יוני 1998

Transurethral Microwave Thermotherapy

Boaz Moskovitz, Shahar Madjar, Sarel Halachmi, Ofer Nativ

Dept. of Urology, Bnai Zion Medical Center, Haifa

The effectiveness of transurethral microwave thermotherapy (TUMT) for benign prostatic hypertrophy in poor surgical risk patients (ASA class IV) with indwelling catheters, was assessed. All had had an indwelling catheter for 1-12 months. Removal of the catheter was possible in 14 out of the 24 (58.3%). Urinary peak flow rates were 12.2±3.5 ml/sec at 3 months of follow-up and post-voiding residual urine volumes of less than 50 ml were recorded in 13 catheter-free patients. Our data suggest that TUMT is an effective procedure for management of high risk patients with indwelling catheters in whom surgery or anesthesia are contraindicated.

Combined Treatment of Hepatic Tumors by Cryosurgery and Resection

Doron Kopelman, Alexander Beny, Ahmed Assalia, Diana Gaitini, Yoram Klein, Moshe Hashmonai

Depts. of Surgery B, Oncology and Radiology, Rambam Medical Center and Technion Faculty of Medicine, Haifa

Cryosurgery is an old technique which is being used for hepatic tumors as an adjuvant to hepatic resection. We recently treated 7 patients with multiple malignant liver tumors, 5 of whom had colorectal metastases, 1 carcinoid metastases, and 1 multiple hepatic lesions of hepatocellular carcinoma. 6 underwent combined liver resection and cryoablation of lesions in the remaining liver. In the 7th patient, only cryoablation was performed because hepatic resection was rejected and there was an extrahepatic metastasis. The advantages of this treatment are removal or destruction of all liver lesions found by any method, including intraoperative ultrasound examination, maximal preservation of normal liver parenchyma and that it is curative in patients inoperable by standard criteria.

Mechanism of Primary Hypertension

Ludwig Kornel,* Arthur V. Prancan

Steroid Research Laboratory, Depts. of Internal Medicine and Biochemistry, and Dept. of Pharmacology, Rush Medical Center, Chicago and *Endocrinology-Diabetes Outpatient Clinic, Kupat Holim Klalit, Jerusalem

We review various theories of the pathogenetic mechanisms of steroid-induced and essential hypertension. We investigated the possibility that a pathogenetic mechanism leading to glucocorticoid (GC)-induced hypertension or to mineralocorticoid (MC)-induced hypertension, or both, may be of critical importance in primary hypertension. We studied plasma levels of corticosterone (BK) and aldosterone (Aldo), and their concentrations in arterial and renal tissues of spontaneously hypertensive rats (SHR), a model of primary hypertension, and in the antecedent strain WKY rats as a normotensive control. Plasma levels of BK and Aldo were found to be normal and identical in SHRs and WKYs. Tissue (intracellular) levels of BK were more than double in SHRs than in WKYs. Subsequently we examined the activity of 11b-hydroxy steroid dehydrogenase (11-HSD) in both aortic and renal tissues of SHRs and WKYs. 11-HSD converts BK to the corresponding 11-keto compound, 11-dehydro-corticosterone (cpd.AK), which is inactive, in view of its inability to bind to the MC receptors (and also to the GC receptors). BK, the main glucocorticoid in the rat, as well as cortisol, have high affinity for the MC-receptor (MR). Normally BK or cortisol are present in 10²-10³ times greater concentrations than Aldo in tissues possessing MR. The enzyme 11-HSD deactivates BK (or cortisol), thus protecting MC-receptors in the MC target tissues from being activated by GC. When we examined arterial and renal tissue activities of 11-HSD in SHRs, the activity of 11-HSD was only one-third that found in the WKY rats. This explained higher levels of BK in the tissues of SHR, and suggested that decreased activity of 11-HSD is a pathogenetic factor for hypertension in SHRs.

Thus, in a model of primary hypertension such as SHR, decreased activity of 11-HSD in the target tissues of MC appears to lead to glucocorticoid-induced mineralocorticoid hypertension.

Splenic Artery Aneurysm

M. Shimonov, M. Nobel, M. Kunichevski, E. Antebi

Depts. of Surgery A and Pathology, Rabin Medical Center, Petah Tikva

Splenic artery aneurysm is an uncommon form of vascular disease of unknown etiology. Its clinical importance is due to its high mortality, especially in pregnancy, when maternal mortality is 70% and fetal mortality 95%. Most cases of splenic artery aneurysm are asymptomatic and are diagnosed incidentally. We present a woman with incidentally diagnosed splenic artery aneurysm in whom the splenic artery and its aneurysm were resected.

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.