Israel Medical Association Journal

Background: Advances in surgical techniques and retractor-stabilizer devices allowing access to all coronary segments have resulted in increased interest in off-pump coronary artery bypass. The residual motion in the anastomotic site and potential hemodynamic derangements, however, render this operation technically more demanding.

Objectives: To evaluate the OPCAB[1] experience in a single Israeli center.

Methods: Between 2000 and 2003 in our institution, 1,000 patients underwent off-pump operations. Patients were grouped by the type of procedure, i.e., minimally invasive direct coronary artery bypass or mid-sternotomy OPCAB.

Results: One hundred MIDCAB[2] operations were performed. Of the 900 OPCAB, 767 patients received multiple grafts with an average of 2.6 ± 0.6 grafts per patient (range 2–4) and the remaining patients underwent single grafting during hybrid or emergency procedures. In the multiple-graft OPCAB group, complete revascularization was achieved in 96%. Multiple arterial conduits were used in 76% of the patients, and total arterial revascularization without aortic manipulation, using T-graft (35%) or in situ configurations, was performed in 61%. The respective rates for early mortality, myocardial infarction and stroke in the MIDCAB were 1%, 0% and 2%, and 2%, 1.3% and 0.9% in the multiple-vessel OPCAB groups. Multivariate analysis identified renal dysfunction (odds ratio 11.5, confidence interval 3.02–43.8; P < 0.0001) and emergency operation (OR[3] 8.74, CL[4] 1.99–38.3; P = 0.004) as predictors of mortality. The proportion of off-pump procedures increased from 9% prior to the study period to 59%.

Conclusions: The use of OPCAB does not compromise the ability to achieve complete myocardial revascularization. Our procedure of choice is OPCAB using arterial conduits, preferably the 'no-touch' aorta technique.

Background: Cardiac rupture is a rare but ominous complication of myocardial infarction.

Objectives: To study the clinical presentation, medical course, outcome and echocardiographic predictors of patients with myocardial rupture.

Methods: We evaluated 15 consecutive patients with cardiac rupture during a 4 year period in our department. The current report explores the presence of potential risk factors, timing, relation to the thrombolysis, coronary interventions and outcome.

Results: The index event in all patients was first ST elevation myocardial infarction. In seven patients rupture occurred in the first 24 hours. Pericardial effusion on admission with a clot was present in three patients. Five patients received thrombolytic therapy. Only three patients underwent coronary angioplasty, but in one case it was performed late and in two patients the culprit artery could not be opened. Six patients reached the operating room, of whom three survived.

Conclusions: The lack of early mechanical reperfusion in acute myocardial infarction and thrombolytic therapy are risk factors for cardiac rupture. Pericardial effusion on admission and evidence of a clot are echocardiographic indicators of cardiac rupture and should alert the medical team to further assess the possibility of cardiac rupture.
 

Background: An estimated 10% of all children are subject to recurrent attacks of abdominal pain of unknown origin. When no organic cause is found, the working diagnosis is usually functional abdominal pain.

Objectives: To investigate the possible causative role of occult constipation.

Methods: We defined occult constipation as the absence of complaints of constipation on initial medical history or of symptoms to indicate the presence of constipation. The diagnosis was made by rectal examination and/or plain abdominal X-ray.

Results: Occult constipation was found to be the cause of RAP[1] in 42.6% of children examined. Treatment consisted of paraffin oil and phosphate enema. In 82.84% of cases the abdominal pain subsided considerably or disappeared within 2 weeks to 3 months of treatment. On telephone interview of the parents at 1–1.5 years after discharge, 96.5% reported that both the abdominal pain and constipation had subsided or disappeared.

Conclusions: Occult constipation can be easily identified and treated in a large number of children with RAP who were diagnosed as having functional abdominal pain.

Background: The long-standing and ongoing controversy regarding administration of analgesia to patients with acute abdominal pain prior to final diagnosis has not yet been resolved, despite considerable research. Consequently, wide variations in clinical practice exist.

Objectives: To determine the motives, attitudes and practices of emergency physicians, internists and surgeons in Israeli emergency departments regarding the administration of analgesia before diagnosis in patients with acute abdominal pain.

Methods: Questionnaires were completed by 122 physicians in 21 EDs[1] throughout Israel and the replies were analyzed.

Results: Most EDs did not have a clear policy on analgesia for undifferentiated abdominal pain, according to 65% of the responders. More internists (75%) than surgeons (54%) (P = 0.02) and more emergency physicians (81%) than all other physicians (60%) (P = 0.05) held this opinion. Most respondents (64%) supported administration of analgesia pre-diagnostically. Support for analgesia was significantly stronger among internists (75%) compared to surgeons (52%) (P = 0.03). Despite this wide support, most respondents (68%) indicated that analgesia was rarely or never given pre‑diagnostically and, when it was, more surgeons (58%) than other physicians made that decision. Most internists (73%) and all surgeons reported that patients receive analgesia only after being examined by surgeons. Time allocated to the ED (part‑ or full‑time) significantly (P = 0.02) influenced decision-making, with 51% of part-time physicians vs. 25% of full-time opposing prompt administration of analgesia. Opinions on who should decide were divided according to medical specialty, with surgeons and internists almost opposed, as well as by physician age and percent of his/her time spent working in the ED. More surgeons than internists (P = 0.0005) reported that analgesia sometimes interfered with making a diagnosis. Most physicians (90%) stated that opiates impede diagnosis, to some extent. However, 58% of them supported the administration of opiates, more or less frequently. Intramuscular diclofenac was the most preferred analgesic, followed by intravenous morphine and pethidine; individual preferences extended beyond the list of actually administered drugs.

Conclusions: There is no consensus on the administration of analgesia for undiagnosed acute abdominal pain in EDs in Israel. Physicians’ attitudes are influenced by training, experience, and percent of personal time allocated to work in the ED.