תוצאת חיפוש

Tension-Free Repair of Inguinal Hernia with Properitoneal Mesh

Eduard Ramadan, Dan Seror, Roman Belavsky, Zeev Dreznik

Dept. of Surgery A, Rabin Medical Center, Golda Campus (Hasharon Hospital) Petah Tikvah, and Sackler School of Medicine, Tel Aviv University

The results of properitoneal mesh repair of inguinal hernia were evaluated in 38 of 43 consecutive patients operated by Stoppa's technique. In 33 patients the hernia was bilateral and in 10 unilateral; in 20 it was recurrent. In 33/43 patients the mesh was fixed either by sutures or metal clips. The overall recurrence rate after 22 (14-36) months of follow-up, was 10.5%. This result was composed of a 3.0% recurrence rate in the fixated-mesh group, and 30.0% among those with non-fixated mesh.

The outcome following the Stoppa method for tension-free properitoneal mesh repair of inguinal hernia, compares favorably with those of other methods, provided proper attention is paid to adequate mesh placement and fixation. Further prospective studies are needed to define the role and indications for this technique in the laparoscopic era.

The Fate of Gallstones "Dropped" during Laparoscopy

Menashe Barzilai, Arie Bitterman, Dorit Schlag-Eisenberg, Nathan Peled

Depts. of Radiology and Surgery B, Carmel Medical Center, Haifa

Laparoscopic cholecystectomy is considered the procedure of choice for removing symptomatic, stone-containing gallbladders. It is estimated that in 30-40% of these operations stone(s) spill into the peritoneal cavity. It was assumed that these "dropped stones" are harmless and are dissolved and absorbed spontaneously. We present a 70-year-old woman in whom such a stone, dropped during laparoscopy, led to formation of an intraperitoneal abscess.

Proper use of Pressurized Hand-Held Inhalers in Patients with Chronic Airway Obstruction 

Shabtai Varsano, Ilana Jacoby, Mila Garenkin

Asthma Care and Education Unit, Dept. of Pulmonary Medicine, and Epidemiology Unit, Meir General Hospital, Sapir Medical Center, Kfar Saba; and Sackler School of Medicine, Tel Aviv University

Inhaling drugs via hand-held inhalers in recommended for those with chronic obstructive airway disease (COPD). Approximately 8%-9% of Israel's population use hand-held inhalers, many of them pressurized. Skill in using them and ability of chronic users to learn their proper use have not been assessed.

During 1993 and 1994 we studied 200 patients with bronchial asthma or COPD who regularly used a pressurized hand-held inhaler (PI), but were not trained to use it in our out-patient pulmonary clinic. Only a third were found to be skilled in its use. About half were completely unable to use it properly, and 17% used it in a suboptimal way. Remarkably, only 40% had been taught anything with regard to its use. About 75% of the suboptimal users significantly improved their skill in its use immediately after receiving a single individual teaching and corrective demonstration session. While 15% failed to learn the proper use of the PI, many of those who improved immediately after a single teaching session retained the learned skills for months.

We conclude that the physician who recommends the use of a PI is responsible for the patient's being taught its proper use in a demonstration session. Skill in its use should be reassessed periodically during the entire treatment period.

The Israel Teratogen Information Service: A 10-Year Report 

A. Ornoy, S. Shechtman, J. Arnon

Hebrew University - Hadassah Medical School and Israel Ministry of Health, Jerusalem

The Israel Teratogen Information Service (TIS) was established 10 years ago with the help of the Ministry of Health and the Hebrew University-Hadassah Medical School. During these 10 years we have had 20,631 calls. We describe the results of our experience in counseling.

There was a gradual increase in the number of calls, which in 1997 reached 4,447. Most calls (84.5%) were during pregnancy, while 12% were prior to pregnancy. In 75.7% the calls were due to drug exposure during pregnancy; 10.9% were due to exposure to X-rays; there was maternal infection in 6.6% and in 5% immunization during pregnancy. The callers were: physicians in 46.6%, nurses 18.9%, pregnant women 39.5%, and 4.8% others.

In 76.6% there was no additional risk to the embryo or fetus and in 17.4% there was a small additional risk of less than 1%; a significant additional risk to the fetus was expected in only 6%. In 3625 pregnant women with known outcome there were 8.9% spontaneous and 9.2% induced abortions. Of the 2968 live-born children, 2.3% were malformed, a rate similar to that among controls.

The information provided by the TIS alleviated the fears most pregnant women have, and reduced unnecessary terminations of pregnancy planned because of unjustified fear of the teratogenic effects of agents to which women were exposed. It reduced the number of children born with congenital anomalies, since pregnancies were interrupted whenever there was a high risk for congenital anomalies.

Investigating Chest Pain: is there a Gender Bias?

Leonardo Reisin, Chaim Yosefy, Sharon Kleir, Emil Hay, Ronit Peled, Shimon Scharf

Cardiology and Emergency Depts. and Epidemiology Unit, Barzilai Medical Center, Ashkelon (Affiliated with Ben-Gurion University, Beer Sheba)

Ischemic heart disease (IHD) in women is characterized by a higher morbidity and mortality in the peri-infarction and coronary bypass peri-operative periods. These epidemiological data strengthen our impression that the health system unintentionally "ignores" the high proportion of females with IHD.

The process of investigating chest pain, diagnosing IHD, and the subsequent treatment and rehabilitation, seem to differ between the genders. Time elapsed from beginning of chest pain to diagnosis of IHD seems to be longer in women than in men. Personal, educational and social factors are contributory.

Although time elapsed between diagnosis and rehabilitation is usually similar in the genders, peri-operative morbidity and mortality are higher in women. It may be that the higher rates in women are caused by delay in diagnosis and treatment, which allows worsening of the disease in women before treatment. This delay can occur during the time needed for evaluation of chest pain, from the door of the physician to diagnosis and treatment.

In our retrospective study we determined the difference in referral of men and women with chest pain to the emergency department (ED) and the attitude of physicians in the ED and medical department to chest pain in men and in women, including final diagnosis on discharge. 615 patients over 18 years referred to the ED for chest pain during 3 randomly chosen, consecutive months were studied. We found that women constituted only 39.5% of the referred patients, but the proportion hospitalized was similar to that in men. Hospitalized women were older (57.7±18.4 versus 49.7±17.8 years in men), and had more risk factors (4 versus 2 in men). Proportions of specific diagnoses on discharge from hospital were equal in the genders.

To bridge the differences and to implement education in prevention, investigation and treatment of IHD in women, we established the "Female Heart" clinic. The objective of this clinic is to reduce differences in the first step, in the process of evaluating chest pain in women, by educating and encouraging them to present early to their physicians, and by changing physicians' attituin the investigation of chest pain in women. We plan to determine in a prospective study if these goals are.

Radiologic Appearance of "Falling Gallstones" during Laparoscopic Cholecystectomy

E. Alkalay, D. Yaffe, Z. Spindel

Eyn Vered Clinic and Depts. of Radiology and Surgery, Sapir Medical Center, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University

Laparoscopic cholecystectomy is the "gold standard" in treating cholelithiasis. Stones are frequently lost in the peritoneal cavity during the procedure, but "missing stones" have been regarded as insignificant. However, there is accumulating evidence that untreated "lost" stones may cause complications even years after operation.

We present a 65-year-old woman who presented with vague complaints, anemia and an elevated ESR. CT scan showed an infiltrating process in extra-abdominal muscles compatible with sarcoma. At operation, 2.5 years after previous laparoscopic cholecystectomy, an abscess was found which contained biliary stones. Because of their small size they were not visible on CT scan. We discuss the possible ways of handling "falling stones."

Bowel-Lengthening in a Newborn with Short Bowel Syndrome

Schmuel Katz, Ilan Erez, Ita Litmanovitz, Ludwig Lazar, Arie Raz, Zipora Dolfin

Depts. of Pediatric Surgery, Neonatology and Pediatrics; Meir Hospital, Kfar Saba

Advances in parenteral nutrition and supportive therapy have led to improvement in survival of babies with short-bowel syndrome. Those whose intestinal mass is very unlikely to be adequate should have surgical therapy as soon as possible, before they develop the complications of long-term parenteral nutrition or significant enteritis.

We present a newborn with short-bowel syndrome due to prenatal midgut volvulus. At operation the remaining viable jejunum, 15 cm long, was anastomosed to the cecum. All feeding attempts failed, and the infant suffered from malabsorption. Calories and proteins had to be supplied by intravenous total parenteral nutrition.

At 3 months of age there was significant widening of the remaining bowel and Bianchi's bowel-lengthening procedure was performed. The postoperative course was uneventful and there was gradual improvement in intestinal absorptive capacity. The patient was weaned from parenteral nutrition at 3 years of age. Now, 2 years later, she eats a normal diet.

Evaluation of Predictive Factors for Stroke Rehabilitation

Abraham Adunsky, Shlomo Levenkrohn, Yehudit Fleissig, Angela Chetrit, Zvia Blumstein

Geriatric Medicine and Clinical Epidemiology Depts., Chaim Sheba Medical Center, Tel Hashomer

Our objective was to assess the functional disability of stroke patients by the functional independence measure (FIM) and to examine predictive factors for successful rehabilitation. In 127 consecutive stroke patients efficacy of FIM was 23.9±188, efficiency 0.54±0.45 and 81.9% of patients returned home. Functional improvement was statistically significant (p<0.001) in all FIM domains. Multivariate analysis showed that improvement in FIM score was significantly greater in the younger, among the married, the hemiparetic, and those with an admission FIM of 40-60, while efficiency was related only to type of diagnosis. In addition, the hemiparetic were 3.3 times more likely to return home than the hemiplegic.

We conclude that rehabilitation priorities should be directed towards patients younger than 75 years and to those with an admission FIM of 40-60 points. The results of this study reaffirm the usefulness of the FIM index in assessing stroke rehabilitation.

Use of Restraints in a General Hospital

Bella Bar-Cohen, Orly Rotem-Picker, Zvi Stern

Nursing Services and Administration, Hadassah University Medical Center, Jerusalem

28 in-patient units were surveyed during a 5-day period to determine the extent of the use of physical restraints in hospitalized patients. Information was gathered on the characteristics of restrained patients and indications for use and removal of restraints, patterns and means of restraints, monitoring, and written notations. 31 different patients (6% of those surveyed) were restrained in 13 units during the 5 days of the survey, an average of 15 (3%) daily.

Characteristics of restrained patients were: age 70 and over requiring emergency hospitalization, reduced level of consciousness, limitation of mobility, incontinence, history of 2 or more chronic diseases, requiring multiple drugs, and use of multiple medical devices. Bilateral, soft hand restraints were most often used to prevent patients from removing tubes. Nurses initiated the decision to apply or remove restraints, which were usually removed as the patients' condition improved. Written policies were lacking regarding monitoring and follow-up of restrained patients. Clearly written policies and increased staff awareness of potential hazards may reduce the use of restraints and the length of time they are employed.

Open Reduction and Internal Sternal Fracture Fixation

Y. Kluger, Y. Paz, N. Gebart, B. Sagie, A. Kremer

Rabin Trauma Center and Dept. of Cardiothoracic Surgery, Tel Aviv-Souraski Medical Center and Sackler Faculty of Medicine, Tel Aviv University

We describe a 63-year-old woman who sustained a sternal fracture after a motor vehicle crash. Due to persistent pain, open reduction and internal fixation of the sternal fracture were performed; recovery was uneventful.

Is Ileostomy Necessary In Surgical Treatment of Ulcerative Colitis and Familial Polyposis?

Michael M. Krausz, Simon Daniel Duek

Dept. of Surgery A, Rambam Medical Center, Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Proctolectomy with ileal pouch anal anastomosis (IPAA) has become the procedure of choice for the surgical treatment of ulcerative colitis (UC) and familial polyposis (FP). Ithas traditionally been performed in 2 stages, but recently the necessity for an ileostomy hbeen challenged by several authors who recommend a 1-stage procedure.

5 years ago we started to test this policy for treatment of UC and FP. In 48 patients (Group A), 45 with UC, the 2-step procedure, and in 17 of the 27 in Group B with FP, the 1-stage procedure were performed. The indications for surgery were intractable UC in 37 patients in group A and in 5 patients in Group B (p<0.01).

Postoperative infection due to bowel leakage developed in 2 in Group A and in 6 in Group B (p<0.01). Reoperation was necessary in 4 patients (15%) in Group B and only 1 (0.9%) in Group A (p<0.01). Bowel leakage in Group B occurred in 5 (19%) with UC and in only 1 with FP (p<0.05), which responded to medical treatment. All those with UC who developed this complication were relatively malnourished, with serum albumin levels lower than 3.0 g% and were regulated with corticosteroids.

We therefore conclude that the 2-stage IPAA is feasible and safe for the treatment of UC and FP. The 1-stage IPAA should be limited only to FP or good risk UC patients.

Autonomic Dysregulation in Post-Traumatic Stress Disorder: Power Spectral Analysis of Heart Rate Variability

Hagit Cohen, Uri Loewenthal, Mike A. Matar, Hanoch Miodownik, Zeev Kaplan, Yair Cassuto, Moshe Kotler

Mental Health Center, Israel Ministry of Health; Anxiety and Stress Research Unit, Faculty of Health Sciences; Dept. of Life-Sciences, Ben-Gurion University of the Negev, Beer Sheba

Spectral analysis of heart rate variability (HRV) has been shown to be a reliable noninvasive test for quantitative assessment of cardiovascular autonomic regulatory response, providing a dynamic map of sympathetic and parasympathetic interaction. In a prior study exploring the state of hyperarousal that characterizes the post traumatic stress disorder (PTSD) syndrome, we presented standardized heart rate analyses in 9 patients at rest, which demonstrated clear-cut evidence of a baseline autonomic hyperarousal state.

To examine the dynamics of this hyperarousal state, standardized heart rate analysis was carried out in 9 PTSD patients, compared to a matched control group of 9 normal volunteers. 20-minute ECG recordings in response to a trauma-related cue, as opposed to the resting state, were analyzed. The patients were asked to recount the presumed triggering traumatic event, and the control subjects recounted a significant stressful negative life event.

Whereas the control subjects demonstrated significant autonomic responses to the stressogenic stimulus of recounting major stressful experiences, the patients demonstrated almost no autonomic response to the recounting of the triggering stressful event. The patients demonstrated a degree of autonomic dysregulation at rest comparable to that seen in the control subjects' reaction to the stress model.

The lack of response to the stress model applied in the study appears to imply that PTSD patients experience so great a degree of autonomic hyperactivation at rest, that they are unable to marshal a further stress response to the recounting of the triggering trauma, as compared to control subjects. A subsequent study of the effect of medication on these parameters showed that they are normalized by use of selective serotonin re-uptake inhibitors (SSRI's).

Neither the clinical implications of these findings, nor their physiological mechanisms are clear at present. We presume that they reflect a central effect, as the peripheral automatic effects of SSRI's are relatively negligible.

The Diagnosis and Treatment of Fournier's Gangrene

M. Cohen, E. Tamir, S. Abu-Abid, Y. Galili, M. Giladi, S. Avital, R. Shafir, Y. Klausner

Surgery and Infectious Disease Depts. and Division of Surgery, Tel Aviv-Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

We treated 2 women and 8 men suffering from Fournier's gangrene during 1990-96. 2 had diabetes, 1 suffered from ulcerative colitis and 1 was an alcoholic. In 8 of them the infection was triggered by a mixture of aerobic and anaerobic bacteria. Treatment consisted of repeated wide debridement and early colostomy. This aggressive approach resulted in relief of the septic signs within 24 hours and permitted early skin grafting of the wounds. 2 patients died due to sepsis that caused multiple organ failure. The 8 who survived were hospitalized for an average of 35 days. On follow-up examination 1-5 years later all patients had undergone closure of the colostomy and were completely rehabilitated.

Fournier's gangrene is not rare in the geriatric population. We believe that early diagnosis and aggressive wide debridement, combined with early colostomy, are the keys to successful treatment.

Nasopharyngeal Colonization with Streptococcus Pneumoniae in Pediatric Respiratory Infections

Isaac Srugo, Irena Chystiakov, Ella Cohen, Yoram Tal, Michael Jaffe

Clinical Microbiology and Pediatric Depts., Bnai Zion Medical Center and Technion Faculty of Medicine, Haifa

During the winter of 1995, nasopharyngeal colonization of Streptococcus pneumoniae was evaluated in 204 children with respiratory infection and 107 normal control children. There was no difference in gender or mean age between the groups, and no difference in carrier rate between sick (24.5%) and normal (22%) children (p=0.6). Carrier rates were 19%, 32%, 31% and 17% at 6, 12, 24 and 48 months, respectively. Penicillin-resistant pneumococci (PRP) were found in 42% of sick and 16.6% of normal children, (p<0.05). Resistance to more than 2 antibiotics was found in 28% of sick and in 12.5% of normal children. PRP were found in 67% and 34% of sick children with and without prior antibiotic treatment (p<0.05). We conclude that there is no difference in the carrier rate of Streptococcus pneumoniae between sick and normal children. However, the high prevalence of PRP in children with respiratory infections is probably due to prior antibiotic treatment.

Diagnosis of Hyperprolactinemia: Determination at Rest Rules Out Stress-Induction

Avraham Ishay, Rafael Luboshitzky

Endocrine Institute, HaEmek Medical Center, Afula and Rappaport Faculty of Medicine, The Technion, Haifa

We present 3 women who were referred for evaluation of stress-related mild-to-moderate hyperprolactinemia. This frequent finding may mistakenly be considered a clinical problem, and lead to inappropriate investigation and therapy. We emphasize the importance of serial blood sampling for prolactin determination. We collected blood samples repeatedly under resting conditions from an indwelling venous brachial catheter, every 30 minutes for a total of 6 samples. All 3 patients had normal prolactin levels 30-60 minutes after starting the test. Neither further investigation nor medical therapy were needed and these anxious patients were reassured that their hyperprolactinemia was factitious.