first morning urine samples).


In the general population most had the D allele (DD or ID) and a minority the II genotype. There was no association between genotype and hypertension, ischemic heart disease, hyperlipidemia, and cerebrovascular or peripheral vascular disease. In diabetics the genotype distribution was not different from that in the general population. Within the diabetic group, there was no association between genotype and hypertension, hyperlipidemia, duration of diabetes, or HbA1C levels. Nephropathy, found in 81 of the 156 with NIDDM, was not associated with genotype. Diabetic nephropathy was not associated with retinopathy, neuropathy, or ischemic heart, cerebrovascular or peripheral vascular disease. We conclude that in the population sampled, there was no association between the D allele of the ACE gene and the risk of developing nephropathy in NIDDM.

פלטיאל וינר, יוסף ויצמן, רסמי מג'דלה, נועה ברר-ינאי ובני פלד

Effect of Specific Inspiratory Muscle Training on Dyspnea and Exercise Tolerance in Congestive Heart Failure


Paltiel Weiner, Joseph Waizman, Rasmi Magadle, Noa Berar-Yanay, Benny Pelled


Depts. of Medicine A and Cardiology, Hillel Yaffe Medical Center, Hadera


It has been shown that the inspiratory muscles of patients with congestive heart failure (CHF) are weaker than normal. This weakness may contribute to dyspnea and limit exercise capacity. But respiratory muscles can be trained for increase in both strength and endurance. This study was designed to evaluate the effect of specific inspiratory muscle training (SIMT) on muscular performance, lung function, dyspnea and exercise capacity in moderate heart failure.

10 patients with CHF (NYHA functional class II-III) received 1/2 hour of SIMT daily, 6 times/week, for 3 months. They started breathing at a resistance 15% of their Pimax for 1 week and the resistance was then increased incrementally to 60%. Spirometry, inspiratory muscle strength and endurance, and the 12-minute walk test were performed before and after the training period. All showed an increase in inspiratory muscle strength and endurance. This was associated with a small but significant increase in FVC, a significant increase in the distance walked (458±29 to 562±32 m, p<0.01), and improvement in the dyspnea index score.

SIMT resulted in increased inspiratory muscle strength and endurance. This increase was associated with decreased dyspnea and an increase in submaximal exercise capacity. SIMT may prove to be useful complementary therapy in CHF.

הראל גילוץ, אהרון גבריאל ושמואל יורפסט

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.

צבי שטיינר, אשר פרסמן וג'ורג' מוגילנר

Combined Sclerotherapy and Surgery for Huge Cervical Lymphangioma


Zvi Steiner, Asher Pressman, Jorge Mogilner


Dept. of Pediatric Surgery, B'nei Zion Medical Center and Faculty of Medicine, Technion Institute of Technology, Haifa


Lymphangioma is a benign developmental anomaly of the lymphatic system located in about 40% of cases in the neck and usually completely resectable. In some cases it invades adjacent structures such as the larynx, pharynx, or tongue. In such cases it is almost impossible to resect completely, as this would endanger vital structures.

We describe a baby born with a huge cervical lymphangioma which invaded the tongue, larynx, pharynx and other cervical structures. He was treated with bleomycin and aethoxysklerol. The sclerotherapy shrank the lymphangioma considerably and it became resectable. At 2 years of age the cosmetic result is good and vital function, such as swallowing and facial expression, are preserved.

נטע נוצר

Determining Power Factors of Clinical Departments in a Medical Center


Netta Notzer


Medical Education Unit, Sackler Faculty of Medicine, Tel Aviv University


The intradepartmental power factors in a medical center were studied. 3 strategic contingency factors were examined, based on the model of Hickson et al. (1971): centrality, substitutability, and coping-with uncertainty. Only coping-with-uncertainty contributed directly to departmental power, and not the summation of the 3.


Power derives from department resources, connections and influence outside the medical center. Aspects related to in- patient treatment or teaching of residents did not contribute directly to departmental power status. Power is gained in stages: in the first the department contributes to the factor of centrality (mainly patient treatment, teaching and research). In the middle stage, power is gained due to the factor of substitutability- the unique services and research which the department has developed. The third stage contributes directly to power-coping with uncertainty. This implies the ability of a department to solve crucial problems of the medical center. Surprisingly, the clinical field (i.e. surgery) did not contribute significantly to power. The current trend is toward empowering ambulatory units in the medical center.

הבהרה משפטית: כל נושא המופיע באתר זה נועד להשכלה בלבד ואין לראות בו ייעוץ רפואי או משפטי. אין הר"י אחראית לתוכן המתפרסם באתר זה ולכל נזק שעלול להיגרם. כל הזכויות על המידע באתר שייכות להסתדרות הרפואית בישראל. מדיניות פרטיות
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