אורה שובמן, בוריס גילבורד, פנינה לנגביץ', יהודה שינפלד

המח' לרפואה פנימית ב' והיחידה לחקר מחלות אוטואימוניות, המרכז הרפואי שיבא תל השומר והפקולטה לרפואה סאקלר, אוניברסיטת תל אביב

מילות מפתח:

נוגדני RA33, RA33, מחלות אוטואימוניות, אורה שובמן, בוריס גילבורד, פנינה לנגביץ', יהודה שינפלד, שובמן, גילבורד, לנגביץ', שינפלד

Familial Parinaud Oculo-Glandular Syndrome in Cat-Scratch Disease 

Nir Shoham, Dan Miron, Raul Raz, Hanna J. Garzozi

Depts. of Ophthalmology and Pediatrics A, and Infectious Diseases Unit, HaEmek Medical Center, Afula

Cat-scratch disease is manifested by subacute, regional lymphadenitis and occurs mainly in children. The causative agent is a pleomorphic, gram-negative bacillus, Bartonella henselae carried by asymptomatic cats. Parinaud oculoglandular syndrome is the most common ocular manifestation of this disease. It is characterized by unilateral conjunctivitis with polypoid granuloma, usually of the palpebral conjunctiva, and preauricular lymphadenopathy. The diagnosis is supported by a history of exposure to cats and is confirmed by positive serologic tests or positive PCR assay.

The occurrence of more than 1 case of Parinaud syndrome in a family is rare. We describe 2 sisters with Parinaud oculoglandular syndrome, proven by serologic tests. They reported that they used to cuddle with their cats, among them a kitten. Because of the refractory conjunctivitis and signs of imminent periorbital cellulitis, they were treated with oral tetracycline with apparently good responses.

We recommend asking about contacts with cats in any atypical conjunctivitis accompanied by regional lymphaden-opathy, especially in young patients. Systemic antibiotics should be given when there is any suspicion of significant ocular involvement, if the patient is immunosuppressed, or if there are systemic manifestations of cat-scratch disease.

Benign Paroxysmal Positional Vertigo: Diagnostic Pitfalls 

C.R. Gordon, O. Zur, R. Furas, E. Kott, N. Gadoth

Depts. of Neurology and of Physical Therapy, Meir General Hospital, Kfar Saba, and Sackler Faculty of Medicine, Tel Aviv University

Benign paroxysmal positional vertigo (BPPV) is a common but often unrecognized cause of treatable vertigo. Possible causes of misdiagnosis of BPPV were studied by review of the records of 191 patients referred to our neurology clinic; 36 were identified as having BPPV not previously diagnosed. On referral the patients carried the following diagnoses: unspecified dizziness/vertigo (33%), transient ischemic attacks (28%), cervicogenic vertigo (19%), psychogenic dizziness/vertigo (11%), and others (8%).

The paroxysmal nature of the vertigo and position-precipitating factors were not spontaneously reported by 31%. Atypical, even bizarre, symptoms including dizzy sensations were reported by 19%, and neck pain and headache were cardinal symptoms that accompanied vertigo.

The Dix-Hallpike maneuver, which is essential for the diagnosis of BPPV, was not performed in any of the patients prior to referral. 30 (83%) experienced complete resolution of signs and symptoms after the first physical treatment session.

We conclude that non-paroxysmal, non-positional vertigo does not rule out BPPV. Atypical and even bizarre complaints of dizziness, as well as neck pain and headache could be cardinal symptoms of BPPV. The Dix-Hallpike maneuver is mandatory in those complaining of dizziness and vertigo.

Familiarizing Medical Students with Hospital Social Worker's Role 

Barbara Rabin (Rabinowitz), Dafna Manor

Dept. of Social Work, Meir Hospital, Kfar Saba

Patient care in a general hospital is usually provided by a multi-professional team. Treatment is most effective when each professional understands the functions of the various other members of the team. Professional literature and research have highlighted differences in perception by social workers and physicians of the proper function of the medical social worker.

Our social work department has developed a teaching program for medical students to enhance their knowledge with regard to this issue. It is presented at a single-session group meeting of an hour and a half, with structured content and goals.

Mitral Valve Repair in Ischemic Cardiomyopathy with Severeleft Ventricular Dysfunction

Dani Bitran, Ofer Merin, Jeffrey Fisher, Nadiv Shapira, Marc W. Klutstein, Shuli Silberman

Depts. of Cardiothoracic Surgery, Anesthesiology and Cardiology, Shaare Zedek Medical Center, Jerusalem

Patients with ischemic mitral insufficiency and poor left ventricular function are high operative risks. We present 101 patients who had mitral valve repair in our department: 21 had severely reduced left ventricular function, 19 were in NYHA functional Class IV, and 2 in Class III. All had concomitant coronary artery bypass.

There was no early operative mortality, but there were 2 late deaths (9.6%). At follow-up (3-36 months) all valves were functioning normally, 9 patients (43%) were in NYHA functional Class I, and 4 (19%) in Class II.

Our experience shows that repair of ischemic mitral insufficiency in the presence of severe left ventricular dysfunction can be performed with good results, and is preferable to mitral valve replacement. Late follow-up showed significant symptomatic improvement.

Tacrolimus does not Accentuate Hepatic Damage due to Hypoperfusion 

Ron Ben Abraham, Ivgeni Isartal, Richard Nakache, Vallery Rudick, Daniel Ogorek, Gideon Paret, Avi Weinbroum

Dept. of Anesthesiology and Critical Care Medicine, Organ Transplantation and Postoperative Care Units, Tel Aviv-Sourasky Medical Center; and Pediatric Intensive Care Units, Sheba Medical Center, Tel Hashomer; and Sackler Faculty of Medicine, Tel Aviv University

Deterioration of hepatic function following liver transplantation is a known complication, sometimes attributed to the use of cyclosporin A. Reaction to tacrolimus (Prograf), a relatively new and effective immunosuppressant drug, is thought to result in a much lower grade of organ dysfunction, especially in the transplanted liver.

Using the ex-vivo rat model of isolated perfused liver, we evaluated hepatocellular damage and oxygen extraction when tacrolimus was administered following liver hypoperfusion. Tacrolimus did not worsen hepatic dysfunction caused by the hypoperfusion. Therefore using tacrolimus in the perioperative period might be safer than cyclosporin A, which tends to worsen hepatic damage in the presence of hypoperfusion.

Color Doppler Imaging of Central Retinal Artery in Retinopathy of Prematurity

Alon Harris, Hanna J. Garzozi, Mira Harris-Izhak, Nir Shoham, Daniel R. Holland

Depts. of Ophthalmology, Indiana University School of Medicine, Indianapolis and of HaEmek Medical Center, Afula; and Eye Health Northwest, Portland, Oregon

Color Doppler imaging (CDI) is a noninvasive technique, combining 2-dimensional brightness-modulated (B-mode) ultrasound evaluation of eye and orbital structures, with simultaneous color-coded Doppler imaging of orbital blood flow. It has been used to characterize various ophthalmic disorders in adults. Currently there is no data describing orbital blood flow parameters in either normal children or in those with ophthalmic disease, such as the retinopathy of prematurity (ROP).

We evaluated blood flow in the central retinal artery of preterm infants undergoing examination for ROP. We also investigated whether useful readings could be obtained on a consistent basis, and the reproducibility of differences in central retinal artery blood flow between subjects with and without ROP (including the influence of "plus" disease).

We obtained hemodynamic readings in 43 of 46 eyes of preterm infants. 13 eyes had no signs of ROP; 18 had ROP (at least stage 1) without "plus" disease, and 12 had ROP with "plus" disease. There were no statistically significant differences in systolic blood flow velocity within the 3 groups. However the average velocity was slower in the "plus" disease group, correlating with the clinical finding of dilated and tortuous blood vessels which characterize the posterior retina of ROP eyes with "plus" disease.

Development of Molecular Tests for Rapid Detection of Enteropathogens 

Miri Yavzori, Nir Uriel, Nurith Porat, Ron Dagan, Ruhama Ambar, Ofer Shpilberg, Dani Cohen

Army Health Branch Research Unit, Medical Corps, Israel Defense Forces; Pediatric Infectious Disease Unit, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba; and Sackler Faculty of Medicine, Tel Aviv University

Amplification of specific DNA sequences by polymerase chain reaction (PCR), enables rapid, sensitive and direct, specific identification of pathogens at very low concentrations in clinical samples. Studies in recent years have reported identification of several enteropathogens directly from stool samples by PCR. The amplification process includes the use of primers complementary to the DNA sequences specific to the pathogen, thus relying on the pathogen's genotype, rather than its phenotype on which identification by the methods of classical microbiology were based.

We have developed PCR protocols for the differential identification of enteropathogens resembling the normal flora (enterotoxigenic E. coli (ETEC), E. coli O-157), Shigella spp, and the detection of enteropathogens that can not be grown on classic growth media (Norwalk virus). The amplification process is inhibited by several substrates present in fecal material (phenol, hemoglobin), limiting DNA extraction by phenol. The protocols we have developed for direct detection of Shigella spp and ETEC in stools circumvent inhibition of PCR by the use of a 4-hour pre-enrichment step in brain-heart infusion broth.

Rapid and accurate identification of enteropathogens is important for prompt and focused intervention to stop the chain of transmission in outbreaks of gastroenteritis in military and civilian populations.

Prediction of Physiological Response from Mathematical Models 

Yoram Epstein, Yuval Heled, Daniel Moran, Yair Shapiro

Institute of Military Medicine, Medical Corps, Israel Defense Forces and Heller Institute of Medical Research, Sheba Medical Center, Tel Hashomer

The ability to predict the physiological responses of workers exposed to extreme environmental conditions, has been a challenge to environmental physiologists for more than 3 decades. Therefore, mathematical models have been developed to predict metabolic rate under various levels of work intensity and dynamic changes in body temperature and heart rate.

Based on the effect of exercise on the cardiovascular system, a model was developed to predict mean arterial blood pressure as a function of heart rate. Physiological strain could also be estimated on the basis of thermoregulatory and cardiovascular strains.

This paper summarizes knowledge accumulated during 25 years of studies in the field of mathematical modeling of physiological parameters. Besides analyzing the logic underlying each model, it explains the scientific approach in developing a model from its early concept to the model's application in the field.

Physicians' Assessment of Computerized Prescribing

Daniela Zalman, Majed Odeh, Arie Oliven

Dept. of Internal Medicine B, Bnai Zion Medical Center, Technion Faculty of Medicine, Haifa

Prescription errors are a major source of preventable adverse drug events. Computerized prescribing (CP) which screens physicians' order for mistakes, drug-allergy, drug-disease, drug-laboratory and drug-drug interactions can prevent many of these errors and improve quality of care. However, computerized systems are often time-consuming, difficult to handle, and may create their own mistakes.

Following the introduction of CP on an internal medicine ward, we administered a questionnaire to evaluate physicians' opinions about the new system. The survey assessed computer literacy, ease of using CP, effects on time management, opinion of users regarding error prevention, and usefulness of the information provided. Opinions were generally favorable; most users felt that CP makes their work more accurate, reduces errors, is easy to learn and to use, and provides important and useful information. Physicians were most critical of equipment failure and drugs and dosages not included in the CP program, a result of rapid development of the system.

Errors resulting from the use of CP were considered minimal. Comparison of physicians, with and without previous experience with computer work, as well as local and foreign graduates, revealed minor differences. But once physicians learn to work with a well-organized CP system and computerized work stations, they appreciate the order, safety and knowledge they provide.

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.

Sclerosing Mesenteritis: An Unusual Cause of Abdominal Pain

Meir Mouallem, Zehavit Turok, Danny Rosin, Bruria Shalmon

Depts. of Medicine E, General Surgery and Transplantation, and of Pathology, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Sclerosing mesenteritis (SM) is rare and fewer than 300 cases had been reported up to 1997. We describe a 29-year-old woman who had abdominal pain for 1 year and presented with a palpable abdominal mass. The diagnosis of SM was made only after diagnostic laparoscopy and biopsy of the peritoneum.

Early Detection of Glaucoma by a Mobile Unit

S. Kurtz, M. Goldenfeld, S. Melamed

Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer

Glaucoma, the third leading cause of blindness in the western world, is characterized by painless, gradual loss of visual fields which may lead to severe visual impairment or even blindness. In 4 years of operation of a mobile glaucoma unit for screening and early diagnosis of glaucoma, 10,037 subjects aged 18-95 years were screened (4504 women, 45%); 55% were under 50 years (Graph 1).

Ocular hypertension was diagnosed in 8.0%; primary open angle glaucoma (POAG) in 0.8%, with 2/3 already under treatment, the rest newly diagnosed. Pseudo-exfoliative glaucoma was diagnosed in 0.2%; only 2 cases had closed angle glaucoma; 91% of those screened were normal (Fig. 4; age stratification, Graph 3).

POAG increased with age, from 0.2% in those under 40 years to 10% in those over 80; POAG was more common in men, but OHT was similar in both sexes (6.0% vs. 5.3%). There was no correlation between incidence of POAG and place of work except in the Sorek Nuclear Center (1.9% vs. 0.8%, p=0.11). Other conditions significantly more frequent in POAG than normals were diabetes mellitus (x 2.5), systemic hypertension (x 4), myopia (x 2) and history of intraocular surgery (x 6).

Transarterial Oil Chemoembolization for Hepatocellular Carcinoma 

Izhar Levy, Anthony Verstandig, Talia Sasson, Dana Wolf, Ilia Krichon, Eugin Libson, Pinchas Levensart, Orit Papo, Oded Yurim, Ahmed Id, Daniel Shouval

Division of Medicine, Liver Unit and Invasive Radiology, Radiology, Pathology and Surgery Depts., Hadassah University Hospital, Ein Kerem, Jerusalem

Hepatocellular carcinoma (HCC) is a common malignancy with a grave prognosis. Most patients have both the malignant tumor as well as hepatic cirrhosis. Liver transplantation or hepatectomy are considered the only curative procedures, but can be applied in fewer than 10% of patients. In recent decades the most common treatments of HCC are transarterial chemoembolization with oil (TOCE) and percutaneous ethanol injection (PEI). We summarize our retrospective study of 100 patients (mean age 64) 3‏ treated by TE.

In 271 procedures between 1989-1998, in 16 patients hepatectomy was combined with TOCE and in 8 PEI was combined with TOCE, while the rest were treated by TOCE alone. Tumor mass was reduced in 36% of those treated by TOCE (tumor volume reduced 24-75%). Alpha-feto protein (AFP) was reduced 25-90% in 20/32 of those with elevated AFP levels. Median survival for the 100 in the entire group was 19 months (10.9 months in those with conservative treatment). Median survival in the 57 in Okuda stage 1 and the 43 in stages 2 or 3 was 30.1 months and 10.9 months, respectively (p<0.0001). Of the 57 in stage 1, 16 underwent hepatectomy in addition to TOCE and 41 were treated only by TOCE (median survival 15 and 26 months, respectively, p not significant).

Comparing Okuda 1 patients treated by TOCE only with the natural history of the disease and historical controls (Okuda 1 patients treated conservatively in 1984) median survival was 26 and 10 months respectively (p<0.001). The side effects of TOCE were relatively mild. There was 1 fatality (3 days after treatment), and quality of life was maintained. Despite progress in the treatment of HCC by TOCE, PEI, and liver transplantation, long-term survival has remained unsatisfactory.

Diabetic Ketoacidosis during the Ramadan Fast 

I. Friedrich, Y. Levy

Dept. of Medicine A, HaEmek Medical Center, Afula, and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

We report a 15-year-old Muslim boy with insulin-dependent diabetes mellitus (IDDM) who presented with diabetic ketoacidosis (DKA) during the Muslim Ramadan month of day-time fasting. DKA apparently occurred due to omitting pre-lunch insulin combined with dehydration and overeating during the permitted sunset-to-sunrise meals.

It is well-known that fasting accelerates development of lipolysis and ketosis and increases glucagon levels. Thus, these pathophysiological aberrations related to fasting in ketosis-prone patients, in conjunction with fasting, endanger metabolic control in IDDM.