Zvi H. Perry

Briefly Trained Medical Students Can Effectively Identify Rheumatic Mitral Valve Injury Using a Hand-Carried Ultrasound

Rheumatic heart disease (RHD) is common and remains a major cause of morbidity, particularly in developing countries. Its diagnosis relies on expertise‐dependent echocardiographic studies. We evaluated the accuracy of briefly trained examiners in identifying RHD utilizing a hand‐carried cardiac ultrasound (HCU) device.

Maternal and neonatal outcome following cerebrovascular accidents during pregnancy

Objective. To assess the clinical characteristics of maternal and neonatal outcome among women with cerebrovascular accidents (CVA) during pregnancy. Methods. Our computerized database was used to identify patients with CVA during pregnancy and puerperium from January 1988 to March 2004. Their medical records were identified and reviewed. Results. There were 16 cases of CVA among 173 803 deliveries, giving a risk of almost one case per 10 000 pregnant women. Out of 16 patients, 14 (88%) had a stroke and the remaining two cases were diagnosed with venous thrombosis. Of those 14 cases, nine (64%) had ischemic strokes and five (36%) had hemorrhagic strokes. Ten of the CVAs occurred antepartum, two intrapartum and four postpartum. Hypertensive disorders were diagnosed in 75% (12/16) of the patients. Out of these 12 patients with hypertension, 9 (75%) suffered from preeclampsia. One woman had a history of chronic hypertension. Smoking was associated with 63% (10/16) of the cases. There were two maternal deaths, both in women who had hemorrhagic strokes, and both in the first half of the study (1994 and 1996). Nine out of 16 women (56%), were delivered within 48 hours of the CVA including 7 (78%) antepartum, and two (22%) intrapartum. Cesarean deliveries were performed in 11/16 women (69%) including 8/10 with CVAs occurring antepartum, 1/2 intrapartum and 2/4 postpartum. One case of neonatal mortality was identified in a patient who was delivered at 24 gestational weeks. Conclusions. (1) Hypertensive disorders and smoking were the most important factors associated with CVA during pregnancy. (2) Maternal mortality was high among patients with CVA during pregnancy. (3) Neonatal outcome was considered generally good in cases of CVA.

Laparoscopic appendectomy as an initial step in independent laparoscopic surgery by surgical residents.

BACKGROUND Laparoscopic appendectomy (LA) can be used as a training model for the start of the independent experience of young residents. We tried to evaluate whether LA is a risk factor for patients when it is done by novice surgeons during the different steps of their training. MATERIALS AND METHODS A retrospective study of all the patients who underwent LA in our department between 2000 and 2008 was conducted. The patients were operated on by novice surgeons, chief residents, and senior surgeons. Preoperative variables were compared, as well as surgical outcomes and complications. RESULTS During the study period, 477 LA, were performed on 320 women and 157 men, with a mean age of 39 years. In 11 cases (2.3%), the operation was converted. No difference was found in preoperative patient status. There was no difference between groups in the rate of accurate preoperation diagnosis, in comparison with the pathologic report. The rates of conversion, postoperative complications, and negative appendectomies were similar between residents and seniors. These findings were also found in a subgroup analysis, in which we compared each group. CONCLUSIONS There is no additional risk in a LA done by a resident, whether a chief or a novice. LA is a good model for training young surgeons in laparoscopic surgery: It enables the young surgeon to engage and lead a real case and does not imbue any risk upon the patient.

Admission Cell Free DNA as a Prognostic Factor in Burns: Quantification by Use of a Direct Rapid Fluorometric Technique

Background. Despite great advances in the treatment of burn patients, useful prognostic markers are sparse. During the past years there has been increasing interest in circulating plasma cell free DNA as a potential marker for tissue injury. We have developed a rapid direct fluorescent assay for cell free DNA quantification that allows obtaining accurate, fast, and inexpensive measurements. Objective. To use this technique for measuring plasma cell free DNA levels in burn patients and to further explore the use of cell free DNA as a potential marker of patient outcome in burns. Methods. Cell free DNA levels obtained from 14 burn victims within 6 hours of injury and 14 healthy controls were quantified by a direct rapid fluorometric assay. Results. Patient admission cell free DNA levels were significantly elevated compared with that of controls (1797 ± 1523 ng/mL versus 374 ± 245 ng/mL, P = 0.004). There are statistically significant correlations between cell free DNA admission levels and burn degree (Spearmans correlation = 0.78, P = 0.001), total body surface area (Spearmans correlation = 0.61, P = 0.02), and total burn volume (Spearmans correlation = 0.64, P = 0.014). Conclusions. Admission cell free DNA levels can serve as a prognostic factor in burns and future routine use can be made possible by use of our direct rapid fluorometric assay.

Giant enterolith in ileal diverticulum following ileoplastic bladder augmentation

INTRODUCTION When adhesions, internal hernias, malignant intra- and retro-peritoneal neoplasms are excluded in patients presenting with new onset constipation and abdominal mass appearance after previous abdominal surgery, other causes must be considered. PRESENTATION OF CASE Giant enteroliths formed within ileal diverticula in the site of small bowel anastomosis may extrude and produce a palpable abdominal lump. Recent experience with such a patient is the basis of this report. DISCUSSION Ileal diverticula with interior enteroliths may be suspected in patients presenting with an abdominal lump following previous small bowel resection. CONCLUSION Open or laparoscopic assisted surgical resection of the involved segment is the treatment of choice.

Emotional Processing — The Use of Balint Groups for Medical Students as a Means for Improving Interpersonal and Communication Skills and Competence

Academic and emotional burdens are common in medical school. We created a course for medical students based upon the principles of Balint groups to aid students in their introduction to the clinical ward. To evaluate if the course helped students cope with their new environment, we used a semi-structured debriefing questionnaire and a competence and readiness questionnaire. Before the course, students were skeptical, but acknowledged the need for training in stress management. At the end of the course, students revealed a similar picture, but reported that they felt comfortable enough to share their feelings with peers, and that the group built a trustworthy relationship. We found that using Balint groups as a stress management technique for medical students entering their clinical phase of studies is both feasible and efficient.

Work satisfaction, quality of life, and leisure time of neonatology fellows and senior neonatologists in Israel

ObjectivesTo examine work satisfaction, quality of life, and leisure time of neonatology fellows and senior neonatologists in Israel.MethodsA validated questionnaire was delivered during the second half of 2008 to all the neonatology fellows and senior neonatologists in Israel. Descriptive analysis, parametric Student’s t-test, and aparametric Mann Whitney and χ2 tests were conducted.ResultsOf 114 practicing neonatologists in that period in Israel (including both seniors and fellows), 112 (98.25%) participated in the study. The majority of neonatologists were male (53.2%), married (91.7%), 40–60 years old (69.7%), and studied in Israeli medical schools (62.0%). Most did their pediatric residencies and fellowships in Israel (97.2% and 75.7%, respectively). The average number of night/on-call shifts of fellows and senior neonatologists was 8.8 per month (SD ± 3.425) and the number of active on-call shifts was 4.04 (SD ± 3.194). The satisfaction level of neonatologists in Israeli medical centers with patient care, self-reward, work relations, and quality of life was high, but their satisfaction level with workload, income and prestige, and leisure time was low. The general index of work satisfaction and the general index of indices were both high in relation to the mid-range values. The majority of neonatologists stated that they would choose to practice medicine again. Most of them would encourage medical students to choose the same specialty they had chosen. Only a few neonatologists were contemplating changing their choice of specialty. Most neonatologists want to continue practicing medicine; however, a significant number will not recommend that their children do so.ConclusionsThe satisfaction level of neonatologists in Israel is high, mainly due to satisfaction with their work. High satisfaction levels promise high quality patient care, as well as high satisfaction levels of patients and their families. However, satisfaction with leisure time was low and it will require greater attention and focused steps to correct this.

Breaking Bad News: Attitudes of Physicians and Patients in Primary Care

Objective To understand and evaluate the skills primary care physicians need to convey bad news, from both the patients’ as well as the physicians’ points of view. These data were used to formulate clinical guidelines about conveying bad news.

Pre-Surgical Assessment of Left Ventricular Function in High Risk Patients: The Use of Hand-Carried Cardiac Ultrasound by a Novel Operator

Pre-Surgical Assessment of Left Ventricular Function in High Risk Patients: The Use of Hand-Carried Cardiac Ultrasound by a Novel Operator Assessment of left ventricular (LV) function for evaluation of surgical risk in high risk patients relies on echocardiography studies that are expertise dependent and costly. We evaluated the accuracy of a briefly trained examiner to identify asymptomatic left ventricular dysfunction (ALVD) utilizing a handcarried cardiac ultrasound (HCU) device as part of the first patient examination.

Management of gastrosplenic fistula in the emergency setting - A case report and review of the literature

Introduction A gastrosplenic fistula (GSF) is a very rare complication that arises mainly from a splenic or gastric large cell lymphoma. The proximity of the gastric fundus to the enlarged fragile spleen may facilitate the fistulisation. This complication can lead to massive bleeding, which, though uncommon, may be lethal. We present a patient with massive upper gastrointestinal bleeding secondary to a GSF. Case presentation We present a 48-year-old man with a refractory diffuse large B-cell lymphoma who was admitted to our hospital due to hematemesis. On arrival, he was in hemorrhagic shock, and was taken directly to the intensive care unit. The source of bleeding could not be identified on gastroscopy, the patient remained hemodynamically unstable and a laparotomy was performed. A fistula between a branch of the splenic artery and the stomach was identified. The stomach appeared to be involved in the malignant process. After subtotal gastrectomy and splenectomy, the bleeding was controlled. After stabilization, the patient was admitted to the intensive care unit, and 24 hours later was discharged in stable condition. Discussion We describe a fistula between a branch of the splenic artery and the stomach, which was accompanied by massive bleeding. An emergency laparotomy saved the patients life. Conclusion The purpose of this report is to alert physicians that surgical intervention can be lifesaving in this rare malignant condition. A literature review focusing on the presenting symptoms and the epidemiology of GSF is presented.