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עמוד בית Thu, 19.09.19

Mars 2014


Focus
Firas Abu Akar, Revital Arbel, Zvi Benninga, Mushira Aboo Dia and Bettina Steiner-Birmanns
All victims of violence encountered in our emergency rooms and clinics need to be recognized and documented as such. Although there has been progress in the implementation of rules concerning (domestic) violence against women, children and the elderly, the management of cases where patients have been subjected to violence while under the custody of legal enforcement agencies, or patients who have been victims of torture, is still not sufficiently standardized. We describe the Istanbul Protocol of the United Nations, an excellent tool that can help physicians and health professionals recognize and treat cases of torture or institutional violence.

Perspective
Tal Bergman-Levy, Jeremia Heinik and Yuval Melamed
Testamentary capacity refers to an individual's capability to write his or her own will. Psychiatrists are required occasionally to give expert opinions regarding the testamentary capacity of individuals with a medical history or suspected diagnosis of a mental illness. This may stem from the patient/lawyer/family initiative to explore the current capacity to testate in anticipation of a possible challenge, or may be sought when testamentary capacity of a deceased has been challenged. In this article we examine the medico-legal construct of testamentary capacity of the schizophrenic patient, and discuss the various clinical situations specific to schizophrenic patients, highlighting their impact on the medical opinion regarding testamentary capacity through examining the rulings of the Israeli Supreme Court in a specific case where the testamentary capacity of a mentally ill individual who was challenged postmortem, and provide a workable framework for the physician to evaluate the capacity of a schizophrenia patient to write a will.

Original Articles
Orly Goitein, Yishay Salem, Jeffrey Jacobson, David Goitein, David Mishali, Ashraf Hamdan, Rafael Kuperstein, Elio Di Segni and Eli Konen
 Background: Patients with complex congenital heart disease (CHD) have a high incidence of extracardiac vascular and non-vascular malformations. Those additional abnormalities may have an impact on the precise planning of surgical or non-surgical treatment.

Objectives: To assess the role of electrocardiography-gated CT-angiography (ECG-CTA) in the routine evaluation of CHD in neonates and infants particularly for the assessment of extracardiac findings.

Methods: The study cohort comprised 40 consecutive patients who underwent trans-thoracic echocardiography (TTE) and ECG-CTA. TTE and ECG-gated CTA findings regarding extracardiac vascular structures, coronary arteries and airways were compared with surgical or cardiac catheterization findings. Scans were evaluated for image quality using a subjective visual scale (from 1 to 4). Effective radiation dose was calculated for each scan.

Results: Median age was 28 ± 88 days and mean weight 3.7 ± 1.5 kg. Diagnostic quality was good or excellent (visual image score 3–4) in 39 of 40 scans (97.5%). ECG-CTA provided important additional information regarding extracardiac vascular structures and airway anatomy, complementing TTE in 75.6% of scans. Overall sensitivity of ECG-gated CTA for detecting extracardiac findings as compared with operative and cardiac catheterization findings was 97.6%. The calculated mean effective radiation dose was 1.4 ± 0.07 mSv (range 1.014–2.3 mSv).

Conclusions: ECG-CTA is an accurate modality for demonstrating extracardiac structures in complex CHD. It provides important complementary information to TTE regarding extracardiac vascular structures and coronary artery anatomy. This modality may obviate the need for invasive cardiac catheterization, thus exposing the patient to a much lower radiation dose. 

Sharon Orbach-Zinger, Alexander Ioscovich, Amir Aviram, Sergei Babytz, Shai Fein, Alon Reuveni and Leonid A. Eidelman
 Background: Postoperative pain is a common problem after cesarean deliveries.

Objectives: To characterize common obstetric anesthesia practices after cesarean deliveries in Israel in order to standardize postoperative pain relief protocols.

Methods: A questionnaire was completed during an interview with every obstetric anesthesia unit in all 25 delivery wards in Israel. Data were gathered on intraoperative anesthesia and analgesia protocols as well as postoperative pain relief protocols. A sub-analysis compared units whose director completed a formal obstetric anesthesia training program with those whose directors did not.

Results: Neuraxial morphine was used routinely in 12% of hospitals. No unit providing intrathecal morphine complied with American Society of Anesthesiologists guidelines for respiratory monitoring after use of neuraxial opioids. Additionally, non-steroidal anti-inflammatory drugs (NSAIDs) were used routinely in only half the wards, while patient-controlled analgesia was used infrequently. Postoperative verbal analog scores were not recorded routinely in 71% of units on postoperative day 1. The unit director's training significantly influenced the unit protocols.

Conclusions: Intrathecal morphine, the gold standard of care in cesarean deliveries, is rarely used, mainly due to shortage of staff and lack of formal obstetric anesthesia training. In addition, NSAIDs are also underused. There is a need for more formal training for obstetric anesthesiologists in Israel.

Kineret Mazor-Aronovitch, Danny Lotan, Dalit Modan-Moses, Akiva Fradkin and Orit Pinhas-Ham
Background: The prevalence of obesity in children and adolescents has increased dramatically in the last few decades. Primary hypertension, a known secondary complication among obese adults, has been considered rare in children.

Objectives: To investigate the prevalence of hypertension and its relation to body mass index (BMI) in obese children aged 9–17 years in Israel.

Methods: Weight, height, BMI, and systolic and diastolic blood pressure (BP) (twice) were measured in children attending general and pediatric endocrine clinics. Obesity was defined as BMI ≥ 95th percentile and overweight as BMI ≥ 85th percentile. Pre-hypertension and hypertension were defined as systolic and/or diastolic BP ≥ 90th percentile for age, gender and height and BP ≥ 95th percentile respectively. In children with pre-hypertension or hypertension, repeated measurements were performed.

Results: We evaluated 264 children of whom 152 had BMI ≥ 85th percentile (study group). Their mean age was 12.5 years. The prevalence of elevated BP (both pre-hypertension and hypertension) in the study group was 44.1% and 31% at the first and second measurements respectively, compared to 11.6% and 1.9% in the normal-weight group. Hypertension was documented in 17.2% of the study group at the second measurement.

Conclusions: Elevated BP was diagnosed in 31% of overweight and obese children and adolescents. Increased awareness and early diagnosis and treatment are essential.

Aleksandra Djokovic, Ljudmila Stojanovich, Milica Kontic, Natasa Stanisavljevic, Slavica Radovanovic and Dragomir Marisavljevic
Background: Antiphospholipid syndrome (APS, also known as Hughes syndrome) may manifest itself as a primary or secondary disease, most commonly with systemic lupus erythemathosus (SLE) and various cardiac manifestations. 

Objectives: To report the first results from the Serbian National Cohort study, which was started in January 2000.

Methods: Our study included 374 patients: 260 primary APS patients and 114 SLE patients with secondary APS. Antiphospholipid antibody (aPL) analysis included detection of anticardiolipin antibodies (aCL) (immunoglobulin G and M), ß2-glycoprotein 1, and lupus anticoagulant. Echocardiography was performed in all patients, and data on myocardial infarction, unstable angina, chronic cardiomyopathy and acute heart failure were collected.

Results: There were 30.7% secondary APS patients and 9.2% primary APS patients with pseudo-infective endocarditis (P = 0.0001). Cardiac manifestations were observed in 28.7% of patients who had more than one type of antibody (category I), in 24.1% with category IIa, in 23.1% with category IIb, and in 27.8% with category IIc (P = 0.78). Age was confirmed as a significant factor for cardiac manifestations in APS patients (52.3 and 43.3 years, respectively, P = 0.001). aCL IgG and IgM positivity was related to valvular changes in all APS patients and high levels of those antibodies increased the risk of these manifestations.

Conclusions: Patients with secondary APS had a higher prevalence of valvular lesions, and some aPL types and high levels of aPL were risk factors for specific cardiac manifestations in APS patients.

Ilan Goldberg, Oksana Finkel, Andrea GatD, Eli Sprecher and Helena Martinez de Morentin
Erythema nodosum and pyoderma gangrenosum are common skin manifestations in inflammatory bowel diseases. Curiously, these two cutaneous features have seldom been reported to occur simultaneously.  We present three patients affected with inflammatory bowel disease, with concomitant erythema nodosum and pyoderma gangrenosum.

Education
Avraham Unterman, Anat Achiron, Itai Gat, Oren Tavor and Amitai Ziv
 Background: Physicians are often insufficiently trained in bedside teaching and mentoring skills. Objectives: To develop, implement and assess a simulation-based training program designed to improve clinical teaching among physicians.

Methods: We developed a one-day tutor training program based on six simulated scenarios with video-based debriefing. The program's efficacy was assessed using questionnaires completed by the participating physicians and their students. Main outcome measures were self-perceived teaching skills at baseline, after participation in the program, and following completion of the tutor role. Secondary outcome measures were the students' perceptions regarding their tutor skills.

Results: Thirty-two physicians (mean age 35.5, 56% females) participated in the program. Self-assessment questionnaires indicated statistically significant improvement following the program in 13 of 20 measures of teaching skills. Additional improvement was observed upon completion of the tutor role, leading to significant improvement in 19 of the 20 measures. Questionnaires completed by their students indicated higher scores in all parameters as compared to a matched control group of tutors who did not participate in the program, though not statistically significant. Most participants stated that the program enhanced their teaching skills (88%), they implement program-acquired skills when teaching students (79%), and they would recommend it to their peers (100%). Satisfaction was similar among participants with and without previous teaching experience.

Conclusions: A novel one-day simulation-based tutor training program was developed and implemented with encouraging results regarding its potential to improve clinical teaching and mentoring skills. 

Imaging
Lela Migirov, Gahl Greenberg, Ana Eyal and Michael Wolf
Cholesteatoma is an epidermoid cyst that is characterized by independent and progressive growth with destruction of adjacent tissues, especially the bone tissue, and tendency to recurrence. Treatment of cholesteatoma is essentially surgical. The choice of surgical technique depends on the extension of the disease, and preoperative otoscopic and radiological findings can be decisive in planning the optimal surgical approach. Cholesteatoma confined to the middle ear cavity and its extensions can be eradicated by use of the minimally invasive transmeatal endoscopic approach. Computerized tomography of the temporal bones fails to distinguish a cholesteatoma from the inflammatory tissue, granulations, fibrosis or mucoid secretions in 20–70% of cases showing opacification of the middle ear and mastoid. Using the turbo-spin echo (TSE), also known as non-echo planar imaging (non-EPI) diffusion-weighted (DW) magnetic resonance imaging, cholesteatoma can be distinguished from other tissues and from mucosal reactions in the middle ear and mastoid. Current MRI sequences can support the clinical diagnosis of cholesteatoma and ascertain the extent of the disease more readily than CT scans. The size determined by the TSE/HASTE (half-Fourier acquisition single-shot turbo-spin echo) DW sequences correlated well with intraoperative findings, with error margins lying within 1 mm. Our experience with more than 150 endoscopic surgeries showed that lesions smaller than 8 mm confined to the middle ear and its extension, as depicted by the non-EPI images, can be managed with transmeatal endoscopic approach solely. We call upon our otolaryngologist and radiologist colleagues to use the newest MRI modalities in the preoperative evaluation of candidates for cholesteatoma surgery.

הבהרה משפטית: כל נושא המופיע באתר זה נועד להשכלה בלבד ואין לראות בו ייעוץ רפואי או משפטי. אין הר"י אחראית לתוכן המתפרסם באתר זה ולכל נזק שעלול להיגרם. כל הזכויות על המידע באתר שייכות להסתדרות הרפואית בישראל. מדיניות פרטיות
ז'בוטינסקי 35 רמת גן, בניין התאומים 2 קומות 10-11, ת.ד. 3566, מיקוד 5213604. טלפון: 03-6100444, פקס: 03-5753303