תוצאת חיפוש

Diarrheal Disease among Care-Givers at Children's Day- Care Centers 

S. Koton, D. Cohen, M.S. Green

Israel Center for Disease Control, Ministry of Health and Gertner Institute, Chaim Sheba Medical Center, Tel Hashomer; Medical Corps, Israel Defense Forces; Dept. of Epidemiology and Preventive Medicine; Sakler Faculty of Medicine, Tel Aviv University

Diarrheal disease tends to spread from infected children to their families. Due to the increased risk of exposure, children's caregivers in day-care centers may have a higher incidence of diarrhea, particularly when caring for very young children. We therefore examined the incidence of diarrhea and antibodies to Shigella among caregivers in day-care centers, according to age groups of children in their care (<18, 18-34, and >35 months) and in comparison with the general population. 2 studies with a retrospective cohort and seroepidemiological cross-sectional design were carried out. Questionnaires were completed by 401 caregivers in 36% of all WIZO day-care centers. As a measure of past exposure to Shigella, levels of S. sonnei and S. flexneri antibodies were examined in the blood of 110 caregivers (ELISA method).

There was a higher incidence of diarrhea among young children, increasing the potential exposure to diarrheal agents among their caregivers. Nevertheless, no statistically significant differences in diarrhea incidence were found among caregivers of the various age groups during the previous year (p=0.768) and during the previous month (p=0.319), nor in absenteeism due to diarrhea during the last month (p=0.761). Levels of Shigella antibodies were similar among caregivers in all 3 groups. Diarrheal incidence was higher among women in the population control group than among caregivers during the previous year (p=0.005) and month (p=0.067). No statistically significant differences in levels of S. sonnei and S. flexneri antibodies were found between caregivers and women in the control group.

There was no evidence that diarrhea is an occupational hazard for caregivers of young children. An explanation may be the development of protective immunity against common diarrheal agents due to recurrent exposure.
 

Second Degree A-V Block in Graves© Disease

Yoram Singer, Pesach Shvartzman

Dept. of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Cardiac tachyarrhythmias are common in thyrotoxicosis. We report an uncommon case of a 53-year-old woman with Grave's disease who developed second degree A-V block while euthyroid on propylthiouracil. The most likely mechanism is an autoimmune response causing infiltration of the cardiac conduction pathways.

Influence of Warning Labels on Medicines and Physicians' Orders on Patient Behavior

Yehuda Limony, Pesah Shwarzman

Child Health Center of Kupat Holim Klalit, Kiryat Gat and Dept. of Family Medicine, Ben-Gurion University of the Negev, Beer Sheba

Compliance of 40 mothers with a warning label, "for external use," on a medicine package was checked in a survey in a primary care clinic for children. We also checked parents' attitudes to giving a medicine to their child when instructions given by the physician or by a friend contradicted the printed warning on the label. All mothers who were told that the medicine was recommended by their physicians accepted the recommendation without hesitation. Another group included 20 mothers who were told that the medicine was recommended by a friend. 9 of 20 mothers in this group refused to use the medicine. Talking with the nurse about the potential risk of medicine in general, some mothers, after second thought, refused to give the medicine to their child. At the end, 65% of recommendations made by a friend were rejected by mothers as compared to only 15% of the physicians' recommendations.

35 of 40 mothers (87%) understood the meaning of the warning label, but only 13 (32%) had noticed it at all. We conclude that patients may accept their physicians' recommendation to use a medicine despite a contradictory warning label much more readily than when it was recommended by a friend. Therefore, any intervention program intended to promote a more cautious use of medicines should include not only the explanations of the various warning labels but should also promote a change in the patient's behavior to a more active search for warning labels.

Investigating Chest Pain: is there a Gender Bias?

Leonardo Reisin, Chaim Yosefy, Sharon Kleir, Emil Hay, Ronit Peled, Shimon Scharf

Cardiology and Emergency Depts. and Epidemiology Unit, Barzilai Medical Center, Ashkelon (Affiliated with Ben-Gurion University, Beer Sheba)

Ischemic heart disease (IHD) in women is characterized by a higher morbidity and mortality in the peri-infarction and coronary bypass peri-operative periods. These epidemiological data strengthen our impression that the health system unintentionally "ignores" the high proportion of females with IHD.

The process of investigating chest pain, diagnosing IHD, and the subsequent treatment and rehabilitation, seem to differ between the genders. Time elapsed from beginning of chest pain to diagnosis of IHD seems to be longer in women than in men. Personal, educational and social factors are contributory.

Although time elapsed between diagnosis and rehabilitation is usually similar in the genders, peri-operative morbidity and mortality are higher in women. It may be that the higher rates in women are caused by delay in diagnosis and treatment, which allows worsening of the disease in women before treatment. This delay can occur during the time needed for evaluation of chest pain, from the door of the physician to diagnosis and treatment.

In our retrospective study we determined the difference in referral of men and women with chest pain to the emergency department (ED) and the attitude of physicians in the ED and medical department to chest pain in men and in women, including final diagnosis on discharge. 615 patients over 18 years referred to the ED for chest pain during 3 randomly chosen, consecutive months were studied. We found that women constituted only 39.5% of the referred patients, but the proportion hospitalized was similar to that in men. Hospitalized women were older (57.7±18.4 versus 49.7±17.8 years in men), and had more risk factors (4 versus 2 in men). Proportions of specific diagnoses on discharge from hospital were equal in the genders.

To bridge the differences and to implement education in prevention, investigation and treatment of IHD in women, we established the "Female Heart" clinic. The objective of this clinic is to reduce differences in the first step, in the process of evaluating chest pain in women, by educating and encouraging them to present early to their physicians, and by changing physicians' attituin the investigation of chest pain in women. We plan to determine in a prospective study if these goals are.

Radiologic Appearance of "Falling Gallstones" during Laparoscopic Cholecystectomy

E. Alkalay, D. Yaffe, Z. Spindel

Eyn Vered Clinic and Depts. of Radiology and Surgery, Sapir Medical Center, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University

Laparoscopic cholecystectomy is the "gold standard" in treating cholelithiasis. Stones are frequently lost in the peritoneal cavity during the procedure, but "missing stones" have been regarded as insignificant. However, there is accumulating evidence that untreated "lost" stones may cause complications even years after operation.

We present a 65-year-old woman who presented with vague complaints, anemia and an elevated ESR. CT scan showed an infiltrating process in extra-abdominal muscles compatible with sarcoma. At operation, 2.5 years after previous laparoscopic cholecystectomy, an abscess was found which contained biliary stones. Because of their small size they were not visible on CT scan. We discuss the possible ways of handling "falling stones."

Characteristics, Management and Prognosis of Acute Myocardial Infarction (Israel 1990-1996)

Israeli Survey Group On Acute Myocardial Infarction

From 1990 to 1996 we conducted consecutive 2-month surveys in all CCUs (n=26) in Israel. The aim was to compare the characteristics, management, and prognosis of patients with acute myocardial infarction (AMI) between the 4 surveys.

Patient characteristics were similar in all surveys. About 75% of patients were males and had a first MI. Mechanical and arrhythmic complications decreased slightly between 1990 and 1996. In contrast, frequency of treatment with thrombolysis, aspirin, beta-blockers and ACE-I, as well as coronary interventional procedures, increased tremendously.

In parallel, 30-day and 1-year mortality decreased significantly, from 16.5% and 22.5%, respectively, to 9.0% and 13.9%. After multiple adjustment for factors associated with mortality, the 30-day relative risk of death for patients hospitalized in 1992, 1994 and 1996 was 0.79 (95% CI 0.59-1.08), 0.75 (95% CI 0.56-1.01) and 0.54 (95% CI 0.39-9.74), respectively, as compared with 1990.

Although there is no direct proof that changes in management of AMI are related to the reduction in mortality seen during the course of the surveys, the association seems likely.

Methotrexate Treatment in Refractory Juvenile Rheumatoid Arthritis

R. Brik

Pediatrics B Dept., Rambam Medical Center, Haifa

The mean time from initiation of methotrexate (MTX) treatment of juvenile rheumatoid arthritis (JRA) to partial remission of clinical symptoms and total clinical remission was assessed. 9 girls and 8 boys, from 3 to 18 years of age (mean 11.4±5.4) with active JRA by American College of Rheumatology (ACR) criteria (5 systemic, 8 polyarticular and 4 pauciarticular disease onset), who failed to respond to adequate courses of non-steroidal anti-inflammatory drugs (NSAID), steroids or disease-modidrugs were studied.

Clinic visits were scheduled at monthly intervals for physical and laboratory assessment disease activity and drug safety. Partial response to MTX was defined a 25% reduction of the active joint count and/or articular severity score. Total clinical remission was defined as in adult rheumatoid arthritis. The duration of disease activity until enrollment ranged from 6 months to 14 years (4.5±3.7 yr); duration of therapy was 3 months to 3 years (14.6±9.3mo) and dosage ranged from 5 to 15 mg/m²/week. Prednisone in doses below 10 mg/day and NSAID were permitted.

14 of 17 patients (82%) had a 25% reduction in joint activity after 6 weeks to 4 months (9.2±3.2 weeks); 10 (59%) went into full clinical remission after 5 to 26 months (14.3±9 months); 3 relapsed after an initial response to treatment, and 4 (23%) did not respond to MTX. The non-responders were males who required higher doses of prednisone (p<0.0001).

MTX appears to be effective therapy for children with JRA. An initial response can be expected in most patients after 9 weeks of treatment, and full clinical remission occurs after a mean of 14 months.

Ultrasonographic Imaging of Superior Sagittal Thrombosis

Ilan Shelef, Avi Cohen, Yehiel Barki

Depts. of Radiology and Neurosurgery, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Ultrasonographic findings of superior sagittal sinus thrombosis include dilated and hyperechoic sinus (direct imaging of the thrombus). No flow should be demonstrated by the various Doppler techniques. In the deeper sinuses, if the thrombus can not be visualized after a negative Doppler study, MR imaging is recommended. Recanalization and reflow can be demonstrated on follow-up study.

Serotonin Re-Uptake Inhibitors as Primary Therapy for Carotid Sinus Hypersensitivity

Amos Katz, Angel Kantor, Alexander Battler

Cardiology Dept., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Carotid sinus syndrome is a well-recognized cause of unexplained syncope in older patients, and may lead to significant morbidity due to trauma from falls. Dual chamber pacing has been shown to be effective in relieving symptoms due to bradycardia, but not due to vasodepressor response. We report an 84-year-old man with recurrent syncope due to carotid sinus hypersensitivity. He was treated only with a serotonin re-uptake inhibitor and was symptom-free after 3 weeks of therapy. He has remained symptom-free for the past year.

Normotensive Hydrocephalus Complicating Recurrent E. Coli Meningitis

Doron Zamir, Rasmi Magadle, Paltiel Weiner

Dept. of Medicine A, Hillel Yaffe Medical Center, Hadera

E. coli meningitis is a disease that occurs in predisposed patients, either as a result of trauma or in neonates after neurosurgery. Recurrent E. coli meningitis in an adult without any apparent predisposition is uncommon, and hydrocephalus complicating bacterial meningitis is even more rare. We report a unique case of a 67-year-old alcoholic man who had had 2 consecutive episodes of E. coli meningitis within 2 months. In both episodes there was a favorable response to ceftriaxone. However, normotensive hydrocephalus appeared a few weeks later, with mental and physical deterioration.

The Mitrofanoff Pouch in Lower Urinary Tract Reconstruction

J.H. Pinthus, Y. Mor, J. Ramon

Urology Dept., Chaim Sheba Medical Center, Tel Hashomer

The Mitrofanoff principle, first described in 1980, consists of implanting a tubular organ such as the appendix, ureter, or fallopian tube into the wall of the bladder (or urinary reservoir) to create a non-refluxing, catherizable urinary conduit. Between 1993-1996, 7 men and 1 woman (aged 48-64, average 59) underwent radical cystectomy and urethrectomy combined with the creation of a MAINZ I urinary reservoir (based on the Mitrofanoff principle). In men the indication for the procedure was the diagnosis of invasive transitional cell carcinoma of the bladder with involvement of the prostatic urethra. All patients had refused urinary diversion to an ileal conduit because of its deleterious effect on the quality of life.

In all patients the postoperative course was uneventful, apart from intraperitoneal urinary leakage from the reservoir in 1, successfully managed conservatively. The patients have gained full control of urinary drainage, performing intermittent self-catheterizations every 4-5 hours. In 3 patients there were difficulties with catheterization due to stenosis of the conduit, usually at the skin level. None have suffered leakage from the reservoir, during the day, even when it was full.

Our experience shows that creation of a continent urinary reservoir according to the MAINZ I technique is an excellent surgical solution for patients in whom the creation of an orthotopic reservoir is impractical. The use of the umbilicus as a stomal site preserves normal body image and thus does not interfere with quality of life as in those undergoing radical cystectomy.

Is Ileostomy Necessary In Surgical Treatment of Ulcerative Colitis and Familial Polyposis?

Michael M. Krausz, Simon Daniel Duek

Dept. of Surgery A, Rambam Medical Center, Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Proctolectomy with ileal pouch anal anastomosis (IPAA) has become the procedure of choice for the surgical treatment of ulcerative colitis (UC) and familial polyposis (FP). Ithas traditionally been performed in 2 stages, but recently the necessity for an ileostomy hbeen challenged by several authors who recommend a 1-stage procedure.

5 years ago we started to test this policy for treatment of UC and FP. In 48 patients (Group A), 45 with UC, the 2-step procedure, and in 17 of the 27 in Group B with FP, the 1-stage procedure were performed. The indications for surgery were intractable UC in 37 patients in group A and in 5 patients in Group B (p<0.01).

Postoperative infection due to bowel leakage developed in 2 in Group A and in 6 in Group B (p<0.01). Reoperation was necessary in 4 patients (15%) in Group B and only 1 (0.9%) in Group A (p<0.01). Bowel leakage in Group B occurred in 5 (19%) with UC and in only 1 with FP (p<0.05), which responded to medical treatment. All those with UC who developed this complication were relatively malnourished, with serum albumin levels lower than 3.0 g% and were regulated with corticosteroids.

We therefore conclude that the 2-stage IPAA is feasible and safe for the treatment of UC and FP. The 1-stage IPAA should be limited only to FP or good risk UC patients.

Nonpenetrating Deep Sclerectomy

Orna Geyer

Ophthalmology Dept., Tel Aviv-Sourasky Medical Center

This is the first report from Israel of nonpenetrating deep sclerectomy (DS), a new operation for the surgical management of glaucoma. It facilitates ocular fluid drainage without entering the eye. It involves performance of a conjunctival flap and creation of a 565 mm superficial scleral flap. A deeper scleral flap is dissected off the scleral bed together with the roof of the canal and corneal stroma, leaving behind the wall of the canal and membrane. Aqueous will flood the dissected area. A collagen device is then sutured to the scleral bed, the superficial scleral flap sutured into position and the conjunctiva closed. With this procedure, the surgeon can avoid the common complications of conventional glaucoma surgery.

We report a 6-month follow-up of 15 patients after DS. Mean preoperative intraocular pressure was 26.7+2.5 mm Hg, which decreased to 15.5+4.7. After 6 months there was no change in visual acuity after surgery. DS is associated with good middle-term intraocular pressure control and a low rate of postoperative complications. It is therefore a good alternative to standard glaucoma surgery.

Autonomic Dysregulation in Post-Traumatic Stress Disorder: Power Spectral Analysis of Heart Rate Variability

Hagit Cohen, Uri Loewenthal, Mike A. Matar, Hanoch Miodownik, Zeev Kaplan, Yair Cassuto, Moshe Kotler

Mental Health Center, Israel Ministry of Health; Anxiety and Stress Research Unit, Faculty of Health Sciences; Dept. of Life-Sciences, Ben-Gurion University of the Negev, Beer Sheba

Spectral analysis of heart rate variability (HRV) has been shown to be a reliable noninvasive test for quantitative assessment of cardiovascular autonomic regulatory response, providing a dynamic map of sympathetic and parasympathetic interaction. In a prior study exploring the state of hyperarousal that characterizes the post traumatic stress disorder (PTSD) syndrome, we presented standardized heart rate analyses in 9 patients at rest, which demonstrated clear-cut evidence of a baseline autonomic hyperarousal state.

To examine the dynamics of this hyperarousal state, standardized heart rate analysis was carried out in 9 PTSD patients, compared to a matched control group of 9 normal volunteers. 20-minute ECG recordings in response to a trauma-related cue, as opposed to the resting state, were analyzed. The patients were asked to recount the presumed triggering traumatic event, and the control subjects recounted a significant stressful negative life event.

Whereas the control subjects demonstrated significant autonomic responses to the stressogenic stimulus of recounting major stressful experiences, the patients demonstrated almost no autonomic response to the recounting of the triggering stressful event. The patients demonstrated a degree of autonomic dysregulation at rest comparable to that seen in the control subjects' reaction to the stress model.

The lack of response to the stress model applied in the study appears to imply that PTSD patients experience so great a degree of autonomic hyperactivation at rest, that they are unable to marshal a further stress response to the recounting of the triggering trauma, as compared to control subjects. A subsequent study of the effect of medication on these parameters showed that they are normalized by use of selective serotonin re-uptake inhibitors (SSRI's).

Neither the clinical implications of these findings, nor their physiological mechanisms are clear at present. We presume that they reflect a central effect, as the peripheral automatic effects of SSRI's are relatively negligible.

Aphthous Stomatitis as a First Manifestation of Crohn's Disease in a Child

Y. Gold, S. Reif

Dana Children's Hospital, Tel Aviv Medical Center

The incidence of Crohn's disease has risen dramatically over the past few years. The peak age of onset is in late adolescence, but it rarely occurs in the first few years of life. We describe a 5-year-old boy with recurrent bouts of fever, aphthous stomatitis, and anemia which did not respond to routine antibiotic therapy. It was only after a few months, when the characteristic symptoms of inflammatory bowel disease (IBD): abdominal pain and diarrhea appeared, that the diagnosis of Crohn's disease was made.

This case illustrates the difficulty in diagnosing IBD in young children. The presenting symptoms of IBD in children are often nonspecific and extra-intestinal. There is usually a low index of suspicion by the physician as to the possibility of IBD in a young child.