אפריל 1997

Biological Test for Menopausal Osteoporosis

Benjamin Klein, Nathan Rojansky

Depts. of Experimental Surgery and of Obstetrics and Gynecology, Hadassah- Hebrew University Medical Center, Ein Kerem, Jerusalem

Osteoporosis has become a major public health problem in many western countries in which about 25% of women by the age of 65 will have had osteopenic fractures. The most important contributing factor to this condition is loss of gonadal function. This progressive disease, characterized by reduction in bone mass, may be prevented by estrogen replacement therapy. While there are several methods of diagnosing the disease when already established, there is no method that can identify women at high risk of developing osteoporosis. We have developed a biological test in which the serum of postmenopausal women is added to rat osteoprogenitor cell culture and its influence on proliferation, differentiation and mineralization of bone cells is determined. The serum of 20 menopausal women was examined by the biological test and the results compared to the findings of dual photon absorptiometry. This showed that rapid bone-losers had a significantly lower mineralization index as compared to nonosteopenic women (p<0.0001). The proliferation index (cell count) and alkaline phosphatase activity did not show significant differences between osteopenic and nonosteopenic groups. This preliminary study showed that a test based on serum reacting with a culture of bone cells to induce mineralization may be of value in the diagnosis of osteoporosis.

Urinary Bladder Transitional Cell Carcinoma with Trophoblastic Differentiation

M. Moldavsky, A. Sazbon, N. Kuchersky, H. Turani

Cytology Division, Dept. of Pathology and Dept. of Urology, Rebecca Sieff Government Hospital, Safed

Transitional cell carcinoma (TCC) with trophoblastic differentiation (TD) is a newly recognized variant of urothelial cancer which produces placental proteins, predominantly beta-human chorionic gonadotropin (HCG). It has a poor prognosis. About 210 cases were described, mostly from North America, Europe and Japan. This is the first report of TCC TD in a resident of Israel's upper Galilee. A 69-year-old man whose urinary papillary bladder tumor was established cystoscopically, refused treatment and stopped follow-up. 3.5 years after his last visit, he returned and cytologic examination revealed malignant urothelial cells, while intravenous pyelography disclosed a urinary bladder defect. Cystoscopy showed numerous papillary masses dispersed over the bladder mucosa, which were resected transurethrally. Histopathologic examination revealed TCC grade III, stage A. Tumor cells were immunopositive for beta-HCG and human placental lactogen. 4 transurethral resections of large masses were performed within 2 months. Pulmonary metastases developed and the patient died 4 years after the detection of the urinary bladder tumor.

Insertion of Hickman Catheters in an Interventional Radiology Suite

Eli Konen, Alex Garniak, Binyamina Morag, Izhar Hardan, Zalman Rubinstein

Depts. of Radiology and Hemato-oncology, Chaim Sheba Medical Center, Tel Hashomer

In the past 20 years Hickman catheters have gained increasing acceptance for many uses, including bone marrow transplantation, long-term chemotherapy, total parenteral nutrition, dialysis, and administration of antibiotics and fluids. Until the past decade these catheters were inserted in the operating room. We present our experience in the percutaneous placement of 203 Hickman catheters in an interventional radiology suite in 190 consecutive patients within a period of 30 months. Catheter placement was successful in 202 (99.5%). The main complications were infections, necessitating removal of the catheter in 11 cases (5.4%) and unintentional dislodgement of the catheter in 8 (3.9%) - all in women and most on the right side. Pneumothorax and thrombosis in the catheter each occurred once. In another patient the guide wire broke during insertion and had to be percutaneously removed from the pulmonary artery. Late fracture of the catheter occurred in 2 others in whom the intravascular fragment was removed percutaneously. We believe that percutaneous Hickman catheter placement in the radiology suite offers advantages over traditional surgical placement.

Between "Transparent Room" and "Sealed Room:" Professional Confidentiality and Therapeutic Judgement

Yuval Melamed, Ami Levy, Henry Szor

Abarbanel Mental Health Center, Bat Yam and Shalvata Mental Health Center, Hod HaSharon

Patients and therapists are concerned with the complexities of protecting medical confidentiality. The traditional perception of protection of patient confidentiality is that the individual's interest in protecting his confidentiality may conflict with the public's need for information, especially in cases involving possible danger. In fulfilling his dual role of representing both the patient and the public, the therapist acts according to existing laws and regulations. We describe 3 cases in which refraining from providing the Army with information in accordance with the law was recognized in retrospect as having caused the patient suffering, and even danger. It is recommended that the therapist's judgement be considered in addition to other legal criteria for determining whether or not to protect patient confidentiality.

Ischemic Hepatitis in Congestive Heart Failure after an Episode of Hypotension

Ora Shovman, Jacob George, Yehuda Shoenfeld

Dept. of Medicine B and Autoimmune Disease Clinic Research Unit, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Ischemic hepatitis can occur as an acute episode in advanced congestive heart failure (CHF). The mechanism is massive necrosis of the central lobules resulting from acute hypoxia when low cardiac output further reduces oxygen supply, aggravating underlying congestion due to poor venous outflow. We describe a 70-year-old woman with congestive heart failure for 7 years who was admitted with jaundice, vomiting, abdominal pain and oliguria after an episode of hypotension. The diagnosis of ischemic hepatitis was established by a documented episode of severe hypotension, followed by elevation of serum transaminases, a rise in serum bilirubin and LDH levels, prolonged prothrombin time and acute renal failure. Other causes of acute hepatitis, such as a virus or drugs were excluded, and improved liver and renal function followed hemodynamic stabilization. We conclude that ischemic hepatitis should be considered whenever acute hepatitis follows a recent episode of systemic hypotension, especially in the context of concomitant CHF.

Treatment of Open Fractures due to Dog Bite

A. Dimant, M. Liebergall, S. Porat R., Mosheiff

Orthopedic Dept., Hadassah-University Hospital, Ein Kerem, Jerusalem

2 patients aged 12 and 19, respectively, sustained open fractures of the wrists due to dog bites. Both were bitten on a wrist by Rotweiller dogs, but with different magnitudes of injury to bone and soft tissue. Treatment, clinical course and recovery are described, together with recommendations for dealing with open fractures due to animal bites. In the presence of considerable injury to soft tissue and bone, and of exposure to canine oral flora, open fractures due to dog bites should be dealt with as high grade open fractures.

Water Intoxication following Desmopressin Overdose

D. Segal-Kuperschmit, O. Dali-Gotfrid, A. Luder

Pediatric Dept., Rebecca Sieff Hospital, Safed

Water intoxication is a serious condition which may be caused by desmopressin overdose, with reversible or irreversible neurological complications. In the past, desmopressin was used in endocrinological centers for the treatment of anti-diuretic hormone deficiency (central diabetes insipidus). Indications for hormone treatment have since widened, especially as an effective solution for nocturnal enuresis. It is now often prescribed in community clinics, and its use has been encouraged by extensive promotion. We describe a 15-year-old boy with primary nocturnal enuresis who started treatment with desmopressin 1 year prior to admission. He was allowed to use the drug without supervision, and drank excessively. The result was water intoxication which required admission for intensive care because of loss of consciousness and convulsions for 36 hours.

Osteoid Osteoma of the Patella

I. Cohen, A. Aner, V. Rzetelny

Dept. of Orthopedics, Edith Wolfson Medical Center, Holon

Osteoid osteoma is a primary, benign, bone tumor with a typical X- ray appearance. The diagnosis is usually straightforward when it involves the long bones of the leg. However it may occur in unusual locations, such as in flat and cancellous bones. The following case demonstrates the difficulty in diagnosing it in an extremely rare site. A 25-year-old woman with long-standing anterior, right knee pain had had 3 interventions: 2 diagnostic arthroscopies and a distal, femoral biopsy. Since there had been no improvement in her condition, the diagnosis of osteoid osteoma of the patella was suggested, supported by recent X-ray and scintigraphicfindings. This rare condition was confirmed by biopsy of the upper pole of the patella, a procedure that was followed by complete recovery. 6 years later, she is now completely free of pain and has no clinical or X-ray evidence of recurrence.Review of the literature revealed only 5 previously reported cases of osteoid osteoma of the patella. All were diagnosed relatively late and in 1 the tumor was diagnosed only after total patellectomy. Diagnosis of these rare cases that mimic much more common causes of patello-femoral pain demands a high index of suspicion.

Smoking Habits of Young Israeli Soldiers

I. Askenazi, J. Shemer

Medical Corps, Israel Defense Forces, and Sackler Faculty of Medicine, Tel Aviv University

A random sample of 32,166 soldiers were interviewed (on their day of discharge from the Israeli Defence Forces, between 1980-1995) with regard to smoking habits. Among men, prevalence of current smoking was 46.8%, and among women 32.9%. Over the study period, prevalence in men decreased 27%. Among women, prevalence decreased from 1981 to 1991, but since then it has steadily increased. Among men, mean number of cigarettes smoked decreased from 21.6 in 1989 to 16.6 in 1995. Among women cigarettes smoked decreased from a mean of 14.3 in 1989 to 13.1 in 1995. 65.9% of the men and 49.3% of the women had started smoking by the age of 18. Among men the age distribution of smoking changed hardly at all over the years of the study. However, the proportion of women who began to smoke in the youngest age bracket (15 years of younger) doubled over the course of the study.

Solid Organ Retransplantation

Yaron Ilan, Dan Admon, Michael Friedlander

Division of Medicine, Dept. of Cardiology and Nephrology Unit, Hadassah Medical Center, Jerusalem

The need for solid organ retransplantation is a major factor in the shortage of available organs. Between 1972 and 1992, 56 out of 309 kidney transplants and 2 out of 20 liver transplants performed in our hospital were retransplantations. The present study evaluates local and world experience with organ retransplantations in terms of the medical and ethical issues.

Multidisciplinary Approach to the Treatment of Musculo-Skeletal Tumors

M. Salai, E. Goshen, T. Tishler, R. Weitzen, S. Apter, A. Garniek, M. Feldman

Depts. of Orthopedic Surgery, Nuclear Medicine, Oncology, Imaging Radiology and Pathology, Chaim Sheba Medical Center, Tel Hashomer

Tumors of the musculoskeletal system are relatively rare. They occur mostly in the young, while in older age groups metastases and myeloma are more prevalent. Treatment has undergone major change in the past 20 years with the introduction of neoadjuvant treatment protocols. According to recent reports 5-year survival rates have increased from 20% to 60-70%. These new protocols involve the use of modern imaging modalities, immunohistochemical pathological analysis and improved surgical technics. This has required establishment of multidisciplinary teams of experts to escort the patient through all the steps of current treatment.

Epidemiologic Characteristics of Pediatric Emergency Room Referral and Hospitalization for Diarrhea in the Negev

Moni Benifla, Drora Fraser, Zvi Weizman, Amalia Levy, Ron Dagan

Dept. of Epidemiology and Health Services Evaluation and S. Daniel International Center for Health and Nutrition, Ben-Gurion University of the Negev, and Pediatric Dept. and Pediatric Infectious Disease Unit, Soroka Medical Center and Ben-Gurion University of the Negev

Diarrheal diseases weigh heavily on the health of children, especially in developing countries, but also impose burdens on health care services worldwide. This study was performed to determine whether patterns of referrals in the Negev to the pediatric emergency room (PER) for diarrhea differ between the Jewish and Bedouin populations of the Negev, and the extent of the burden imposed on the PER and in-hospital services in the Negev. Characteristics of referrals and hospitalizations were examined from March 1994 to February 1995. Of the 27,834 referrals to the PER for children under 16, 2518 (9%) had diarrhea and there were 5,169 hospital admissions, 701 (13.6%). The annual rates of referral were 146 per 10,000 in Jews and 225 in Bedouin, giving an odds ratio (OR) of 1.5 (p<0.001). for Bedouin. The rates of hospitalization were 23 per 10,000 in Jews and 99 in Bedouin (OR 4.4, p<0.001). 1380 (54.8%) of the PER referrals were of infants under a year of age. For hospitalization, the annual rates were 164 per 10,000 in Jews and 756 in Bedouins (OR 4.9, p<0.001). During June to August referrals and hospitalizations for diarrhea were significantly higher, and from December to February significantly lower than during the remaining months. These differences arise from the marked seasonal pattern in the Bedouin population, whereas in the Jewish population there was no seasonal variation. Even in the 90's the burden on health services in the Negev as a result of diarrheal illness is considerable and the Bedouin population still contributes to that burden disproportionately. There is need both to reduce the gap in referrals and hospitalization between the populations, as well as to reduce the rates, using currently available means such as education, while developing new technologies, such as vaccines.

Prevalence Rate, Place of Hospitalization and Source of Referral of Complex Nursing Care Patients in Geriatric Hospitalization

Netta Bentur, Jenny Brodsky, Beni Habot

JDC-Brookdale Institute of Gerontology and Human Development, Jerusalem; Shmuel Harofeh Geriatric Medical Center; Rishon Lezion Geriatric Center; and Sackler Faculty of Medicine, Tel Aviv University

For the past several years, the hospitalization and care of complex nursing care patients (CNCP) has caused concern among organizers, funders and care-givers of the geriatric hospitalization system (GHS). To assist in improving efficiency of the GHS and to address the lack of comprehensive, empirical and up-to-date information on these patients, we conducted a survey to characterize CNCP, to assess their medical problems and to determine their prevalence among the patients in GHS. The survey was conducted in 1994 using a day census. Data were collected on the 2,319 patients in geriatric beds in all the general hospitals and geriatric hospitals in Israel on the day of the survey.

28% of the patients in the GHS were CNCP and a quarter of them (7% of all patients) suffered from more than 1 medical condition. Tube feeding was the most prevalent condition (13% of all patients), followed by terminal illness (9%), deep pressure sores (7%) and intravenous transfusion for more than 3 days (6%). The 80% of the CNCP were hospitalized in geriatric hospitals, primarily in geriatric rehabilitation wards. Their average length of stay was over a year. Internal medicine wards of general hospitals were the most frequent source of patient referral. The survey's findings raise issues related to the organization of care of CNCP. They may serve as a basis for the reorganization of the geriatric hospitalization system in order to improve efficiency and quality of care for the benefit of patients, their families and services providers.

Superficial Dorsal Penile Vein Thrombosis (Mondor's Disease)

Ran Katz, Arye Blachar

Depts. of Urology and Radiology, Hadassah Medical Center, Hebrew University of Jerusalem

Superficial venous thrombosis of the chest wall was first described by Mondor in 1939. Braun-Falco reported in 1955 superficial penile vein involvement in diffuse thrombophlebitis of the abdominal wall and in 1958 Helm and Hodge first described isolated superficial dorsal penile vein thrombosis. Since then, fewer than 50 cases have been reported. The clinical presentation is usually redness and swelling of the dorsum of the penis, accompanied by a palpable, tender thrombotic vein. This acute and painful disease frightens the patient, who is concerned about his fertility and sexual function. The main cause of this disease is frequent sexual intercourse. Diagnosis is based upon anamnesis, physical examination and penile sonography with color Doppler imaging. It is usually a benign disease which resolves quickly under appropriate medical therapy. We present a man who was admitted for this condition and was successfully treated.

Glenoid Fossa Fracture

M. Kligman, M. Roffman

Dept. of Orthopedic Surgery, Carmel Medical Center, Haifa

4 patients with displaced intra-articular glenoid fossa were treated either surgically or conservatively. After an average follow-up of 7 years, the clinical and radiographic results were satisfactory in all. The 2 treated surgically required shorter follow-up than those treated conservatively. Conservative treatment should be considered a good option for displaced intra-articular glenoid fossa fracture.

Salbutamol Intoxication

Haim D. Danenberg

Division of Medicine, Hadassah University Hospital, Jerusalem

A 20-year-old asthmatic woman who ingested 300 mg of salbutamol (Albuterol) and 30 g of paracetamol is presented. She had sinus tachycardia up to 160/min, hypotension (80/50 mmHg), tremor, hypokalemia (2.1 mEq/l) and hyperglycemia (12.1 mEq/l). Treatment was by gastric lavage, fluids, potassium and N-acetylcysteine. Symptoms resolved in 24 hours.

Use of Student Feedback by Pre-Clinical and Clinical Course Directors

Ruth Abramowitz, Netta Notzer

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

We examined the conceptual and instrumental uses of student feedback on teaching by 2 preclinical and clinical course directors with authority to change structure and content of the courses, assess suitability of instructors and to change methods of student feedback questionnaires have been collected systematically for over 2 decades. A report based on this feedback is sent to course directors, the dean, his assistants and the head of the curriculum committee. Course directors from both groups made broad use of the feedback but made greater use of the report than preclinical course directors. Students had greater regard for individual teaching by clinical course directors than by preclinical course coordinators. No relationship was found between the degree of use of feedback by members of either group and their level of teaching. We conclude that senior faculty use student feedback in their decisions regarding the structure and teaching methods of their courses and are not influenced by individual assessments, positive or negative, by their students.

Knowledge of Adolescents about the Fetal Alcohol Syndrome

Shoshana Weiss

Prevention Department, Israel Society for the Prevention of Alcoholism, Ramat Gan

The level of knowledge of the risks of drinking during pregnancy in 175, 17-18 year olds from kibbutzim in the eastern Upper Galilee was studied in January 1996. This population had the highest rate of involvement with alcohol in Israel and had been involved in alcohol education activities in previous years. About 53.71% of the sample believed that heavy drinking increases the risk of birth defects, but only 20.57% could correctly describe the fetal alcohol syndrome.

Characteristics of Hospitalized Alcoholics

Sergio Marchevsky, Shoshana Weiss

Residential Center for Alcoholics and Israel Society for the Prevention of Alcoholism, Ramat Gan

The background characteristics of 1,173 alcoholics hospitalized for 3 months in this center during December 1982 to December 1994 were reviewed. Socio-demographic variables and termination-of-treatment data, are described. The profile of the typical hospitalized alcoholic was that of a Jewish, urban, married, unemployed man, born in Asia-Africa (or in Israel) who had been living for many years in Israel and had many children and a low educational level. They usually start drinking in adolescence and come to the center after more than 15 years of drinking, mainly at home and alone, and also have family relatives who drink. Implications of the data for treatment and for family physicians are presented.