Ethnicity and Emergency Department Visits in the Negev

Shahar Livnat, Eyal Almog, Gad Rabinowitch, Yoram Snir

Dept. of Emergency Medicine, Soroka University Medical Center and Dept. of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer Sheba

The population of the Negev consists mainly of Jews and Bedouin, who have very different life styles. Patients of both ethnic groups use our emergency department exclusively, providing a unique opportunity to study comparative patient habits.

In gathering and processing the information we used Data Mining technology, which allows search for unique patterns in large data bases. We examined demographic data on some 64,000 emergency department visits during 1997-8, mostly medical and surgical cases, but not trauma cases. Many more were by Bedouin than Jews, and between the ages of 25 and 44, more by women than men. There were changes in trends in comparison with an arrival survey conducted some 11 years before.

Placenta Accreta with Placenta Previa after Previouscesarean Sections 

Eylon Lachman, Alexander Mali, Gabriel Gino, Michael Burstein, Michael Stark

Depts. of Obstetrics and Gynecology and of Pathology, Misgav Ladach Hospital, Jerusalem

The increased rate of cesarean sections in recent decades has brought with it an increase in the frequency of placenta accreta. There are direct correlations between previous cesarean deliveries and also maternal age, with the risk of placenta accreta. There is also a direct correlation between placenta accreta and placenta previa.

The risk of placenta accreta in women who have had placenta previa is 2% for those younger than 35 years and with no history of uterine surgery. The risk increases to 39% for those over 35 who have had 2 or more cesarean sections.

We present 3 cases of placenta accreta admitted in 15 months, all of whom had a history of cesarean sections. The frequency of placenta accreta in our hospital is 1:1,579 deliveries, in line with the 1:1,420 in the literature. We consider hysterectomy the treatment of choice for this serious complication. When performing a cesarean in cases of placenta previa with a history of cesarean sections, the possibility of placenta accreta should be considered.

Etoposide and Cisplatin for Non-Small Cell Lung Cancer 

David B. Geffen, Sofia Man, Yoram Cohen*

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

Etoposide and cisplatin (EP) has been the standard therapy for non-small cell lung cancer (NSCLC) at many cancer centers for over a decade. We analyzed our experience with EP in NSCLC to provide a baseline for comparison with new drugs. From 1986 through 1994, 46 of our patients with NSCLC received EP as first-line chemotherapy. Radiation therapy was administered to 25 of them, including 20 who received it immediately before or concomitantly with chemotherapy. Toxicity was mild and included only 1 episode of neutropenic fever and 1 case of reversible renal failure.

Overall response was 22%. In 3, response was complete (pathologically documented in 2 of them) and in 7 partial. Median survival in locally advanced (stage III) and metastatic disease (stage IV and recurrent) were 12 months and 7 months, respectively. 2 patients are alive and free of disease more than 6 years after diagnosis.

Our results are consistent with other published studies of EP in NSCLC. EP provides modest benefit in locally advanced NSCLC, with minimal toxicity.

Jules E. Harris Chair in Oncology.

The Gift of Breastfeeding 

Dorit Nitzan Kaluski, Alex Leventhal

Dept. of Nutrition, Public Health Services, Israel Ministry of Health, Jerusalem

Breast milk is the optimal food for infant growth and development, the prevention of infectious diseases and mother- child bonding. From the economic perspective, breastfeeding is cost-effective both for the family and society as a whole. The Israeli Ministry of Health encourages breastfeeding as the exclusive source of nutrition for infants in the first 4-6 months of life, with gradual addition of complementary foods thereafter. The promotion of breastfeeding in Israel requires comprehensive national activity with involvement of all the stakeholders. This includes implementation of the International Code of Marketing of Breast Milk Substitutes and joining the international "Baby Friendly Hospitals" project. Knowledge of breastfeeding should be spread, health professionals should be encouraged to become agents of change, support by breast counselors should be encouraged, post-delivery vacations from work should be prolonged and empowerment of women implemented.

Alopecia Due to Seroxat 

Leonid Umansky, Abraham Dorevitch, Avner Sella

Psychiatry Chronic Dept., Eitanim Mental Health Center, Jerusalem

There are 2 stages of alopecia, anagen and telogen effluvium, both of which may be associated with medication- related alopecia. We describe massive hair loss in a 51-year-old woman during treatment with Seroxat (paroxetine), which remitted after it was discontinued. Pathological mechanisms of drug-associated alopecia are complex and have yet to be fully elucidated.

Carbamazepine Hypersensitivity 

Shimon Ivry, Doobi Shteinmintz, Hava Tabenkin

Dept. of Family Medicine, HaEmek Hospital, Afula and National Residency Institute, Ben-Gurion University of the Negev, Beer Sheba

Carbamazepine (C) can cause a characteristic hypersensitivity reaction (CHS}. This multisystem reaction typically presents as fever, mucocutaneous eruption and lymphadenopathy. The syndrome usually develops between 1 week and 3 months after starting therapy, with involvement of the liver, lung, kidney and inappropriate secretion of ADH. The incidence is less than 0.001% in those treated with C and it is diagnosed clinically. With onset of CHS, the drug must be stopped and if there is no improvement, cortico-steroids should be started. When the diagnosis is in doubt, the patch test, lymphocyte transformation test, macrophage migration inhibitor factor, and other tests can be helpful.

The pathogenesis is not known. Similar syndromes have been described with phenytoin and phenobarbital. There is clinical and in-vitro evidence of cross reactions between C and phenytoin. It is not known whether the CHS syndrome should be considered a premalignant state, with increased risk for the development of malignant lymphoma.

Elective Repair of Infra-Renal Aortic Aneurysm 

J.D. Cohen, P. Singer, M. Haddad, A. Zelikovski

Depts. of General Intensive Care and Vascular Surgery, Rabin Medical Center, Beilinson Campus; and Sackler Faculty of Medicine, Tel Aviv University

Age over 80 years is generally considered an independent risk factor in elective surgery for abdominal aortic aneurysm (AAA). As the general population increases in age, more elderly are likely to be candidates for such surgery.

We studied prospectively 100 consecutive patients undergoing elective AAA surgery between 1992-1995. All were operated on by the same team of anesthetists and surgeons and all were transferred to the general ICU for at least the first 24 hours. 16 were above the age of 80 (Group I) and 84 below (Group II).

We recorded preoperative factors (demographics, medical history, risk factor indices, EKG findings, as well as left ventricular ejection fraction (LVEF) and stress imaging when indicated); intraoperative factors (duration of surgery, size of aneurysm, complications and units of blood transfused); postoperative factors (length of ICU stay, duration of ventilation, APACHE II [Acute Physiological and Chronic Health Evaluation] and TISS [Therapeutic Intervention Scoring System] scores; complications in the ICU, need for readmission to the ICU, and mortality).

In Group I LVEF was greater (p=0.03) and aneurysm size significantly larger (p=0.036), but there were no other significant differences between the 2 groups with regard to pre- and intraoperative data. Group I patients were not ventilated as long (p=0.038), but there were no significant differences in outcome factors. Mortality for the whole group was 5% and was not significantly different in the 2 groups (1/16 in Group I and 4/84 in Group II).

We conclude that there is no excess morbidity or mortality in octogenarians undergoing AAA surgery. However risk of the aneurysms rupturing is significantly greater since they are larger. We suggest that age not be considered the sole criterion for aneurysm repair, or at least not in selected patients with normal LVEF.

Acute Ischemia of the Lesser Gastric Curvature 

D. Czeiger, A. Ariche, G. Shaked, N. Sion-Vardi, I. Levi

Trauma Service, Dept. of Surgery, and Pathology Institute, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheba

The rich blood supply of the stomach protects it from ischemia and necrosis. Acute gastric ischemia, an emergency with high mortality, is rare. Atherosclerosis is the leading cause of acute ischemia, and the lesser curvature of the stomach is more vulnerable due to its relatively lesser blood supply. Reduction in gastric blood supply usually presents as chronic disease characterized by gastritis, gastric ulcer, or gastroparesis.

Gastroscopy can identify lesions of the gastric mucosa, and angiography demonstrates occluded vessels. Treatment of acute gastric ischemia is surgical, with total gastrectomy preferred over partial resection.

Laparoscopic Adrenalectomy 

G. Zamir, D. Hazzan, D.J. Gross, S. Lyass, O. Jurim, E. Shiloni, P. Reissman

Depts. of Surgery, Endocrinology and Metabolism, Hadassah University Hospital, Ein-Kerem, Jerusalem

Constant advances and increasing experience in laparoscopic surgery renders it applicable for adrenal surgery. The wide exposure required for open adrenal surgery makes this minimally invasive procedure an attractive and advantageous alternative.

Between 1996-1999, we performed 35 laparoscopic adrenal-ectomies in 30 patients 20-72-years old. Indications included: Conn's syndrome - 14, pheochromocytoma - 11, Cushing's syndrome - 6, nonfunctioning adenoma - 3, and metastatic sarcoma - 1.

5 underwent bilateral laparoscopic adrenalectomy. In 3 (8.5%) the procedures were converted to open operations. Overall morbidity was 13% and there was no mortality. Mean operative time was 188 minutes, but only 130 in our last 10 cases. Mean hospital stay was 4 days and they returned to normal activity an average of 2 weeks later.

According to our study and previous reports, laparoscopic adrenalectomy is feasible and safe and it may soon become the procedure of choice for adrenal tumors.

Non-Penetrating Deep Sclerectomy without Collagen Implantfor Glaucoma

Ben Zion Silverstone, Isaac Aizenman, Carmit Landau, Yaacov Rozenman

Ophthalmology Dept., Shaare Zedek Medical Center, Jerusalem

Deep sclerectomy (DS) can be used in glaucoma with increased intraocular pressure when medical treatment fails. It involves removing part of the ocular drainage apparatus. Resistance to intraocular fluid drainage is decreased, improving drainage and decreasing intraocular pressure. By avoiding anterior chamber penetration, DS diminishes frequency of the complications of filtering surgery.

24 eyes of 23 patients underwent DS for primary or secondary open angle glaucoma with elevated intraocular pressure not controlled medically. It included preparation of a 4.0 x 4.0 mm limbal-based external scleral flap, dissecting and removing most of an internal scleral flap (leaving it 1 mm smaller than the external flap), unroofing Schlemm's canal and removing fine endothelial tissue lining its inner walls. The external scleral flap was then repositioned and sutured. Collagen implants were not used. In some cases DS was combined with extracapsular cataract extraction and intra-ocular lens implantation.

Mean intraocular pressure decreased from 24.8‏3.9 mmHg initially to 12.8‏4.4 mmHg 6 months after operation (p<0.0001). There was no difference in postoperative intra-ocular pressure between DS as a single procedure or as part of a combined operation. Comations were mild and of short duration.

If long-term follow-up shows that lowered intraocular pressures are maintained, DS should be a surgical option in earlier stages of glaucoma.

Glucosamine Sulfate and Chondroitin Sulfates for Degenerative Joint Disease 

R. Debi, D. Robinson, G. Agar, N. Halperin

Orthopedic Dept., Assaf Harofeh Medical Center, Zrifin

Osteoarthritis results from progressive catabolic loss of cartilage proteoglycans due to imbalance between synthesis and degradation. The availability of glucosamine, an intermediate in mucopolysaccharide synthesis, can be rate-limiting for proteoglycan production in cartilage tissue culture.

57 patients suffering from osteoarthritis of the knee were randomized into a group treated for 4 weeks with daily IV glucosamine sulfate (GS) together with 800 mg chondroitin sulfate, and a placebo group. Knee pain at rest, on movement and on palpation, as well as range of knee motion were then recorded.

In the GS group, there was significant reduction of clinical symptoms (p<0.01), but no significant reduction in the placebo group. Physicians' assessment of tenderness and range of motion were significantly in favor of the GS group (p<0.01). In those treated with glycosamine there were no adverse reactions and no changes in laboratory blood tests.

Transient Ischemic ECG Changes in Acute Cholecystitis without History of Ischemic Heart Disease

Lior Lowenstein, Amer Hussein

Dept. of Emergency Medicine, Bnai Zion Medical Center, Bruce Rapport Faculty of Medicine, Haifa

That abdominal distention, nausea, and chest pain may be accompanied by ischemic ECG changes is well known and has been described in the literature. However, very few cases have been reported with acute cholecystitis and ECG changes not due to cardiac ischemia.

We present a previously healthy 20-year-old woman admitted with acute cholecystitis. Prior to surgery routine ECG showed ST-depression and T-wave inversion. The day following cholecystectomy the ECG returned to normal. 1 month later, ergometry and echocardiography were both negative.

Based on the literature and our personal experience, although ECG changes may occur in acute cholecystitis, the possibility of cardiac ischemia must be excluded. However, when no cardiac basis is found, ultrasound of the biliary system might reveal the cause of these ECG changes. Thus, in acute cholecystitis with ischemic ECG changes but no other laboratory or clinical evidence of cardiac ischemia, ECG changes alone are not a contraindication to cholecystectomy. Furthermore, delay in treatment could be harmful.

Relationship Between Preterm Birth and Exertion During Pregnancy

S. Gazit-Nissim, E. Sheiner, M. Mazor, I. Shoham-Vardi

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

The relationship between physical activity at home and at work during pregnancy and preterm birth was studied. Using a case-control design, 99 women who delivered preterm were compared with 189 women who had term deliveries. The risk of preterm birth was tested in relation to characteristics of work in and outside the home. All women were interviewed post-partum before discharge.

There were no statistically significant differences between the groups in relation to sociodemographic and obstetrical factors, but level of education was significantly lower in the study group versus the control group (p=0.001).

Women who delivered preterm had devoted less time 3 months prior to delivery to household chores (mean of 3.7 hours vs. 4.8 hours in the control group, p=0.002). They also had spent less time walking around the home than the controls (1.2 vs. 1.5 hours, p=0.02). There were no differences between the groups in relation to physical activity outside the home, not during working hours, nor in duration of work. Significantly fewer women who delivered preterm were active in sports (odds ratio 0.22; 95% confidence interval 0.50-0.65; p=0.002).

A low level of education was significantly related to the risk of preterm birth, which may have resulted from lesser compliance with their physician's recommendations. It appears that in women not used to significant physical activity but who had access to adequate prenatal care, physical effort during pregnancy was not related to a higher risk of preterm birth.

Presurgical Neuropsychological assessment in Epilepsy: The Wada Test

Fani Andelman, Miri Neufeld, Irith Reider-Groswasser, Uri Kremer, Yoram Segev, Itzhak Fried

Functional Neurosurgery and EEG and Epilepsy Units, Section of Neuroradiology; and Pediatric Neurology Unit; Tel Aviv-Sourasky Medical Center, Tel Aviv

37 candidates for epilepsy surgery underwent the intra-carotid amytal procedure (IAP; also known as the Wada test) to determine hemispheric speech dominance and memory capacity. 31 demonstrated left hemisphere speech dominance, 2 showed evidence for bilateral language and 4 demonstrated right hemispheric language dominance.

Our study supports a correlational relationship between handedness, lesion laterality and age of onset of seizures, as reported in earlier studies. Left-handed patients with a left hemisphere lesion whose seizures began to an early age had a strong tendency for reversed language dominance.

Asymmetry of at least 20% in performing the memory test was taken as the cutoff score for demonstrating laterality of lesions. The asymmetry score correctly predicted laterality of lesions in all 28 patients; 6 did not have asymmetry scores and 3 were examined for language only. None of the patients who successfully passed the Wada memory test had any significant postsurgical memory deficits; 1 had transient reduction in verbal memory and 4 who did not pass the test were not operated on for this reason.

Our results demonstrate the importance of the Wada test in determining cerebral speech dominance, in predicting post-surgical amnesia, and support its usefulness in predicting laterality of seizure focus in candidates for temporal lobectomy.

Physicians' Assessment of Computerized Prescribing

Daniela Zalman, Majed Odeh, Arie Oliven

Dept. of Internal Medicine B, Bnai Zion Medical Center, Technion Faculty of Medicine, Haifa

Prescription errors are a major source of preventable adverse drug events. Computerized prescribing (CP) which screens physicians' order for mistakes, drug-allergy, drug-disease, drug-laboratory and drug-drug interactions can prevent many of these errors and improve quality of care. However, computerized systems are often time-consuming, difficult to handle, and may create their own mistakes.

Following the introduction of CP on an internal medicine ward, we administered a questionnaire to evaluate physicians' opinions about the new system. The survey assessed computer literacy, ease of using CP, effects on time management, opinion of users regarding error prevention, and usefulness of the information provided. Opinions were generally favorable; most users felt that CP makes their work more accurate, reduces errors, is easy to learn and to use, and provides important and useful information. Physicians were most critical of equipment failure and drugs and dosages not included in the CP program, a result of rapid development of the system.

Errors resulting from the use of CP were considered minimal. Comparison of physicians, with and without previous experience with computer work, as well as local and foreign graduates, revealed minor differences. But once physicians learn to work with a well-organized CP system and computerized work stations, they appreciate the order, safety and knowledge they provide.