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.

Carbon Dioxide Gas Embolism during Laparascopic Cholecystectomy

Anat Laver-Segal, Miguel Iuchtman, Paltiel Weiner

Depts. of Anesthesiology, Surgery A and Medicine A, Hillel Yaffe Medical Center, Hadera and Rappaport Medical School, The Technion, Haifa

A case of carbon dioxide gas embolism during laparascopic cholecystetomy is presented. Prompt diagnosis and immediate treatment resulted in positive outcome. Laparascopic cholecystectomy is nowadays one of the most common operations for cholecystectomy and certainly the most frequent endoscopic surgical procedure. It is usually safe and effective. However, a number of serious complications have been reported during the procedure.

Gas embolism is one of the complications that may occur during the initial gas insufflation or during dissection of the gall bladder. Symptoms are mainly related to the speed and the amount of gas that reaches the venous system. Early recognition and prompt treatment are required to prevent severe morbidity or even fatal outcome.

Transesophageal echocardiography has detected many unsuspected cases of gas embolism. However, capnograph monitoring of end-tidal CO₂, routinely used in everyday anesthesia, is highly reliable in alerting to the possibility of gas embolism and also in confirming its occurrence.

In cases of suspected gas embolism close collaboration between anesthetist and surgeon is required.

High Dose Endobronchial Brachy - Therapy for Malignant Airway Obstruction

Alex Yarmolovsky, Alan Katz, Eyal Fenig, G. Fink, Daniel Bendayan, Aaron Sulkes, Mordechai R. Kramer

Institutes of Pulmonology and Oncology, Rabin Medical Center, Beilinson Campus, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University

Brachytherapy is especially suitable for palliative treatment of endobronchial tumors adjacent to internal organs that might be damaged by intensive external beam radiation, but are easily accessed with a flexible bronchoscope. This treatment is mostly palliative.

30 patients underwent such palliative high-dose endobronchial brachytherapy to alleviate malignant airway obstruction. With the aid of a flexible fiberoptic bronchoscope an endobronchial catheter was inserted adjacent to the tumor and treatment delivered using a 192Ir remote afterloader for 5-10 min, in 2 or 3 sessions.

There was symptomatic improvement in 26 (86%) and objective improvement in 27 (90%). 1 patient died of hemoptysis.

Autologous Chondrocyte Transplantation - from Science Fiction to Routine Clinical Practice

Dror Robinson, Hana Ash, David Aviezer, Gabriel Agar, Nahum Halperin, Zvi Nevo

Dept. of Clinical Biochemistry, Sackler Medical School, Tel Aviv University, Ramat Aviv; Dept. of Orthopedic Surgery, Assaf Harofeh Medical Center, Zerifin; and CTI Ltd., Science Park, Kiriat Weizmann, Nes Ziona

Adult articular cartilage lacks the capacity for self-repair. The limiting factor appears to be the inability of chondrocytes to proliferate while embedded in the extracellular matrix typical of hyaline cartilage. Cartilage defects larger than 1 cm² change articular biomechanics and lead to eventual osteoarth-ritis and joint destruction.

During the past decade, several competing techniques have evolved to stimulate articular cartilage repair. Small lesions can be successfully treated by either micro-fracture or osteochondral cylinder grafting. The latter technique allows immediate weight bearing but leads to damage of previously uninvolved areas of articular cartilage, which limits its application to lesions of less than 2 cm².

When the damaged area is more extensive, grafting of autologous chondrocytes should be considered. First a diagnostic arthroscopy is performed to assess the damaged area and a small cartilage biopsy is taken. 6 weeks later, arthrotomy and chondrocyte transplantation are performed. In the interval, the antologous chondrocytes have expanded by 2 to 3 orders of magnitude. Our experience to date includes 10 cases with follow-up of 6 months to 5 years. Preoperative complaints of crepitation and locking disappear. There is functional improvement and pain reduction of approximately 50%. This procedure, currently limited to patients under 55 years of age with limited damage to an articular surface, for the first time allows reconstruction of damaged articular areas without resorting to allografts.

Cannabis Has Dangerous Implications for Mental Health 

Emi Shufman, Eliezer Witztum

Jerusalem Institute for Treatment of Substance Abuse, Kfar Shaul Mental Health Center, Jerusalem and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Accepting and forgiving attitudes to the use of cannabis in its various forms, such as marijuana or hashish, are not justified, as they may result in dangerous mental health consequences.

A theoretical framework for this opinion is provided, including information on the various forms of cannabis available. Case studies presented exemplify possible complications resulting from use of cannabis or its derivatives.

Favorable Outcome of Hyperacute Epidural Hematoma in an Octogenarian

A. Rakier, I. Orlovsky, M. Feinsod

Center for Applied Research in Head Injuries, Neurosurgery Dept. Rambam Medical Center, and B. Rappaport Faculty of Medicine, The Technion, Israel Institute of Technology, Haifa

Acute epidural hematoma is very rare in the elderly after head injury. It is usually associated with extremely high mortality or severe disability. In an 87-year-old woman a large, hyperacute, epidural hematoma was diagnosed. She was treated promptly and enjoyed an uneventful, complete recovery. This exceptional case should encourage an intensive approach even in seemingly minor head trauma in the elderly.

SYME Amputation for Foot Infections in Diabetics 

Michael Michailevich, Ehud Lebel, Menachem Itzchaki

Dept. of Orthopedics, Shaare Zedek Medical Center, Jerusalem

Syme ankle disarticulation for foot infections in diabetics with concomitant peripheral vascular disease is often unsuccessful. The need for re-amputation usually results from recurrent infection or ischemia of the posterior heel flap. We present 5 such cases of deep foot infections in diabetics who underwent Syme amputation after failure of local debridement. All patients needed reamputation in 4-18 days for ischemia of the flap.

Unconventional Treatment of Severe Heart Failure in the Elderly

Z. Fidelman, Z. Korshun

Geriatric Medical Center, Natanya

In the elderly, congestive heart failure is common and associated with significant morbidity and mortality.

Comprehensive management of heart failure improves functional status and decreases mortality. Diuretics remain the mainstay in treating congestive heart failure. However, some patients are resistant to diuretics. This is a serious problem as it seems to represent a final manifestation of congestive heart failure.

In an 85-year-old woman diuretic resistance was recognized as the cause of failure of conventional diuretic therapy. When the dose of furosemide was rapidly increased from 120 mg per os to 1000 mg IV within 4 days, diuresis began and there was dramatic improvement in her condition. The dose was then gradually decreased until a conventional maintenance dose of 200 mg/day per os was reached. This dose was sufficient to keep her heart failure under control.

Smoking by an Israeli Hospital Staff, its Attitude to Smoking in Hospitals and to “Smoke-Free” Hospitals

Shabtai Varsano, Giora Hevion, Mila Garenkin

Depts. of Pulmonary Medicine, Asthma Care-Education Unit, Hospital Management Office, and Epidemiology and Medical Data Unit; Meir General Hospital, Sapir Medical Center, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University

Smoking within hospitals is common in general hospitals in Israel. It has a strong negative educational impact, has a negative image and curing its ill effects help keep our hospitals busy. An anonymous questionnaire was answered by 128 members of our hospital staff (28%). Their distribution, according to occupation and sex was representative of the rest of our hospital staff.

19% of our workers are smokers, a much lower proportion than in our general adult population. The proportion was highest among maintenance (40%) and sanitary-help staff (36%). 23% of nurses and 15% of physicians were smokers. This situation is better than that among Italian or Japanese medical staff, but much worse than among North American medical staff.

75% of our workers who smoke declared that they smoke outside the room in which they work. 66% and 72% of the staff believe that hospital workers and visitors, respectively, should smoke outside hospital buildings. Only 19% of all workers do not believe that a "smoke-free hospital" is attainable. 34% believe that a "smoke-free hospital" is achievable, and 47% said that it is perhaps achievable. 86% of all the workers, and 41% of the smokers, expect the hospital director to implement an effective policy of enforcing the law limiting smoking within hospitals (and other public buildings) in Israel. 60% are willing to contribute actively to this effort.

We believe these results strongly suggest that the time is ripe for implementation of the "smoke-free hospital" in Israel. This requires a strong and effective central policy, like that in the USA. We suggest measures that the Israel Ministry of Health take measures to successfully implement this policy.

Microlaparoscopy in Diagnostic and Operative Gynecologic Procedures 

Dov Dicker, Shmuel Nitke, Itai Bar-Hava, Raul Orvieto, Zion Ben-Rafael, Arie Dekel

Depts. of Obstetrics and Gynecology, Rabin Medical Center, Beilinson and Golda Campuses, Petah Tikva; and Sackler School of Medicine, Tel Aviv University

A recent further development in laparoscopic surgery is microlaparoscoopy. The technique is identical to standard 10 mm laparoscopy except for the use of small, 2 mm scopes and trocars. We used this technique in 19 patients treated from June 1998 to February 1999.

The advantages of microlaparoscopy are: smaller incisions, less risk of damage to pelvic organs and less postoperative pain. However, the use of microlaparoscopy for operative procedures is limited to simple operations due to the limited field of vision. We urge our colleagues to consider microlaparoscopy whenever diagnostic laparoscopy is needed.

Botulin Toxin for Spasticity in Spinal Cord Damage

Ofer Keren, Flabia Shinberg, Amiram Catz, Neer Giladi

Loewenstein Rehabilitation Hospital, Ra'anana; Movement Disorder Unit, Tel Aviv Medical Center; and Sackler Faculty of Medicine, Tel Aviv University

Therapeutic injection of botulin toxin is well-recognized for reducing tonus in local dystonia. However, its efficacy in reducing spasticity in spinal cord injuries is still unproven. 4 men and 1 woman (mean age 39 years, range 20-56) with spinal cord injury and debilitating spasticity, and no response to standard treatment for spasticity received injections of botulin, 200-300 U, into 4-8 points in their legs to block muscle-nerve synapses.

In all 5 tonus was reduced in the area of the block, while in some it was also reduced in more distal muscles. In 1 there was reduced tonus in both the injected and contralateral leg. The therapeutic effect on tonus persisted for 3 months. In spite of objective improvement in tonus in all 5, only 3 felt subjective improvement, but in none was there improvement on standard functional scaling.

We found injection of botulin toxin effective in reducing tonus in the spinal cord-injured, and to some extent in improving subjective feeling of well-being in some of them. Obective measurement might show functional improvement after larger doses of toxin injected into more muscles. This might be necessary because the muscle mass of the legs is large and the intensity of involuntary contraction is especially high in these patients.

Nocturnal Eating Disorder - Sleep or Eating Disorder?

Orna Tzischinski, Yael Lazer

Sleep Laboratory, Faculty of Medicine and Israel Institute of Technology; and Eating Disorders Clinic, Psychiatric Division, Rambam Medical Center, Haifa

Nocturnal eating disorder (NED) is a rare syndrome that includes disorders of both eating and sleeping. It is characterized by awakening in the middle of the night, getting out of bed, and consuming large quantities of food quickly and uncontrollably, then returning to sleep. This may occur several times during the night. Some patients are fully conscious during their nocturnal eating, while some indicate total amnesia. The etiology of NED is still unclear, as research findings are contradictory.

Those suffering from NED exhibit various levels of anxiety and depression, and many lead stressful life-styles. Familial conflict, loneliness and personal crises are commonly found. Recently, a connection has been discovered between NED and unclear self-definition, faulty interpersonal communication, and low frustration threshold. Several authors link it to sleepwalking, leg movements during sleep, and sleep apnea. Treatment is still unclear and there have been trials of pharmacotherapy, psychotherapy, or a combination of both. However, pharmacological treatment has generally been found to be the most effective, although each case must be considered individually.

In 1998, 7 women referred to our Eating Disorders Clinic, 5% of all referrals, were subsequently diagnosed as suffering from NED. Of these, 3 suffered from concurrent binge-eating disorder and 4 also from bulimia nervosa. 2 case studies representative of NED are presented.

Identifying the Elderly at Risk for Falling 

D. Galinsky, V. Fried, A. Biderman, J. Cwikel, Y. Ben Moshe

Geriatric Dept., Soroka University Hospital and Depts. of Family Medicine and of Social Work, Faculty of Health Sciences, Ben-Gurion University of the Negev; and ESHEL, Beer Sheba

Falling is one of the main problems affecting the health of the elderly. A community project was carried out to detect elderly people at high risk for falls. One of its aims was also to develop tools allowing primary care professionals to detect the elderly at risk for falling. Such a screening test in the community-dwelling elderly (EFST) and a protocol for diagnosis and treatment of the elderly at risk for falls is presented.

Introduction of Routine Hepatitis Immunization in Israel 

Emilia Anis, Alex Leventhal, Malvina Roitman, Paul E. Slater 

Notification of hepatitis A, which is endemic in Israel, has been compulsory since the establishment of the State. From 1992-98 an average of 2,600 cases were reported annually. Many infections are asymptomatic and mild, especially in children. In general, severity increases with age; in Western countries the case fatality rate is 1.5/1,000 among children less than 5 years old and 27/1,000 among those over 50. Until 1987 incidence in Israel was higher in Jews than in non-Jews, but since 1988 incidence has been about 50% higher in non-Jews.

Among Jews highest age specific rates shifted from children 1-4 years old to children 5-9 years old in 1970, and in non-Jews in 1989. Improved sanitary conditions and personal hygiene have reduced very early childhood exposure and hence increased the proportion of susceptible older children and adults, in whom symptomatic disease is more prevalent.

Israel is the first country in the world to include hepatitis A vaccine in its routine immunization schedule. The vaccine is given in 2 doses: at 18 months and 24-30 months of age, and there will be epidemiologic and serologic follow-up. A significant decrease in hepatitis A morbidity is expected in small children within 5 years. The percentage of reported cases in older children and in adults is expected to increase, although the absolute incidence among these groups will decrease.
 

Dept. of Epidemiology and Public Health Services, Israel Ministry of Health, Jerusalem