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Patients present daily with conditions affecting the superficial surface of the body of all somatic regions. From scalp hair, skin, and ocular structures all the way to the anal sphincter. In this regard, elusive clinical detail that is imperceptible to the naked eye may be revealed through

Background Limited fluoroscopy ablation using 3D electro-anatomical system (3DS) has been used for arrhythmias in children, however it is not a common practice. We aimed to facilitate a fluoroscopy limited approach for ablation of accessory pathways (AP) in children. Methods Following electrophysiologic (EP) catheter placement a single dual-plane fluoroscopic image (right anterior oblique-30° and left anterior oblique-60° views) was acquired and the 3DS views were rotated to be a perfect match to the fluoroscopy. Ninety-four consecutive pediatric patients [mean age 11.8 ± 4.1 (4.2–18) years, 61.7% males] with Wolf–Parkinson–White syndrome underwent ablation of an AP. Fifty-seven had manifest AP, 54 had left-sided AP (LSAP) and 40 had right-sided AP (RSAP). Results The acute success rate was 95.7% (90/94), with a recurrence rate of 1.1% (1/90) at a mean follow-up of 13 ± 5.5 (4.4–22.9) months. Mean procedure and fluoroscopy times were 144 ± 45 (55–262) min and 1.8 ± 1.4 (0.1–5.6) min, respectively. Comparison of the first 20 procedures to the next 74 procedures demonstrated an extended procedure time (171 ± 53 min vs 135 ± 38 min, p

Emerging microprocessor technology has revolutionized all aspects of life in the modern era. Feats previously achieved through sophisticated, cumbersome and expensive devices are currently both commonplace and feasible with convenient instruments available at low-cost. Body surface inspection can prove very challenging when seeking minute alterations of anatomy and miniature inflicting culprits. USB (universal serial bus) dermatoscopy (UD) is the most economical and widespread technique widely utilized in industry and even lay use but inadeqautely addressed in the field of medicine. This manuscript provides a preliminary exposure of UD to those unfamiliar with this technique and demonstrates its merits improving patient care. UD constitutes an ideal method to magnify, up to over 100 fold, minute detail and project images on a screen of choice, be it a laptop, tablet or standard smartphone. Clinical practice, especially in rural areas, has much to gain from a device that can expose illusive clinical detail that is imperceptible by the naked eye. The basis of the technique is described and genuine cases where it was utilized are shared. Personal experience with this technique demonstrates that employing ample magnification and thorough illumination facilitates reaching the correct diagnosis whenever physical examination of the superficial body surface is necessary. Body regions amenable for improved visualization with this method extend from scalp hair, skin and ocular structures, all the way to the anal sphincter. The objective of this paper is to familiarize physicians with the advantages of digital microscopy through numerous clinical illustrations, as: characterization and surveillance of lesions, sores, cutaneous and corneal foreign bodies, painful conditions of the nipple, hematomas retained sutures, secretions and purulent lesions. This introduction is hoped to arouse enthusiasm towards digital microscopy and encourage its adoption into routine practice.

Objective Many indications justifiably drive the pediatrician to request a urine sample in order to assess the health status of the incontinent baby or infant. Urine collection by means of an adhesive perineal bag is the most widely used in children who do not control urine emission, despite its inaccurate reflection of bacteriuria. We suggest a novel technique to immediately visualize the micturition event upon occurrence, in attempt to shorten waiting times and exhausting checking and rechecking opaque diapers in order to determine whether the desired sample has finally been delivered. Methods The perineal urine collection bag is pulled through a vertical slit created in the front of the disposable diaper. The bag is now visible at all times. Results In general, waiting times appear shortened since the implementation of this practice. Since the adoption of this technique at a number of our clinics, we have not experienced bag displacement as was previously experienced. Forgoing the need to manipulate the diaper and repeatedly awakening irritable infants was gladly welcomed by parents. Conclusions Widespread adoption of the diaper slit technique seems a promising procedure enhancing comfort and facilitating the process of obtaining a urine sample in the incontinent child. Assumptions that this procedure actually shortens waiting times and raises the success rates of sample retrieval remain to be proven by formal comparative trials.

Summary Objective Abnormal healing after neonatal ritual circumcision is a source of significant concern to patients' parents and their caregivers. This report presents a series of male infants who underwent ritual circumcision and subsequently developed obliteration of the normally distinct structure of the corona. Methods We report a case series of infants recruited from the community and a medical center. The compulsory inclusion criterion was absence of the normal landmarks of the glans penis with confirmed integrity of normal male genitalia. Illustrative cases are presented. The possible pathogenetic mechanisms leading to this condition are discussed. A literature search was conducted to discern whether this phenomenon has ever been previously reported. Results The eight cases we diagnosed were all otherwise normal. In one case, where we discovered use of an active substance on the circumcision wound, the condition persisted for an extended period but it resolved completely by 15 months of age. In all but one of the subjects the condition was transient and resolved over time. We could not reveal any previous publication on this topic. Discussion This noteworthy complication of circumcision raises debate whether it was previously existent, though unreported or a novel phenomenon. We postulate that contributing factors leading to tissue injury may possibly be injured tissue exposure to irritating substances, vascular compromise, the technique chosen to control bleeding or an idiosyncratic response to tissue trauma. More attention to the occurrence of this phenomenon is compulsory to collect more data and learn of its incidence and eventual impact. Conclusions Obliteration of the corona, constitutes an unreported, rare albeit significant complication following circumcision. We recommend refraining from potentially inciting factors leading to this undesirable condition. More extensive experience with this disorder may enable us to employ preventive measures to eliminate it or at least provide reassurance wherever possible. Download : Download high-res image (195KB) Download : Download full-size image

Background In Israel, there is a shortage of family medicine (FM) specialists that is occasioned by a shortage of students pursuing a FM career. Methods A questionnaire, based on methods adapted from marketing research, was used to provide insight into the medical specialty selection process. It was distributed to 6th-year medical students from two Israeli medical schools. Results A response rate of 66% resulted in collecting 218 completed questionnaires. Nineteen of the students reported that they were interested in FM, 68% of them were women. When compared to students not interested in FM, the selection criteria of students interested in FM reflected greater interest in a bedside specialty which provides direct long-term patient care. These latter students were also more interested in a controllable lifestyle that allowed time to be with family and children and working outside the hospital especially during the daytime. These selection criteria aligned with their perceptions of FM, which they perceived as providing them with a controllable lifestyle, allowing them to work limited hours with time for family and having a reasonable income to lifestyle ratio. The students not interested in FM, agreed with those interested in FM, that the specialty affords a controllable lifestyle and the ability to work limited hours Yet, students not interested in FM more often perceived FM as being a boring specialty and less often perceived it as providing a reasonable income to lifestyle ratio. Additionally, students not interested in FM rated the selection criteria, academic opportunities and a prestigious specialty, more highly than did students interested in FM. However, they perceived FM as neither being prestigious nor as affording academic opportunities Conclusion This study enriches our understanding of the younger generation's attitudes towards FM and thus provides administrators, department chairs and residency program directors with objective information regarding selection criteria and the students’ perceptions of FM. We identified the disconnect between the selection criteria profiles and the perceptions of FM of students not inclined to pursue a residency in FM. This allowed for recommendations on how to possibly make FM more attractive to some of these students.

Lateral thoracic or abdominal cutaneous nerve entrapment syndrome (C.N.E.S.) refers to the pain originating from thoracic or abdominal wall. It is a common ailment which is often misdiagnosed as arising from a source inside the abdominal cavity mistakenly leading to inappropriate diagnostic investigations, unsatisfactory treatment, and considerable costs. The thoracoabdominal nerves terminate as the cutaneous nerves at a point from which accessory branches are given off in the rectus channel ending in the skin. Peripheral nerve entrapment occurs at anatomic sites where the nerve changes direction to enter a fibrous or osseofibrous tunnel because mechanically induced irritation is most likely to occur at these locations. Controlled investigations demonstrate that satisfactory alleviation is to be gained by immediate intervention by the most widely adopted technique of a fanning infiltration of the region of maximal point of tenderness with anesthetic and anti-inflammatory agents. Unfortunately, we observe that clinicians inexperienced performing this procedure are deterred from this technique owing to fears of inaccurate medication deposition or penetrating the abdominal cavity and perforating viscera. In this paper we describe a method to provide a safe and accurately targeted injection precisely at the necessary location without risking iatrogenic harm. This is easily achieved by raising a mound of the superficial soft tissue at the point of maximal tenderness and inserting the needle oriented Method Article Naimer; BJMMR, 7(8): 672-677, 2015; Article no.BJMMR.2015.375 673 parallel to the surface of the anterior body surface. Adoption of this method provides a simple, safe and effective solution for C.N.E.S. and will allow recruiting more physicians to join the circle of those actively treating this condition.

Maternal cardiac arrest during gestation constitutes a devastating event. Training and anticipant preparedness for prompt action in such cases may save the lives of both the woman and her fetus.To address a previous Jewish guideline that a woman in advanced pregnancy should not undergo any medical procedure to save the fetus until her condition is stabilized.Current evidence on perimortal cesarean section shows that immediate section during resuscitation provides restoration of the integrity of the mother's vascular compartment and increases her probability of survival. We analyzed Jewish scriptures from the Talmud and verdicts of the oral law and revealed that the Jewish ethical approach toward late gestational resuscitation was discouraged since it may jeopardize the mother.We discuss the pertinent Jewish principles and their application in light of emerging scientific literature on this topic. An example case that led to an early perimortem cesarean delivery and brought about a gratifying, albeit only partially satisfying outcome, is presented, albeit with only a partially satisfying outcome. The arguments that were raised are relevant to such cases and suggest that previous judgments should be reconsidered.The Jewish perspective can guide medical personnel to modify and adapt the concrete rules to diverse clinical scenarios in light of current medical knowledge. With scientific data showing that both mother and fetus can prosper from immediate surgical extrication of the baby during resuscitation of the advanced pregnant woman, these morals should dictate training and practice in urgent perimortal cesarean sections whenever feasible.

Historically speaking, in many societies a select few carried the burden of preserving and transferring knowledge. While modern society has broadened the scope of education, this is not enough in the medical sciences. We must ensure that all those who pursue a career in medicine become life-long learners who will grow and contribute well beyond their years in medical school. In considering how to attain this goal, we were intrigued by the similarities between generations-old wisdom of teaching and learning methods in Jewish culture and modern educational principles. Both aim to nurture a culture of learners. Our objective was to parallel the methodologies, pedagogic directives, and demands made of students in the Jewish tradition, to the principles used in medical education today. We surveyed the traditional Jewish culture of teaching and learning. We compared it to modern medical teaching methods and looked to see what lessons might be gleaned. In the traditional Jewish community, life is focused on education, and producing "learners" is the ideal. This culture of learning was developed over the generations and many educational methods are similar to modern ones. Some of the pedagogic principles developed successfully in Jewish society should be considered for adaptation in medical education. Further comparative research could help to expand the ways in which we teach medicine.

Background Despite the broad differential diagnosis in any patient referring with symptoms involving the chest or abdomen, a small number of conditions overshadow the rest by their probability. Chest and abdominal wall pain continues to constitute a common and expensive overlooked source of pain of unknown cause. In particular, cutaneous nerve entrapment syndrome is commonly encountered but not easily diagnosed unless its specific symptoms are sought and the precise physical examination undertaken. Case Report A primigravida woman with unbearable abdominal pain was referred repeatedly seeking a solution for her suffering. Numerous laboratory and imaging studies were employed in order to elucidate the cause of her condition. After numerous visits and unnecessary delay, the diagnosis was finally made by a physician fully versed in the field of torso wall pain. The focused physical examination disclosed abdominal cutaneous nerve entrapment syndrome as the diagnosis, and anesthetic infiltration led to immediate alleviation of her pain. Why Should an Emergency Physician Be Aware of This? Cutaneous nerve entrapment is a common cause of abdominal pain that is reached on the basis of thorough history and physical examination alone. Knowledge dissemination of the various torso wall syndromes is imperative for prompt delivery of suitable care. All emergency physicians should be fully aware of this entity because the diagnosis is based solely on physical examination, and immediate relief can be provided in the framework of the first visit. Wider recognition of this syndrome will promise that such mishaps are not repeated in the future.

Objective. In pediatric primary care, an adjunct for ophthalmology diagnosis and monitoring of treatment could be of great advantage. The portable polarized dermatoscope can readily fit the purpose as an alternative to the classic slit lamp device. Methods. We describe and demonstrate our clinical experience using the dermatoscope for diverse ocular conditions. Main message. Beyond its effective primary role as an examination tool for detecting dermatopathology, the dermatoscope proves its worth in a variety of separate ophthalmologic clinical states where intricate details need recognition. From corneal or subtarsal foreign body identification, to tear gutter assessment, this instrument can facilitate our work whenever magnification and illumination is beneficial. Conclusion. The technique described raises the option of using a substitute for usually lacking, cumbersome equipment for many therapeutic situations, rural clinics and home visits, easily available for the busy pediatrician, demanding little training, and at a reasonable cost.

The large selection of techniques and modalities for field treatment of the bleeding wound may appear as a potpourri of arbitrarily introduced devices. Nevertheless, if we analyze the various offered solutions systematically in an orderly approach, they can be differentiated into set categories. It is necessary to recognize the pros and cons of each available product in order to decide when and where each is the most applicable for any given clinical scenario. Identification, development and evaluation of new products and technologies capable of stopping life threatening hemorrhage are still ongoing. Despite paucity of research on this topic recently more and more information has accumulated to assist in supporting those techniques of superior efficacy. The objective of this review is to guide the reader through the diverse products according to mechanism of action and expose the important literature relevant to this topic. Justification is found for use of each of the categories: tourniquets, hemostatic agents and compression dressings however close scrutiny is needed to select the most appropriate choice in each group. Hopefully, continuing appraisal of these devices together with the growing experience of trauma teams and combat medics can assist to establish the superior products in each class for the benefit of all casualties and trauma victims.

Background Limited fluoroscopy cryo-ablation using a 3D electro-anatomical system (3DS) has been used for AVNRT in children. We aimed to facilitate a fluoroscopy limited approach of RF ablation of AVNRT in children. Methods A retrospective study was performed of procedure parameters in children undergoing RF ablation of AVNRT in 75 consecutive children (June 2011 to November 2013 — Group A) using standard fluoroscopy techniques compared to those of 64 consecutive children (December 2013 to May 2015 — Group B), using a fluoroscopy limited approach with 3DS. Results The acute success rate was 98.7% (74/75) and 98.4% (63/64) for groups A and B, respectively. The recurrence rate was 2.7% (2/74) and 0% (0/63) with a mean follow-up period of 45.5±12.1 and 14.3±6.1months for group A and group B, respectively. The mean procedure and fluoroscopy times were significantly lower for group B compared to group A (119±37 (43–203) and 0.83±1.04 (0.05–3.83) minutes versus 146±53 (72–250) and 16.1±8.9 (4.39–55) minutes, p p Conclusions A fluoroscopy limited approach for RF ablation of AVNRT in children using a 3DS is easily acquired and adapted, and significantly reduces the fluoroscopy and procedure time with excellent efficacy, safety and low recurrence rate. Condensed ABSTRACT This study confirmed that a 3D mapping system (3DS) to guide ablations of AVNRT in children reduces radiation exposure. Combined, limited fluoroscopy and 3DS in a methodology that resembles the familiar conventional fluoroscopy approach for RF ablation of AVNRT in children is proposed. Combined limited fluoroscopy and RF-energy in children with AVNRT are associated with a shorter procedure time, minimal fluoroscopy time, a high success rate and a low recurrence rate.

Microcomedonal lesions can be aesthetically and psychologically displeasing. The burden of comedones increases when considering their frequency and demand for time-consuming attention. The objective of the current study was to describe a novel technique to facilitate open microcomedone extraction. The instrumentation used includes smartphone photography with dermatoscopy. The dermatoscope is an effective tool for diagnosing a broad range of dermatologic conditions. The polarized dermatoscope can facilitate execution of cutaneous procedures whenever magnification and optimal illumination are necessary. Its connection to a smartphone with a unique adapter enabled single-handed examination of microcomedones. Under magnification with this unit, the involved lesions are photographed to clearly demonstrate the condition and achieve informed consent. The complete procedure can be recorded on video for documentation. In this case, four separate lesions of the left auricle of a young man were treated using direct pressure extraction. The procedure undertaken was rapid, convenient, and completed without any adverse sequelae. This procedure is recommended for similar cases using the dermatoscope, which does not require additional specific training and is readily available at no extra cost. This technique could be used in various dermatologic conditions.

It is well recognized that breastmilk provides optimal nutrition and immunological protection for infants. Many women, however, experience nipple pain while breastfeeding, leading to premature cessation of nursing. To overcome these difficulties, timely diagnosis is crucial to effectively treat the underlying pathology and permit resumption of breastfeeding. Examination of the superficial breast plays a key role in accurate diagnosis. Traditional direct inspection is clearly inadequate for this task.The dermatoscope is a useful tool, enlarging and illuminating an area of epidermis to obtain an optimal image. Improvements in dermoscopy involving polarization obviate the need for full contact with the examined surface, thereby providing anatomical detail in three dimensions.A novel practice presented in this article features clinical cases introducing this technique as it is applied to the lactating breast, conclusively distinguishing normal from abnormal and illustrating the efficacy and added diagnostic value of this approach. The dermoscope is shown to facilitate identification of the causes of nipple pain ranging from asymptomatic candidal infection to exquisitely painful, minute traumatic erosions, aiding, thereby, in diagnosis of the underlying causes of nursing difficulties. Improved wound surveillance and standardization for purposes of research documentation are additional benefits anticipated with the use of breast dermoscopy.We conclude that real-time, high-quality, magnified imaging of the lactating breast represents a recognizable advance in pursuit of a rapid and accurate technique that aids in the identification of the factors responsible for lesions affecting nursing women. Moreover, it features an already existing technology requiring little training at a reasonable cost.

A new attitude recently raised in the literature emphasizing the role of the family in the care of the patient introduces a novel paradigm of family presence during resuscitation, which continues to be a debatable issue without widespread implementation. Can the same recommendations rooted at medical centers be extrapolated to the traumatic scene where a physician is called to treat his own community members? In this paper the scenario presented depicts a family physician called to treat terrorist victims of his own community overwhelmed by dilemmas including ethical considerations. He is subjected to stress and strain that seem beyond his capacity. The physician in rural settings may be placed in situations that confront challenges demanding metamorphosis in order to answer unexpected needs towards which he has not been fully trained. Despite the hardships involved, withstanding such situations can lead to profound satisfaction.

Foreign bodies are occasionally seen by family physicians. Plantar foreign bodies in particular pose a special challenge because they involve weight-bearing regions that are difficult to access. If left undetected long enough, these may lead to hospitalization, surgery, or even longstanding complications such as tumors, contractures, infections, and chronic ulcers. Dermoscopy of the cutaneous surface allows early detection of indwelling foreign bodies with a far greater degree of accuracy than with the naked eye. Furthermore, use of a polarized dermatoscope provides ideal illumination and 3-dimensional visualization of the involved site, and facilitates extraction of the penetrating object. This technique could be used for similar injuries involving other body surfaces.

Ophthalmomyiasis in humans caused by the larvae of the sheep nasal botfly (Oestrus ovis) and is a rare phenomenon in Israel. We describe the utilization of the dermatoscope as a diagnostic tool for the facilitation of early diagnosis of conjunctivitis due to the infestation of the eyes by the sheep nasal botfly in two patients. After the physical removal of the larvae with the help of a cotton swab applicator under a slit lamp examination and the topical use of antibiotics, the clinical symptoms improved within 1-2 days. Undoubtedly the dermatoscope played a crucial role leading to the definitive diagnosis and immediate therapeutic intervention.

While many issues regarding emergency care of polytrauma are still under debate, it is agreed that immediate control of acute external traumatic hemorrhage is the most critical instance where intervention by the rescue team plays a decisive role in determining the fate of the wounded. The aim of this report is to describe the evolution of a novel procedure for treating the bleeding wound that offers clear and obvious advantages. The method uses an elastic, adhesive dressing (ELAD) that eventually resulted in a single unit, utilizing a transparent material. This product is also termed Rapid Wrap™ (currently developed by Rapid Healing Technologies). The elastic adhesive dressing application is performed by placing the contact pad over the area of injured tissue and rapidly wrapping the roll component over the wound with growing tension. This paper follows the development of a new life saving device and demonstrates rewarding research for the treatment of profusely bleeding injuries.

The frequency of recurrent aphthous stomatitis (RAS), the most common oral mucosa lesions seen in primary care, is up to 25% in the general population. However, there has been no optimal therapeutic approach. Our objective was to confirm our previous clinical observation of the beneficial treatment of RAS with vitamin B(12).A randomized, double-blind, placebo-controlled trial was done using primary care patients. A sublingual a dose of 1000 mcg of vitamin B(12) was used in patients in the intervention group for 6 months.In total, 58 patients suffering from RAS participated in the study: 31 were included in the intervention group and 27 were included in control group. All parameters of RAS among patients in the intervention group were recorded and compared with the control group. The duration of outbreaks, the number of ulcers, and the level of pain were reduced significantly (P.05) at 5 and 6 months of treatment with vitamin B(12), regardless of initial vitamin B(12) levels in the blood. During the last month of treatment a significant number of participants in the intervention group reached "no aphthous ulcers status" (74.1% vs 32.0%; P.01).Vitamin B(12) treatment, which is simple, inexpensive, and low-risk, seems to be effective for patients suffering from RAS, regardless of the serum vitamin B(12) level.

Background Anogenital pruritus is defined as an itch localized to the anus, perianal, and genital skin. Anogenital pruritus is usually a symptom of an underlying disorder of the skin or mucosa or a consequence of anorectal pathology. When no demonstrable cause is found, anogenital pruritus is often described as "idiopathic". Objective To investigate the role of lumbosacral radiculopathy in the pathogenesis of anogenital pruritus. Methods Included in the study were consecutive patients with anogenital pruritus. Radiographs and nerved conduction studies were performed in all patients. Needle electromyography studies and computerized tomography were performed when necessary. Nerve conduction studies included measurement of distal sensory and motor latency, conduction velocity, and F-responses of the peroneal and tibial nerves. Patients with confirmed radiculopathy were treated with paravertebral injection of a mixture of triamcinolne acetonide and lidocaine. Response to the injections was assessed using visual analogue scales by the patients. Mean scores before and after treatment were compared using paired t tests. Results Included in the study were 20 patients with anogenital pruritus. There were 18 men (90%) and 2 (10%) women. The mean age was 52.7 years (standard deviation [SD] 11.7 years). In 16 patients (80%), radiographs demonstrated degenerative changes of the lower spine. In 16 patients (80%) the presence of lumbosacral radiculopathy was confirmed by nerve conduction studies. Fifteen patients (75%) were treated with paravertebral injections, with significant decrease in mean pruritus score as assessed by the patients (6.3 [±2.8]; 4.5 [±2.7], before and after treatment, respectively, P =.033). Conclusion "Idiopathic" anogenital pruritus may be attributable to lumbosacral radiculopathy. Paravertebral blockade may be used for alleviation of symptoms in patients with anogenital pruritus.

Summary Introduction Descriptions of the penile prepuce in anatomical and clinical texts either omit details or contain a small, yet potentially serious, error with regard to the manner of its attachment to the penis. Objective This study sought to cast light on a ubiquitous but poorly understood and under-appreciated structure, while correcting a long-standing mistake in the medical literature. Study design The foreskins of five male stillborn babies were dissected and carefully examined. Tissue from the apposing surfaces of the various regions of the inner and outer prepuce surfaces and the transition zone itself were collected, embedded in paraffin, sectioned, stained, examined and photographed under microscopy. Results Contradicting the prevailing descriptions in the literature that the inner prepuce is a single, uniform sheath, this study's observations and histological findings demonstrated that it actually splits into separate laminae that connect distally to the shaft at the base of the corona and proximally with the shaft fascia, respectively ( Figure ). Discussion The penile prepuce is a discrete and deceptively complex part of the male anatomy, yet key details of its interposing surfaces are inaccurately described or entirely omitted in the literature. Understanding the normal anatomy of the prepuce is critically relevant, particularly for urologists and others involved in the performance of circumcision. For example, avoiding potentially catastrophic avulsion of the inner preputial remnant beyond the coronal sulcus during circumcision and accurate assessment of tissue positioning prior to penile reconstruction in cases of hypospadias. Conclusion The findings of this study correct a misunderstanding in the anatomy of the prepuce.

Religiosity is inherent in human cultures. Being different in many aspects, all have rules regarding appropriate behavior and rituals. Celebrations of social events and of holidays prevail in all major religions. These include code of dress, prayers, special food and activities which may have negative health implications. The Jewish religion is 'blessed' with an abundance of holidays each with its unique health implications. In this paper we provide an outline of the character of these festivals and possible medical repercussions on those celebrating them. Observant members of the Jewish religion and teams treating this population should be knowledgeable of potentially associated risks. Pre-holiday periods should be specifically targeted for educational and preventive activity in order diminish injury or morbidity.

Despite a preoccupation in the medical literature with developing an effective approach for breaking bad news, the sources are based on personal opinion alone and only in some instances on qualitative research. Recognizing the gravity of this topic coupled with respect for the wisdom of the written and oral Jewish scriptures, this work is an attempt to delve into the diverse ancient writings to draw conclusions regarding a recommended methodology to guide and inform this task. It is interesting to learn that most elements related to this topic have previously been raised in various forms in the scriptures. The issues range from where, when, and how the bearer of bad news should undertake this duty, to details such as the environment, the format, the speed, and depth of the details to be disclosed. The essence of this paper is to enrich the reader using both positive and negative examples found in the Jewish heritage. Adopting these principles will hopefully provide an effective method for performing this unpleasant obligation, with the goal of limiting harmful consequences as much as possible.

Background: Over a period of three decades, medical personnel working in our emergency room observed that fewer severe cases presented to the emergency department. The objective of this study is to assess whether a genuine change in the presentation rates of clinically unstable non-trauma patients to the emergency room indeed exists. Methods: We conducted a retrospective review of patients treated in the shock room. Patients’ demographic data, diagnoses and outcomes were accessed. Populations of patients presenting to the shock room over a span of four seasons, in two separate periods eight years apart were compared. This rate was compared with the complementary bulk rate of patients presenting to the emergency room at the center. Results: While absolute rates of emergency room utilization rose, the rate of unstable patients demanding urgent intensive care showed a clear decline. An absolute reduction of close to 50% across the different seasons of the examined years was found. Per patient, the proportion of those requiring artificial respiration and urgent hemodialysis remained uniform in both periods. All parameters of patient outcomes were similar in both periods of the study. Conclusion: This unexplored aspect of emergency care demonstrates a dramatic decline in the incidence of unstable patients. While we should continue to reinforce delivery of superior care, our medical educational system should adapt itself to compensate for the diminished exposure of our trainees to emergencies. Further research in this field should explore whether the trend we observed exists in other geographical locations and whether this parameter can be utilized as a quality measure of medical systems.

We would Like to present a rare case of multiple gestation following a severe event of spinal cord morbidity during a previous singleton gestation. The medical literature carries a paucity of evidence regarding the future fate of pregnancies following gestational induced intervertebral disc prolapse.A 21 year old mother delivered a healthy boy after unbearable back pain. She subsequently developed urinary retention with laxity of the anal sphincter and underwent urgent L5-S1 discectomy. Following in vitro fertilization for infertility she conceived and was warned of the dangers of a gestation with quadruplets. The parents decided to continue the gestation regularly without intervention despite possible complications. At 31 weeks of gestation the mother delivered four normal male babies, each weighing over 1200 grams after a normal (supervised) pregnancy devoid of any back symptoms. This case demonstrates a novel clinical scenario of hitherto unreported major challenges to an established vulnerable vertebral column.To the best of our knowledge this is the first report of a multiple gestation following severe spinal column pathology demanding surgical intervention in order to prevent long term handicap. We could not even locate a series of singleton gestations following such a clinical scenario. The favorable outcome observed in this case is very encouraging and can serve to reassure potential mothers who have experienced a similar previous episode as demonstrated here.Special caution must be taken when consulting pregnant patients. From this case history we may learn that precautions such as indefinite contraception after a previous incident of massive disc prolapse may be widely unnecessary.

Conventional methods for hemorrhage control in the trauma patient fall short of providing a full solution for the life-threatening bleeding injury. The tourniquet is limited specifically to injuries of the distal limbs. Local pressure or tight bandaging with military bandages is cumbersome and often insufficient. Therefore, we sought a superior method to stop bleeding in emergency situations. Our objective is report and description of our experience with this method. Since 1992 our trauma team repeatedly encountered multiple trauma victims presenting with bleeding wounds. We achieved hemorrhage control by means of an adhesive elastic bandage applied directly over a collection of 4 x 4 gauze pads placed on the wound surface. The roll is then wrapped around the body surface, over the bleeding site, until sufficient pressure is reached to terminate ongoing hemorrhage. Three typical cases are described in detail. Adhesive elastic dressing compression was successful in fully controlling bleeding without compromise of distal blood flow. Our method corresponded to the demand for an immediate, effective and lasting form of hemorrhage control without complications. Furthermore, this technique proved successful even over body surfaces normally recognized as difficult to compress. We experienced equal favorable success while working during transit by either ambulance or helicopter transportation. We find our preliminary experience using elastic adhesive dressing for bleeding control encouraging and suggest that this may substitute existing practices as the selected treatment when indicated. This method is presently underrecognized for this purpose. Development of a single unit bandage may further enhance success in the future.

Periodic fever of childhood is a group of diseases that cause repeated febrile illnesses with various associated symptoms. In our article, we present the case of a 6-year-old girl with unusual appearance of periodic fever syndrome. Our patient suffered from repeated episodes of high fever from the age of 2 years old. Each episode usually lasted 24–48 h, the interval between events was 1–3 weeks long. During high fever episodes the child usually felt well, without associated accompanying complaints. As a rule, the physical examination did not reveal any pathologic finding explaining the fever. During the 4 years of follow-up the patient sustained treatment attempts with prednisone for a number of months and half a year with colchicine without any response. We considered treatment with sublingual tablets of vitamin B12 (VIT B12). Beyond all expectation, we witnessed complete resolution of attacks during the first 2 months following treatment. After a long episode-free period, the parents withheld the treatment on their own accord, and in a short time the disease recurred. We advised to renew the treatment with VIT B12, and during approximately half year of follow-up there were no recurrences of periodic fever. Conclusion: we believe that our observation raises interest in systematic evaluation of the therapeutic role of VIT B12 as a treatment option for disorders of the periodic fever spectrum.

The therapeutic experience of both patient and dedicated clinician striving to deliver optimal care is shaped by the assumed mutual interest and benefit to both parties. The caregiver can shape the environment in order to create an experience more rewarding than a mere encounter. Technical aspects such as time allocation, amicable staff, ample equipment supply, and teamwork contribute to a productive working environment. However, the major component affecting the atmosphere of and satisfaction with therapeutic activity is the state of mind of the dominant figure-the surgeon. Can we do more to enhance the experience and relive the original thrill we had when we began training as novices delivering patient care? Do we have the capacity to sustain the excitement of the practice of medicine? This essay is an attempt to invite others to join an adventure of virtual imagery. This proposal is achieved through mental exercise, combining various sides of the physician work and play, in a manner that can boost our spirits and turn an ordinary routine encounter into a fascinating challenge.

The issue of immediate control of acute external traumatic hemorrhage is poorly dealt with in the medical literature. A compact unit incorporating the desired components capable of applying significant compression over diverse body areas has been suggested in the past but not formally demonstrated effective in practice. In this report we describe the treatment of a young man presenting with a very large, complex, profusely bleeding facial gunshot wound. The calvarium remained intact. The upper airway was diverted and secured by performing a cricothyroidotomy. A transparent elastic adhesive dressing was then applied by covering the anterior aspect of the face by a contact pad followed by sequential wrapping of the roll covering all structures between the forehead and the neck. This procedure successfully controlled the hemorrhage and maintained the victim's condition hemodynamically stable until definitive surgical intervention at the level 1 medical center. We attribute the survival of this victim to the innovative dressing technique and excellent cooperation between the trauma team and hospital staff. This case demonstrates the contribution of elastic adhesive compression dressing towards saving the lives of those inflicted by severely challenging bleeding wounds. We suggest this technique be considered by Emergency personnel working in the prehospital arena in selected cases.

We describe a rare case of ischemic fasciitis of the abdominal wall in a child with scoliosis. The fasciitis was apparently caused by the constant pressure exerted by her torso brace. Clinicians should be alert to the possibility of mechanical factors in the etiology of ischemic fasciitis.

Pyogenic granuloma is a benign vascular, inflammatory proliferation that appears following minor trauma in children. The exact pathogenesis of pyogenic granuloma is unknown, but its formation is closely related to minor trauma, chronic irritation, and hormonal influences. We present a unique case of a pyogenic granuloma that appeared in an infant following circumcision.

Compression dressing has been assumed effective, but never formally examined in the field.A prospective interventional trial examined efficacy and feasibility of an elastic adhesive dressing compression device in the arena of the traumatic incident. The primary variable examined was the bleeding rate from wounds compared before and after dressing.Sixty-two consecutive bleeding wounds resulting from penetrating trauma were treated. Bleeding intensity was profuse in 58%, moderate 23%, and mild in 19%. Full control of bleeding was achieved in 87%, a significantly diminished rate in 11%, and, in 1 case, the technique had no influence on the bleeding rate. The Wilcoxon test for variables comparing bleeding rates before and after the procedure obtained significant difference (Z = -6.9, p0.01). No significant complications were observed. Caregivers were highly satisfied in 90% of cases.Elastic adhesive dressing was observed as an effective and reliable technique, demonstrating a high rate of success without complications.

The aim of this study was to examine two techniques intended to prevent accidental displacement of intravenous catheters after proper establishment of infusion line access.After catheter insertion and taping in position, fixation with gauze roll sequentially wrapped around the limb across which the tubing has been extended was compared with the use of a polyethylene roll manipulated by an attached "handle." The experimentation was performed on medical personnel serving as live models.Thirty-eight trials were conducted with 19 of each fixation technique. The variables measured were: time consumption, convenience, general satisfaction, and success score of the fixation. All of the measurements showed that the polyethylene roll was significantly the superior of the two methods. Despite forceful tugging of the tubing, polyethylene fixation virtually prevented any displacement whatsoever and was more than twice as rapid.We demonstrate a novel device allowing faster and more efficacious fixation of the infusion drip tubing and catheter suggested as the technique of choice in emergency medical field care.

Previously, sponsored publications have shown that either terbinafine or itraconazole (pulse regimen) are effective for patients with toenail onychomycosis. However, independent comparative studies are lacking.To objectively compare treatment with terbinafine and itraconazole in patients with toenail onychomycosis.The effectiveness of terbinafine (250 mg/day 3 months) versus itraconazole pulse regimen (400 mg/day for the first week of each month, for three cycles) was retrospectively evaluated in patients with toenail onychomycosis using mycological tests and subjective outcome measures. Statistical analyses were performed using one-way analyses of variance (ANOVA) for continuous variables and Fisher exact tests for categorical variables.Included in the study were 117 patients (74 patients treated by terbinafine and 43 patients treated with itraconazole). Patients were examined at an average period of 20 months after the end of therapy. Mycological cure was observed in 70.6% and 62.8% of the patients who were treated by terbinafine or itraconazole, respectively (not statistically significant). Mean visual analogue scale assessment of treatment outcome was 79.9 mm (SD 24.7 mm) and 65.2 mm (SD 34.6 mm) for patients treated by terbinafine or itraconazole, respectively (p=0.008). When the results were stratified according to age and gender, it was observed that the advantage of terbinafine versus itraconazole retained statistical significance only for patients who were 55 years old and above, or females.Mycological cure proportions were not statistically significant between patients treated by terbinafine or itraconazole for toenail onychomycosis. However, better subjective outcome measures indicated an advantage for terbinafine over itraconazole, noticeable in females and patients 55 years old and above.

Congenital oral adhesions may pose both aesthetic and functional disturbing ailments to wary parents. Most of these as we have experienced, are benign, easily cured and may be treated as soon as possible in the office. A local survey elucidated that these youngsters are usually advised to wait until one year of age and then taken into the operating room and incision of the adhesion is performed under general anesthesia. We assessed the benign nature of this ailment and relative avascularity of the tissue involved and concluded that with minimal risk an office procedure under local anesthesia can replace current practice. We also found that most referrals with this condition present with the lowest grade of severity of ankyloglossia, amenable to a very brief intervention.During the period 1998-2002 we diagnosed nineteen congenital lesions in thirteen patients. All children were treated in a community clinic setting using electrocautery under local anesthesia. Surgical success was defined as significant improvement in the ability to protrude the tongue outwards beyond the gums and teeth. Gingival adhesions were judged by release of soft tissue adhesions.Tongue Surgical success was accomplished in all cases with minimal discomfort and without complications. In one single case the previous functional limitation was not relieved.Our experience indicates that office-based electrocautery dissection is an efficacious economical and safe treatment of mild congenital oral adhesions. We recommend this method as therapy of choice for such lesions.

Background: Despite the fact that the urgent control of active bleeding from external body surfaces demands a basic procedure, it is puzzling that this topic has received little if any attention in modern medical research. Elastic adhesive dressing (ELAD) has been proposed for dressing the bleeding wound. Methods and materials: Three techniques were compared over a simulated wound in a human model. Pressures generated between the chosen dressing surface and the underlying mock wound’s cutaneous surface, time consumption, convenience, satisfaction and pain were tested for each technique. Results: Sixty-eight experiments were performed over nine separate anatomical sites. Average pressures for field dressing, ELAD and manual compression were 33, 88 and 180 mmHg, respectively; these differences in pressure were statistically significant. Manual pressure was equally inconvenient for both patient and caregiver. The more proximal and wider anatomical regions were more difficult and time consuming to compress. The caregivers graded ELAD the highest level of convenience and general satisfaction. Conclusions: Field bandage testing reflected its inadequacy in controlling bleeding from most body regions. The results suggest that ELAD may be the hands-free technique of choice. We hope that this article will stimulate further research and elicit evidence on precisely which technique is most suitable for various anatomical location.

Penile skin bridges are an uncommon complication of circumcision that are often found in general practice. This condition can be treated successfully in the office, avoiding referral for a surgical procedure.Four case reports of the technique of treating penile skin bridges are described, and the literature on the cause and treatment of skin bridges is reviewed.Using local anesthesia and bipolar diathermy, penile skin bridges were successfully treated in the office on 4 patients of different ages. There was no bleeding and the wounds healed without complication. This brief and simple technique, described in detail, is appropriate for an office procedure in family practice.

Papular urticaria often occurs after bites of insects such as mosquitoes, sandflies, bed bugs and fleas. Multiple bites and local pruritus are characteristic symptoms. Treatment is usually symptomatic and includes antihistamines and corticosteroids. The reappearance of the symptoms can be prevented by successful control of the parasite.To find the causative agent of papular urticaria in afflicted households with involvement of numerous family members, all in a narrow geographic area.We describe the cases of 20 patients belonging to seven families, who presented to the local primary clinic, suffering from papular urticaria.The cat flea, Ctenocephalides felis, was the hematophagous insect responsible for all infestations. The pruritus and the papular urticaria were treated symptomatically with calamine lotion, topical corticosteroids or oral antihistamines. All clinical symptoms disappeared within a few weeks after effective control of the parasites by spraying and fumigating the infested locations.Thorough investigation--including, at times, environmental inspection--is necessary to reach the rewarding discovery of the etiology of household papular urticaria. This condition may arise in other environments of similar character.

BACKGROUND: Multiple miliary osteoma cutis of the face represents primary extra-skeletal bone formation that arises within the skin of the face. METHODS: A 60-year-old woman with multiple miliary osteoma cutis of the face was treated by application of 0.05% tretinoin (all- trans -retinoic acid) cream nightly. RESULTS: After 3 months of therapy there were fewer papules and a decrease in size of remaining lesions. In a literature search, it was found that local application of tretinoin was successful and achieved a decrease in the number of papules over the face in all patients with multiple miliary osteoma cutis of the face; however, the length of time to achieve response varied from a few weeks to 6 months. CONCLUSION: It is suggested that local application of tretinoin cream should be considered in the therapy of multiple miliary osteoma cutis of the face, particularly when the lesions are small and superficial.

Background: As part of our clinical experience we encountered a group of patients from a specific population with a similar peculiar pigmentation over the lower dorsal spine. Objective: We investigated these patients to see whether we could determine a common origin. Methods: Patients meeting the inclusion criteria underwent detailed history and complete physical examination; biopsy specimens from 3 patients were studied. Results: All 13 patients were full-time male students at Orthodox Jewish Talmudic seminaries (Yeshivas). The lesion consisted of an elongated, vertical, midline, hyperpigmented patch with indistinct borders, which was distributed along the skin overlying the bony protuberances of the inferior thoracic and lumbar vertebrae. It was often unrecognized by the patients. Mean body mass index was lower than that for the general population. Histologic study showed a marked diffuse hyperkeratosis and hyperplastic epidermis with diffuse hyperpigmentation. We attributed the phenomenon to friction from the rigid backrests against the cutaneous surface of the lower back generated by the characteristic swaying activity that traditionally accompanies Torah study or "davening" (praying) and termed it Davener's dermatosis. Conclusion: We believe this phenomenon represents a new form of benign friction hypermelanosis. This report highlights the importance of a thorough history in patients presenting with pigmented lesions. (J Am Acad Dermatol 2000;42:442-5.)

Background:Many aspects of cutaneous surgical interventions have been perfected, employed, and then scientifically examined. Conversely, ubiquitous, indiscriminate demand for sterile conditions while performing an invasive procedure remains a field devoid of satisfactory critical appraisal.Objective:Ritual neonatal circumcision served as a prototype to assess scientifically the safety of performing a dermatologic intervention under clean, uncontaminated, but nonsterile conditions.Methods:Two hundred subjects, mostly neonates, who were unselectively referred for ritual circumcision, served as the study group. The guillotine excisional technique was employed in the community setting under clean, uncontaminated, nonsterile conditions, in line with traditional practice. Follow-up was continued until full recovery.Results:No wound infections or septic complications were observed in any of the babies at either early (24–36 hours after the procedure) or late follow-up. Many subjects had an exudative discharge at the healing site several days after the procedure. This is a common finding associated with circumcision and was found to be nonindicative of infection.Conclusions:This preliminary study suggests that strict sterile conditions are superfluous for ritual neonatal circumcision, and the effort and expense invested in maintaining an aseptic environment for this sort of intervention may not be justified. Further large-scale investigations are warranted to validate these findings and to determine if they can be extrapolated to other patient populations and other types of cutaneous surgery.