Iron deficiency anemia in patients without gastrointestinal symptoms--a prospective study

BACKGROUND AND OBJECTIVES: Chronic gastrointestinal (GI) bleeding is the leading cause of iron deficiency anaemia (IDA) in men older than 50 years and post-menopausal women. There is a scarcity of data regarding IDA patients without GI symptoms or signs. We conducted a prospective study to determine the prevalence and the locations of the GI tract lesions in patients with asymptomatic IDA. METHODS: Forty-eight patients with asymptomatic IDA (25 men older than 50 years and 23 post-menopausal women) underwent colonoscopy, gastroscopy and abdominal computed tomography (CT) with contrast agent. RESULTS: An anaemia-causing lesion was found in 14 (29%) and 16 (33%) patients in the upper and the lower GI tract, respectively. The prevalence of dual lesions (in both the upper and lower GI tract) was low (6%). In 14 (29%) patients, a malignancy, predominantly right-sided colon carcinoma, was responsible for the IDA. Only one patient had a lesion in the small bowel. In 14 (29%) patients, the work-up was negative. CONCLUSION: Our prospective study demonstrates a high rate of malignancy, predominantly right-sided colon carcinoma, in men older than 50 years and post-menopausal women with asymptomatic IDA. This finding obligates a complete and rigorous GI tract examination in this group of patients, especially of the right colon.     

Perioperative venous thromboembolism prophylaxis in Israel: a survey of academic surgical departments

OBJECTIVE: Postoperative venous thromboembolism (VTE) represents a serious threat to patients undergoing surgical procedures. Without thromboprophylaxis, deep vein thrombosis occurs in up to 60% of patients undergoing major orthopedic surgery and 15% of patients undergoing major abdominal surgery. Although, many studies have shown the efficacy of pharmacologic and mechanical means of VTE prophylaxis, practice variations in this area abound worldwide. The purpose of this study was to determine the attitudes and practice of VTE prophylaxis of academic surgical department heads in Israel. METHODS: A questionnaire covering various aspects of VTE prophylaxis was mailed to all surgical department heads of university teaching hospitals in Israel. Three months later, the same questionnaire was sent to department heads who had not yet replied. Data retrieved from the returned questionnaires were analyzed. RESULTS: A total of 250 departments in 23 hospitals affiliated to the four medical schools in Israel were identified; 130 department heads (52%) returned the questionnaires. The current study analyzes results obtained from the general surgical, orthopedic, urological, vascular and gynecological departments only. The total number of responses from these departments was 90 (69% response rate). Sixty-seven percent of the departments considered VTE to be a clinical problem. Ninety-four percent of departments have a policy for VTE prophylaxis. The most frequently used modalities for VTE prophylaxis (more than one option possible) were low-molecular-weight heparin (LMWH) (59%), unfractionated heparin (43%) and an intermittent pneumatic compression device (20%). VTE prophylaxis is begun 12 h preoperatively by 33% of departments, 2-4 h preoperatively by 20% of departments and with premedication by 8% of departments. VTE prophylaxis was continued during the postoperative period by all departments, with 52% stopping prophylaxis upon patient mobilization. Bleeding complications have been noted by 55% of departments, of these 9% were considered major. In general surgical, orthopedic and gynecologic departments, VTE prophylaxis was widely used for those procedures for which published guidelines exist, while considerable variation in VTE prophylaxis administration was demonstrated in a number of commonly encountered clinical situations for which there are no published recommendations. CONCLUSIONS: This study confirms that academic surgical departments in Israel conform to standard VTE prophylaxis guidelines. However, considerable variations in practice exist regarding the means of prophylaxis, onset of prophylaxis and its duration. These areas should be the focus of ongoing educational efforts including the development of uniform practice guidelines to improve the quality of care regarding VTE prophylaxis. Furthermore, attention should be given to methods for decreasing hemorrhage caused by LMWH and unfractionated heparin usage.     

Early complications of tracheostomy performed in the operating room

Tracheostomy is one of the oldest operations in medicine. The intraoperative and postoperative complications associated with this procedure are well established. Recently, percutaneous and open bedside tracheostomy in the intensive care unit has been reported as an alternative to tracheostomies performed in the operating room. We investigated the early complications in 70 consecutive tracheostomies performed in the operating room in Bnai Zion Medical Center in Haifa, Israel. The study revealed no complications related to patient transportation to and from the operating room. The complication rate of standard surgical tracheostomy performed in the operating room was very low.     

Bilateral tinnitus due to middle-ear myoclonus

Tinnitus is a common otological symptom. Usually it is subjective (perceived only by the patient); very rarely is it objective (heard by both the patient and the examiner) Objective tinnitus due to middle-ear myoclonus is extremely rare, with only a few case reports published in the literature. We present three cases of objective tinnitus caused by middle-ear myoclonus. All patients were cured by tympanotomy with stapedial and tensor tympani tendon section.     

The effects of noise on the vestibular system

PURPOSE: Subjects with noise-induced hearing loss sometimes also complain about balance disorders, but reports of clinical series that give contradictory results are highly controversial. This study was designed to evaluate the effects of intense noise on the vestibular labyrinth, both in subjects with symmetrical hearing loss and in subjects with asymmetrical loss, and to examine the correlation between the subjects' complaints and the results of the vestibular function tests. METHODS: A total of 258 male military personnel, heavily exposed to various intense noises, were included in the study. They were divided into 2 groups according to their hearing; 134 had a symmetrical high-tone hearing loss, and 124 had asymmetrical losses. Each group was divided into 2 subgroups according to the presence or absence of vestibular complaints. All of the subjects underwent a complete audiological and electronystagmographic evaluation. RESULTS: We found that vestibular damage caused by intense noise exposure might be expressed clinically in subjects with asymmetrical hearing loss. There was a strong correlation between the subjects' complaints and the results of the vestibular function tests. There was no correlation between the severity of the hearing loss and the vestibular symptomatology and pathology. CONCLUSIONS: Subjects exposed to intense noise may have evidence of vestibular pathology only when there is an asymmetrical hearing loss. Whenever hearing loss is symmetrical, an equal damage to the vestibular system of both ears is most probably responsible for the absence of abnormal findings on the vestibular function tests. The results of this study have important medicolegal implications for individuals exposed to intense noises.     

Synergistic necrotizing cellulitis as a complication of peritonsillar abscess

Peritonsillar abscess, a complication of tonsillitis, is not uncommon. The usual treatment consists of needle aspiration or surgical drainage and antibiotic treatment. Tonsillectomy may be used in the management of this condition, either at the time of diagnosis or after an interval period. Severe complications of peritonsillar abscess are rare. Synergistic necrotizing cellulitis is a fulminant infection associated with spread along fascial plains, necrosis of connective tissue and muscle, and high mortality. It is usually otondogenic in origin in the cervicofacial area and occurs in debilitated or immune compromised patients. We discuss cervicofacial-necrotizing soft tissue disease and report an unusual case of extensive synergistic necrotizing cellulitis of the neck, chest, and shoulder as a result of a peritonsillar abscess.