[Out-of-hospital resuscitation in Israel 2000].

The aim of the study was to evaluate the impact of pre-hospital cardio-pulmonary resuscitation, performed by mobile intensive cardiac care units of Magen David Adom (MDA) teams in the framework of a national survey conducted in the period February and March 2000. During the survey, MDA performed 539 resuscitations, 485 of which were performed by mobile intensive care units of MDA, and they constitute the study population of the present analysis. The average age of the patients was 70.5 years, and 68% were men. The mean response time of the mobile intensive care units was 10.3 minutes. In 14% of the cases, a bystander initiated basic cardiac life support before the arrival of the MDA team. Upon arrival of the resuscitation team, 242 patients (50%) had asystole, 19% ventricular tachycardia (VT)/ventricular fibrillation (VF), 13% pulseless electrical activity (PEA), and 18% had other severe arrhythmias. One hundred and ninety-nine patients (41%) were transferred alive to the hospital after successful resuscitation. Hospital summaries were obtained for 148 of these patients. The cause of cardiac arrest was cardiac in 64% of the cases and 48% of the patients who reached the hospital had a previous history of heart disease. Fifty-three patients (11%) were discharged alive from the hospital. Patients discharged alive were younger, more promptly resuscitated, 78% had a cardiac cause of death and 38% of them were in ventricular tachycardia/fibrillation when first seen by the resuscitation team. The rate of successful resuscitation to discharge in the sub-group with VT/VF was 21%, and only 4% for patients in asystole, which is in line with other studies. However, the rate of initiation of resuscitation by bystanders is low in Israel. These data may help the medical staff and the health policy providers in Israel.

Translocation of bacteria due to direct mucosal damage caused by Gastrografin. An experimental study in newborn rats.

A study was carried out on 40 newborn rats to determine the effect of Gastrografin (a hyperosmolar solution, 1700 mosm/liter) on the gastrointestinal tract. All the newborns received an inoculum of Klebsiella bacteria to the gastrointestinal tract. Thirty received, in addition to maternal milk, a feeding of Gastrografin twice daily. The Gastrografin was found to cause severe and irreversible damage to the mucosa of the small intestine, causing the death of 24 rats less than a week after start of the experiment. The 10 rats who received no Gastrografin and served as controls showed no signs of disease or damage to the intestinal tract. Cultures taken from the peritoneal cavity after sacrifice were all positive for Klebsiella in the Gastrografin group (30 rats) and negative in the controls (10 rats). This study has therefore demonstrated that severe damage to the small intestine mucosa will lower the intestinal barrier and lead to transmural translocation of bacteria into the peritoneal cavity.

Penetrating stab wound of the gluteus--a potentially life-threatening injury: case reports.

Presented are two cases of stab wounds through the gluteus in which serious damage was incurred by internal organs: in one case there was penetration of the rectum with the appearance of signs of acute abdomen; in the other there was tearing of retroperitoneal muscles and the internal iliac vessels with resultant hypovolemic shock. These observations suggest that there should be greater awareness of the life-threatening nature of stab wounds of the gluteus under similar circumstances.

Acute cholecystitis complicating unrelated disease: etiological considerations.

The phenomenon of acute cholecystitis complicating an unrelated operation has been reported with increasing frequency, and may be preceded by a variety of operative procedures and a lack of previous biliary tract symptoms. Among eight such patients treated by us, seven developed acute cholecystitis postoperatively, and in one it was discovered during operation for bleeding duodenal ulcer. Two patients had undergone wide excision of the breast; two, highly selective vagotomy; one, nephrolithotomy; one, truncal vagotomy and gastroenterostomy; and one, left hemicolectomy and colostomy. In three patients, urgent cholecystectomy was performed, and four were treated conservatively with subsequent elective cholecystectomy. Histopathological studies revealed acute and chronic cholecystitis in all eight patients and cholelithiasis in four. One patient died in septic shock. Numerous contributing factors have been suggested, including hypovolemia and biliary stasis, as well as the presence of stones. It would appear that chronic cholecystitis or other biliary pathology, as found in our eight patients, is a major factor in the development of this manifestation.

Acute inflammation and distension of the gall bladder in infancy.

Acute cholecystitis in children is a rare disease which has been associated with haemolytic anaemias, intercurrent illness and congenital anomalies. Acute inflammation and distension of the gall bladder in infancy is very rare and the underlying cause is usually not identified. This study describes two infants presenting with acute acalculous cholecystitis with marked distension of the gall bladder. It is stressed that this entity must be taken into account in the differential diagnosis when there is a palpable mass and/or tenderness in the right abdomen, particularly in the presence of intercurrent illness. Early operation is recommended and cholecystectomy is the preferred procedure.

Assessment of splenic function in dogs following arterial ligation and autotransplantation.

Two methods for the preservation of splenic function following trauma to the spleen were studied and compared in dogs and puppies. One method was splenectomy and autotransplantation of small pieces of splenic tissue, and the other--ligation of the main branches of the splenic artery after partial splenectomy. Dogs subjected to splenectomy alone or laparotomy alone served as controls. Splenic function was assessed on the basis of resistance to sepsis by virulent pneumococci. Cultures were obtained from the blood, peritoneal fluid and intraabdominal organs 3 days after i.v. injection of the pneumococci; none of the adult dogs in any of the groups had positive cultures. Among splenectomized puppies, 55.5% had positive cultures for pneumococci, whereas those which underwent ligation of the splenic artery and partial splenectomy had negative cultures. Microscopic examination of the autotransplants revealed loss of the characteristic structure of splenic tissue, whereas in the dogs in which the splenic artery had been ligated, the spleen showed numerous islands of tissue with well-preserved follicular structure. We suggest that in children with severe splenic trauma, ligation of the splenic artery may provide a promising alternative to splenectomy.

Fractures of the femoral neck in childhood. Results of conservative treatment.

Experience with nine patients with fracture of the femoral neck in childhood, eight of whom were treated conservatively by closed reduction and fixation with a plaster cast, and one in whom Steinmann pins and open reposition had to be employed to accomplish fixation, is presented in brief. In six children the results were evaluated as good and in three (including the one case of open reduction) as fair. No serious complications were observed. The problem of nonsurgical versus surgical approach is discussed in the light of the relevant literature. It is suggested that while there can be no set rule as to which treatment should be used, conservative management yields results which are comparable with those attained with a more aggressive approach.

The value of Gastrografin in the differential diagnosis of paralytic ileus versus mechanical intestinal obstruction: a critical review and report of two cases.

Two cases in which serious intra-abdominal complications were masked by results of the contrast examination using Gastrografin were encountered. This caused the authors to review critically the use of Gastrografin in the differential diagnosis of paralytic ileus versus mechanical intestinal obstruction. In a series of 41 cases in which the diagnostic problem was not solved initially by means of physical examination and plain abdominal roentgenograms, the Gastrografin examination proved reliable in 28 (68 per cent). The reliability of the examination was defined as the relative number of cases in which a correct decision could be made for or against surgical operation. It is concluded that Gastrografin is a valuable diagnostic aid in controversial cases of ileus. A "negative" result of the examination, however, would never be allowed to damp the surgeon's awareness of possible serious intra-abdominal conditions, which the contrast examination has failed to disclose and which require immediate surgical intervention.

Traumatic rupture of diaphragm: surgical reconstruction with special reference to delayed closure.

Thirteen cases of diaphragmatic rupture following blunt trauma or gunshot wounds are presented. In 10 cases the diagnosis of diaphragmatic rupture was made immediately following the injury, and the defect was closed by primary diaphragmatic suture. In three cases, the diagnosis was delayed for 3 to 16 years after the initial trauma. In all of them, abdominal organs such as the colon or liver had migrated into the thoracic cavity. One of them had acute intestinal obstruction and died following several unsuccessful operations. The remaining two patients required plastic repair of the diaphragmatic hernia by a Dacron patch, and both recovered. The clinical and pathological aspects of diaphragmatic rupture, the importance of early diagnosis and surgical correction, and the surgical approach to this entity are considered. The use of Dacron fabric in delayed closure of diaphragmatic defects is described.

The influence of biliary infection on the postoperative course after biliary tract surgery.

A prospective clinicobacteriological study was undertaken in 167 patients undergoing biliary surgery so as to assess the possible influence of the endogenous preoperative biliary infection on postoperative morbidity. Bile cultures were positive in 33% (55 patients); in those undergoing cholecystectomy alone this finding was present in 23% while in those in whom a choledochotomy was also performed cultures were positive in 65%. The incidence of wound infection was found to be twice as high in those undergoin choledochotomy as in those undergoing cholecystectomy alone--37.8% vs. 18.5%. There was no appreciable difference in the rate of wound infection when a routine appendectomy was performed during biliary tract surgery. Among the 38 patients with wound infection, bile cultures were positive in 16. In 13 cases the offending organism in the wound was identical with that recovered from the bile coulture. This finding suggests an endogenous source for the wound infection. This study further indicated that wound infection is most likely to be encountered in patients with pathogenic organisms in the bile, in the aged and in those whose resistance to infection has been lowered by concomitant disease.

Electroenterography after cholecystectomy. The role of high epidural analgesia.

The electrical activity of the stomach and intestine was monitored during the postoperative period in 30 patients who underwent cholecystectomy. All patients received standard general anesthesia with artificial ventilation during operation; some received high epidural analgesia during surgery and postoperatively, and others, fentanyl analgesia during surgery and nicomorphine afterwards. Electroenterography (EEnG) showed that electrical activity decreased following surgery and returned to base line on the third or fourth day after operation. A marked increase in amplitude and frequency of EEnG oscillations was recorded in 80% of the patients who received bupivacaine injections into the epidural space. A decrease was almost always recorded after nicomorphine injections. During the postoperative period, eating caused a considerable increase in the amplitude and frequency of the electrical activity of the stomach and intestine in patients treated by epidural analgesia, whereas no observable change was recorded in patients treated by nicomorphine injections. It appears that high epidural analgesia may be useful in the treatment of postoperative adynamic ileus.

Unusual congenital coronary arterio-venous fistulae with surgical correction.

A typical case of anginal syndrome in a fifty year old male has been described. The underlying lesion was congenital coronary arterio-venous fistula between the left anterior descending branch of the left coronary artery and pulmonary artery. Diagnosis has been made by coronary angiography and proved at operation. The patient underwent successful operation where a multiple fistulous ostia draining into the pulmonary trunk were obliterated by means of extracorporeal circulation. The pertinent literature related to this congenital anomaly and symptomatology has been reviewed.

Axillary metastases from an unknown primary source.

The appropriate therapeutic approach is considered in patients who present with carcinomatous metastases in the axillary lymph nodes and in whom the site of the primary tumor remains obscure. Eight patients with axillary lymph node metastases are reported, in five of whom the location of the primary tumor could not be established. In three patients the primary growth was ultimately found to be in the adjacent breast. Early death occurred in only one patient, and in this instance the primary site proved to be in the breast. The remaining seven patients have all shown a relatively good prognosis when compared with those in similar series reported in the literature. The conservative policy of using radiotherapy alone for such cases, and the more aggressive approach of blind radical mastectomy of the adjacent breast, are both rejected. Instead, the more conservative sector mastectomy of the upper outer quadrant of the ipsilateral breast is proposed as a diagnostic procedure. Should this, together with general investigation of the patient, fail to detect the primary tumor, therapeutic axillary block dissection followed by radiotherapy is then advocated. If the primary tumor is found in the breast on sector mastectomy, a modified radical mastectomy of the affected breast should be performed and followed by irradiation.