תוצאת חיפוש

Tension-Free "Plug and Patch" Inguinal Hernia Repair

Y. Mintz, D. Goitein, M. Muggia-Sullam

Dept. of General Surgery, Hadassah-Hebrew University Hospital, Jerusalem

Inguinal hernias are common and have highly variable clinical presentations, ranging from the asymptomatic to surgical emergencies when incarcerated, sometimes necessitating bowel resection. Several techniques have been described for repair of inguinal hernias based on the unique anatomic structure of the inguinal region. In 1989 Lichtenstein and co-workers described a "tension free" repair based on using a synthetic mesh patch to reinforce the inguinal canal floor and as a plug to prevent recurrence through the internal inguinal ring. This technique has been used in many centers worldwide with good rates of success.

Danaparoid-Sodium for Dialysis in Heparin-Associated Thrombocytopenia

Ronen Ben Ami, Ruth Rachmimov, Shlomo Berliner

Medicine Dept. D and Anticoagulation Therapy Unit, Tel Aviv-Souraski Medical Center, and Nephrology Institute, Sheba Medical Center, Tel Hashomer

Danaparoid sodium is an anticomposed of 3 glycosaminoglycans: heparan sulfate, dermatan sulfate and chondroitin sulfate. Similar to heparin, operates by activating antithrombin 3, but does not contain heparin or heparin fragments, and is therefore antigenically distinct.

Danaparoid has been advocated as a safe and effective anticoagulant for heparin-associated thrombocytopenia. However, there is little experience in its use as a substitute for heparin in hemodialysis.

We report 2 men, aged 82 and 73 years, respectively, who developed thrombocytopenia while undergoing hemodialysis with heparin, and who subsequently underwent successful dialysis with danaparoid. There was a rise in platelet levels in both while receiving danaparoid, and dialysis was completed without hemorrhagic or thrombotic complications. Danaparoid is a safe and effective substitute for heparin, and may be used as an anticoagulant in hemodialysis.

Portal and Mesenteric Vein Thrombosis after Splenectomy for Idiopathic Thrombocytopenic Purpura

Eldad Silberstein, Alexander Smolikov, Itzhac Levi

Surgery B Dept. and Nathanzon Institute of Radiology, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Mesenteric and portal vein thrombosis are rare complications of splenectomy. Their presentation depends on the underlying disease. It is most frequent in lymphoproliferative disorders but extremely rare in trauma. We describe a 22-year-old man and a 49-year-old woman who underwent splenectomy for idiopathic thrombocytopenic purpura and developed mesenteric and portal vein thromboses. Both were treated successfully with anticoagulants for 3 months until the thrombi regressed, as shown by CT scan. During a year of follow-up they were asymptomatic.

The Wandering Spleen

A. Ravid, D. Lev, V. Makarin, Y. Klausner, M. Umansky Y. Kluger

Surgery B and C Depts., Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

We describe a 26-year-old woman with thrombocytopenia discovered during gestation. On admission for evaluation of abdominal pain, torsion of an ectopic spleen was found. The spleen was removed and the thrombocytopenia resolved.

Neurological Manifestations of Non A-G Viral Hepatitis

Rifaat Safadi, Yaron River, Yosef S. Haviv, Yaron Ilan

Liver Unit, Division of Medicine and Neurology Dept., Hadassah University Hospital, Jerusalem

Guillain-Barre and other neurologic syndromes rarely occur as complications of viral hepatitis (A, B and C). Other neurologic syndromes have also been reported in serologically defined viral hepatitis, including mononeuritis, auditory neuritis, and seizures. Chronic hepatitis B and mononeuritis multiplex are found together in 31-54% of patients with periarteritis nodosa. The mechanisms of these associations are unknown, but may include direct cytotoxicity of the virus or immune-mediated damage. Vasculitis of the vasa nervorum plays an intermediate role, at least in some cases. We describe a 36-year-old man with acute non A-G hepatitis complicated by Guillain-Barre syndrome. The neurological manifestation resolved completely without specific therapy within 6 days, as the hepatitis resolved.

Liver Surgery - Five Years of Experience

Franklin Greif, Moshe Rubin, Eitan Mor, Israel Nudelman, Arnold Sihon, Arie Figer, Alex Belinki, Shlomo Lelcuk

Hepatobiliary Unit and Depts. of Surgery B, Transplantation, Oncology and Radiology, Rabin Medical Center (Beilinson Campus) and Sackler School of Medicine, Tel Aviv University

Major hepatic resections have been associated with significant morbidity and mortality. In the past decade or so this has changed and such procedures are now done in increasing numbers. In the past 5 years we operated on 129 patients with benign or malignant hepatic lesions (75 females, 54 males; age-range 14-84). the reason for surgery was malignancy in 94 (72.9%) and benign lesions in 35 (27.1%). The most common indication for surgery was liver metastases secondary to colorectal cancer in 45% of all patients or 61.7% of those operated for malignancy. Primary liver cancer was the cause for liver resection in 13.2% of all patients or 18.1% for those with malignancy. Of the 35 patients with benign lesions the leading causes for surgery included: giant cavernous hemangioma, simple liver cysts, echinococcus cysts and focal nodular hyperplasia (11%, 22.8%, 20% and 14.3%, respectively).

76 patients underwent anatomical resection and 63 had either a nonanatomical resection or a different operation. Among the former the most common procedure was right hepatectomy (36) and among the later a nonanatomical resection equal to 1-3 Couinod segments (44). Operating time ranged from 55 min. to 8:41 hours with a mean of 3:31‏1:37. Mean hospital stay was 8.7‏5.8 days and 86.8% received between 0-2 units of blood. Overall mortality was 6.2% and 31.2% of the fatalities had cirrhosis. Overall mortality in noncirrhotic patients was 2.6%. The complication rate was 16.3% and only 7 patients (4.4%) were hospitalized in the intensive care unit. This indicates that major liver resections can be done safely, with morbidity and mortality similar to that of other major abdominal operations. 

Balloon Angioplasty of Native Coarctation of the Aorta

Benjamin Zeevi, Galit Bar-Mor, Michael Berant

Cardiac Catheterization Unit, Schneider Children's Medical Center, Petah Tikva, and Sackler School of Medicine, Tel Aviv University

The use of balloon dilatation to treat native coarctation of the aorta is gaining acceptance among interventional pediatric cardiologists, but is still controversial. We describe our experience with this procedure in 21 children, mean age 5.6 years and mean weight 21.1 kg. Most had an additional congenital heart defect, most commonly a bicuspid aortic valve. 17 were asymptomatic, 3 had tachypnea and 1 infant had severe congestive heart failure and was ventilated. The mean systolic blood pressure was 129.7 mm Hg.

Balloon dilatation was successful in 90% (19), decreasing the mean maximal systolic gradient from 35.3 to 9 mm Hg (p<0.001), and increasing the narrowest area from 3.9 to 8.2 mm (p<0.001), with a mean balloon-to-coarctation width-ratio of 2.8. There were no complications. Of 15 who underwent repeat cardiac catheterization at a mean interval of 10.6 months, 2 had a maximal systolic gradient of more than 20 mm Hg. 1 of these underwent successful repeat angioplasty and the other, who also had a small aneurysm, underwent surgical repair successfully. 2 others had small aneurysms and they are being followed clinically.

All patients were seen again after a mean interval of 31 months. The mean systolic blood pressure was 104 mm Hg, significantly lower than before intervention (p<0.002). 1 had an increased pressure gradient between right arm and leg of 35 mm Hg at later follow-up, and repeat cardiac catheterization demonstrated a good result 13 months after the initial procedure. She is awaiting a third catheterization. Overall, 90% had good mid-term results.

Based on our experience and recent reports, balloon angioplasty is safe and effective in most children older than 7 months and should be considered a viable alternative to operation for discrete aortic coarctation. Further long-term evaluation is needed.

Recording Nocturnal Erections and Insurance Claims: Cost-Effectiveness

Ron Peled, Giora Pillar, Y. Berger, Naveh Tov, Nir Peled, Peretz Lavie

Sleep Lab, Gutwirth Building, Technion Medical School, Haifa

Road accidents, work accidents, or other trauma can cause impotence and are frequently followed by insurance claims. During 1990-97 we examined 230 males with such a complaint. All underwent full polysomnographic recordings in the sleep laboratory for 2 nights, during the course of which NPT (nocturnal penile tumescence) was examined with special equipment. It was assessed by an experienced technician following planned awakenings from REM sleep.

In 75 of the 230 subjects (33%), satisfactory erections were observed. In 100 (43%), who experienced at least 3 periods of REM sleep, no erections occurred. These patients were categorized as suffering from organic impotence. In the remaining 55 (24%), the results were inconclusive, with only partial erections or not enough REM sleep periods.

Since a man recognized as suffering from impotence may be awarded large monthly payments for life, these examinations, in our opinion, are an important tool to prevent unjustified claims, and can save the state unnecessary expenses.
 

Circadian Fluctuations in Efficacy of Streptokinase Thrombolysis

E. Goldhammer, L.Kharash, E.G. Abinader

Cardiology Dept., Bnei-Zion Medical Center and Technion Faculty of Medicine, Haifa

This study was designed to assess possible diurnal fluctuations in the efficacy of thrombolysis with streptokinase. 156 consecutive patients treated with streptokinase during the period 1.1.95-1.7.96 were studied retrospectively. Success or failure of thrombolysis was determined according to the accepted clinical and angiographic criteria starting at midnight, 12 times at 2-hour intervals, then 8 times at 3-hour intervals, and then 6 times at 4-hour intervals. A definite peak for successful thrombolysis was found in the late afternoon and early evening hours. Between 16:00-20:00 PM, in 30.23% successful thrombolysis were observed, compared to 6.98% between 20:00-24:00 PM (p<0.05) and in 10.53% between 00.00-04:00 AM (p<0.05).

Multiple regression analysis showed that the independent factor with the greatest impact on successful reperfusion was the actual time until thrombolysis (p=0.037); then came the interval from pain onset to streptokinase administration (p=0.020), while age and gender had much lesser impacts (p=0.328 and 0.215, respectively), and individual risk factors even less.

These findings may have several clinical implications: dose adjustment for the time of day may be required, with larger doses needed during morning hours, or preference for primary coronary angioplasty to avoid increase in bleeding complications due to higher doses of thrombolytic agents.

Knowledge and Practice of Primary Care Physicians Relating to Streptococcal Pharyngitis

S. Leshem, H. Tabenkin, E. Dan, A. Tamir

Family Medicine Dept., Emek Medical Center and Northern District of Kupat Holim; and Northern Branch of Specialization Institute, Faculty of Life Sciences, Ben-Gurion University of the Negev, Beer Sheba

Knowledge and practice of primary care physicians as to diagnosis and treatment of group A, b-hemolytic streptococcal pharyngitis, and the degree to which they agreed with the medical literature and current clinical guidelines were examined. The study was conducted in a group of 195 general physicians, pediatricians, and family medicine specialists and residents. The data were collected using questionnaires which included personal information and questions relating to b-hemolytic streptococcal pharyngitis and were analyzed by chi-square and t-tests, and logistic regression, as appropriate. A new dependent variable, good clinical practice (GCP), was defined as the total number of correct answers to the questions in the questionnaire. 147 of the 195 eligible physicians returned completed questionnaires, a compliance rate of 76%.

96.6% cited pV as the drug of choice at a daily dosage of 1 g (43.7%) or 2 g (25.4%), for 10 days (90%). 133 physicians (90%) stated that the goal of penicillin therapy for beta-hemolytic streptococcal pharyngitis is to prevent late complications. 116 physicians (82%) cited rheumatic fever as a complication of group A beta-hemolytic streptococcal pharyngitis, preventable by appropriate antibiotic therapy. However, only 84 (59%) cited glomerulonephritis as a preventable complication.

When the knowledge and attitudes of the respondents was analyzed in terms of the new variable, GCP, a significant association (p<0.001) was found between physicians’ attitudes and variables such as where they had studied medicine, and work seniority. Those with less seniority and or medical graduates of the Americas demonstrated greater knowledge and better clinical judgment than their more senior colleagues and graduates of European and Asian medical schools. Most primary care physicians in northern Israel treat group A b-hemolytic streptococcal pharyngitis as recommended in the medical literature.

The level of medical studies in Israel and the Americas and the quality of training of residents in family medicine and pediatrics, have a positive influence on the degree of knowledge of as common a subject as b-hemolytic streptococcal pharyngitis. Emphasis should be placed on continuing medical education among primary care physicians, particularly veteran general physicians and those who studied in European or Asian medical schools.

Is Official Data on Reported Morbidity Valid? Hepatitis A in Israel as an Example

Yehuda Lerman, Gabriel Chodik, Hava Aloni, Shai Ashkenazi

Occupational Health and Rehabilitation Institute, Ra'anana, Schneider Children's Hospital, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University

Hepatitis A is one of the most frequently reported notifiable infectious diseases in Israel. The annual incidence as reported is around 70/100,000. The physician or the diagnostic laboratory notifies the district health office of the Ministry of Health.

The purpose of this research was to evaluate the sensitivity of passive surveillance of hepatitis A morbidity among adults, 18 years and over. Methods included study of notifications to the Ministry of Health or hospitalizations of cases of hepatitis A and of positive laboratory tests results (IgM) for hepatitis A. We estimated the extent of under-reporting by 2 different methods of extrapolation.

Data based on passive surveillance among the adult population, between 1.1.1993-31.12.1994, comprised less than 1/5 of the actual number of cases. Physicians notified about 6.2% of their hepatitis A patients. 5.1% of the notifications to the district health office were sent twice or more, usually both by the physicians and labs.

The official data on hepatitis A morbidity, based on passive surveillance, are considerably underestimated. Physicians and public health officials should be aware that such data may not accurately reflect the magnitude of the risk or the amount of disease that can be prevented. Efforts should be made to improve this situation.

A-V Junctional Arrhythmia Due to Oral Phenytoin Intoxication

Rasmi Magadle, Paltiel Weiner, Joseph Waizman

Dept. of Medicine A, Hillel Yaffe Medical Center, Hadera

Phenytoin (Dilantin) is the drug of choice for most of the convulsive disorders. However, even when given orally it causes many adverse reactions, mainly affecting the nervous system, both central and peripheral. When administered intravenously, severe cardiovascular reactions may occur, including conduction disorders, sinus arrest, atrioventricular block or hypotension.

Medline screening did not reveal previous reports of arrhythmias induced by oral phenytoin. We present a case in which oral phenytoin administered chronically for a convulsive disorder caused atrioventricular junctional arrhythmia.

Reactive Increase in Blood Pressure on Immobilization, but not Hypertension, Prevents Pressure Ulcers

Vladimir Shats, Silvio Kozacov

Geriatric Dept., Rebecca Sieff Hospital, Safed

Of 135 geriatric patients immobilized for at least 2 days, 37 (27.4%) had pressure ulcers (PU). Those without PU were the control comparison group. Gender, length of immobilization, number of blood pressure determinations and proportion with hypertension were similar in those with and without PU. Those with PU were slightly older than those in the comparison group: 75.5±8.8 and 74.7±9.6 years, respectively (p>0.05).

Of 66 patients with acute ischemic stroke, reactive increase of systolic or diastolic blood pressure to 140/90 mm Hg or above following immobilization, was seen in 60.6% and 22.7% of patients, respectively, and there were PU in 12.1%. Of 17 with recurrent ischemic stroke, corresponding figures were: 41.2%, 23.5% (p>0.05), and 47.1% (p<0.01). In 7 patients with previous ischemic stroke corresponding figures were: 14.3% and 0% (p<0.01) and 100% (p<0.001). In 36 operated for fracture of the femur, corresponding figures were: 50%, 11.1% (p>0.05), and 27.8% (p>0.05). For 9 patients with severe infections, sepsis or pneumonia, the corresponding figures were: 22.2% and 0.0% (p>0.05), and 44.4% (p<0.04).

The proportion of patients with reactive increase in systolic blood pressure on immobilization was lower in the PU group than in the controls, 27% vs 59.2%, (p<0.001). The corresponding figures for reactive increase in diastolic blood pressure were similar, 8.1% and 20.4%, respectively (p>0.05).

The mean systolic blood pressure on immobilization was higher in the control than in the PU group, 145.4±21.7 and 130.8±14.9 mm Hg, respectively (p<0.001). The corresponding figures for the mean diastolic blood pressure were similar, 81.2±10.5 and 75.7±8.9 mm Hg, respectively (p<0.01). An increase in systolic blood pressure on immobilization reduced the risk of developing PU (p<0.05).

There was no significant statistical relation between diagnosis of hypertension and proportion of patients with PU (p>0.05). Of 67 patients with hypertension, in 23.9% and 74.6% of them there was no increase in systolic or diastolic blood pressure, respectively. Statistical difference between lack of diastolic or systolic response was very significant (p<0.001).

Reactive increase of blood pressure, but not hypertension, predicts reduced risk of PU on immobilization in the hospitalized elderly. Diminished reactive increase of blood pressure in response to stress of any kind may be a criterion of frailty and reduced physiological reserves. Efforts to reduce elevated blood pressure when a patient is immobilized appear irrational.

Influenza Surveillance through Sentinel Reporting Clinics

T. Shohat, N. Versano, A. Kiro, G. Golan, E. Mendelson, M. Weingarten

For the Influenza Surveillance Network: Israel Center for Disease Control, Israel National Laboratory for Influenza and Central Virology Laboratory; Netka Child Health Center and Dept. of Family Medicine, Rabin Medical Center, Beilinson Campus, Petah Tikva

In a joint effort of the Israel Center for Disease Control, the National Center for Influenza in the Central Virology Laboratory, together with a group of collaborating pediatricians and family physicians, a network for influenza surveillance was established in the winter of 1996-97. Nose and throat swabs were obtained from 571 patients with flu-like illness. 133 (23%) were positive for influenza virus. Both influenza A(H3N2) and B were isolated, predominantly influenza B during the beginning of the season. Both circulating strains were antigenically similar to those included in the vaccine for 1996-1997. Patients from whom influenza virus was isolated were significantly more likely to suffer from cough and myalgia in comparison with patients whose cultures were negative (p=0.02 and 0.003. respectively). Results of the first year of surveillance indicate that sentinel reporting clinics are useful for timely detection and identification of the viral strains circulating in the community, thus allowing prompt intervention in preventing the spread of influenza. Conclusions from the first year of the study were drawn and applied in the winter of 1997-1998.

Video-Assisted Thoracoscopic Surgery for Diagnosis of Pulmonary Lesions

O. Zamir, Y. Haskel, R. Spira, D. Eimerl, H.R. Freund

Depts. of Surgery and Anesthesiology, Hadassah University Hospital, Mount Scopus, Jerusalem

23 patients (age 11-66 years) underwent video-assisted thoracoscopic biopsy for diffuse disease or peripheral nodular lesions of the lung. 12 had been previously treated for extra- pulmonary malignancy and lung biopsy was done for suspicious metastases. In all cases except 1, lesions were identified and biopsied by thoracoscopy. The postoperative course was easier and shorter as compared to thoracotomy and the mean hospital stay was only 2.5 days. Thoracoscopic lung biopsy is a safe, effective and accurate diagnostic modality for diffuse lung disease and peripheral lesions. It is associated with minimal postoperative pain and discomfort, short hospital stay, early return to normal activity, and gives good cosmetic results.