תוצאת חיפוש

Diagnosis and Therapy in Acute Stroke: A Rehabilitation Center Viewpoint

M. Motin, J. Streifler, A. Tsur, H. Ring

Neurological Rehabilitation Dept., Loewenstein Rehabilitation Center, Ra'anana; Neurological Unit, Rabin Medical Center, Golda Campus, Petah Tikva and Sackler School of Medicine, Tel Aviv University, Ramat Aviv

The extent of the diagnostic work-up of patients with acute stroke was evaluated in 101 patients admitted for rehabilitation during a 4-month period in 1997. This included specific blood tests and neuro- and cardiac imaging, and compared the extent of work-up in a community hospital versus a rehabilitation center. Comparisons were also made with similar investigations 10 and 20 years earlier.

Results demonstrated that the trend to admit younger stroke patients (<50 years) to neurological (as opposed to medical) departments observed between 1977-1987 persisted in 1997.

The use of CT scan increased dramatically from 1977 to 1987 (19% vs 78%), and in 1997 was actually 100% The use of carotid duplex and echocardiography increased steadily during the 3 decades reaching 26% and 28% respectively. Tests for thrombophilia were seldom done. However, in neurological departments it was done in about 50% of the younger stroke patients. In neurology departments carotid duplex was done 2 to 3 times more often than in medical departments.

During rehabilitation imaging tests were done once or more in almost half the patients. The results and those of additional blood tests, have led to modification of antithrombotic treatment in 14% of the younger group and 4% of the older group.

We have clearly shown that while stroke work-up has become more comprehensive in recent years, there is still much to do in this field. Stroke units or teams in our general hospitals will increase stroke awareness, improve work-up and hasten definitive treatment.
 

Folic Acid for Preventing Neural Tube Defects

Ziv Gil, Adi Aran, Orna Friedman, Liana Beni-Adani, Shlomo Constantini

Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba; Division of Pediatric Neurosurgery, Dana Children's Hospital, Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv

Spina bifida and anencephaly are the most common, serious malformations in neural tube defects (NTD). Randomized trials in the last 2 decades have demonstrated that folic acid, 0.4 mg/d, reduces the incidence of NTD by more than 50%. We investigated the use of folic acid and multivitamins containing folic acid in childbearing women.

Of 221 women interviewed, 67 (30%) regularly took pills containing 0.4 mg folic acid. Women with higher educational levels were more likely to take multivitamins with folic acid than were the less educated (p=0.05). Of the women who took folic acid, only 5 (7.5%) used separate folic acid tablets, before and during their pregnancy. The rest used multivitamins containing folic acid. The 5 women who took folic acid separately were college-educated and nonreligious, and they took multivitamins in addition (p>0.05).

Of the women interviewed, 58 (26.2%) were Bedouin of the Negev. 24 (41.4%) of them took pills containing folic acid on a regular basis. This percentage is higher than that in the Jewish women in the study who took folic acid for prevention of NTD (17%; p=0.038).

Most of the women took folic acid after the first trimester. Only a minority took daily periconceptional folic acid. Multivitamins containing 0.4 mg of folic acid were more popular than folic acid tablets alone. This study emphasizes the need for continuing efforts to increase consumption of folic acid and awareness of its benefits among women of childbearing age.

Surgery for Blepharoptosis in Muscular Dystrophy

Ori Mahler, Asher Milstein, Ayala Pollack, Daniel Hauben

Eye Dept., Kaplan Medical Center, Rehovot; and Plastic Surgery Dept., Rabin Medical Center, Petah Tikva

In some muscular dystrophies there is ocular involvement characterized by blepharoptosis and ophthalmoplegia. These conditions occur in chronic progressive external ophthalmoplegia, oculopharyngeal muscular dystrophy, mitochondrial myopathy, myotonic dystrophy, and ocular myasthenia, among others. Although they differ in their systemic clinical manifestations and in genetic inheritance, ocular involvement is common to all of them. Manifestations include bilateral progressive blepharoptosis with or without extraocular muscle malfunction.

During surgical repair of the ptotic eyelid, consideration must be given to eyeball movements, in addition to maximal eyelid elevation, and to avoiding overcorrection and consequent corneal overexposure, leading to dryness and visual impairment. With these muscular dystrophic disorders, resection of the levator muscle or blepharoplasty alone does not suffice. Follow-up shows that most patients need a secondary repair after a short while. Operative correction uses a frontalis sling for eyelid elevation and support.

A series of 8 patients with these diseases, operated on by various surgical techniques during the past 7 years, is presented.

Laparoscopic Cholecystectomy - 1,000 Procedures in a Surgical Department

Uri Freund, Ami Mayo, Ivan Schwartz, David Neufeld, Haim Paran

Dept. of Surgery A, Meir Hospital, Kfar Saba; and Sackler School of Medicine, Tel Aviv University

The first 1,000 laparoscopic cholecystectomies performed in our department were reviewed. There was no operative mortality; conversion to open cholecystectomy was necessary in 2%. In the last 600 cases the rate of conversion had decreased to 0.5%. There was common bile duct injury in 0.3%, with the injuries identified during primary surgery. This clinical experience is consistent with previous studies, which proved that laparoscopic cholecystectomy is safe and should replace open operation as the procedure of choice. 

Life-Threatening Echovirus 11 Infection During First Month of Life

U. Rubinstein, M. Weisbrod, B. Garty

Neonatal Dept., Laniado Hospital, Kiriat Zans, Natanya; and Pediatrics B, Dept., Schneider Children's Medical Center, Petah Tikva

Infection with Echovirus 11 is mostly asymptomatic, but it may cause a wide variety of clinical diseases, from gastroenteritis to serious diseases such as meningitis and myocarditis. In small infants, especially during the first days of life, echovirus infection may appear as a sepsis-like illness, and cause disseminated intravascular coagulopathy and shock.

We present 2 infants with severe echovirus 11 infections. A 3.5-month old died within 24 hours of shock and probably myocarditis. The other, 6-days old, presented with meningitis, hepatitis and disseminated intravascular coagulopathy. It recovered after treatment with intravenous immunoglobulin.

Echovirus 11 may cause life-threatening infections in small infants. Pediatricians should be alert to the special characteristics of this disease.

אורה שובמן, בוריס גילבורד, פנינה לנגביץ', יהודה שינפלד

המח' לרפואה פנימית ב' והיחידה לחקר מחלות אוטואימוניות, המרכז הרפואי שיבא תל השומר והפקולטה לרפואה סאקלר, אוניברסיטת תל אביב

מילות מפתח:

נוגדני RA33, RA33, מחלות אוטואימוניות, אורה שובמן, בוריס גילבורד, פנינה לנגביץ', יהודה שינפלד, שובמן, גילבורד, לנגביץ', שינפלד

Presurgical Neuropsychological assessment in Epilepsy: The Wada Test

Fani Andelman, Miri Neufeld, Irith Reider-Groswasser, Uri Kremer, Yoram Segev, Itzhak Fried

Functional Neurosurgery and EEG and Epilepsy Units, Section of Neuroradiology; and Pediatric Neurology Unit; Tel Aviv-Sourasky Medical Center, Tel Aviv

37 candidates for epilepsy surgery underwent the intra-carotid amytal procedure (IAP; also known as the Wada test) to determine hemispheric speech dominance and memory capacity. 31 demonstrated left hemisphere speech dominance, 2 showed evidence for bilateral language and 4 demonstrated right hemispheric language dominance.

Our study supports a correlational relationship between handedness, lesion laterality and age of onset of seizures, as reported in earlier studies. Left-handed patients with a left hemisphere lesion whose seizures began to an early age had a strong tendency for reversed language dominance.

Asymmetry of at least 20% in performing the memory test was taken as the cutoff score for demonstrating laterality of lesions. The asymmetry score correctly predicted laterality of lesions in all 28 patients; 6 did not have asymmetry scores and 3 were examined for language only. None of the patients who successfully passed the Wada memory test had any significant postsurgical memory deficits; 1 had transient reduction in verbal memory and 4 who did not pass the test were not operated on for this reason.

Our results demonstrate the importance of the Wada test in determining cerebral speech dominance, in predicting post-surgical amnesia, and support its usefulness in predicting laterality of seizure focus in candidates for temporal lobectomy.

Nocturnal Eating Disorder - Sleep or Eating Disorder?

Orna Tzischinski, Yael Lazer

Sleep Laboratory, Faculty of Medicine and Israel Institute of Technology; and Eating Disorders Clinic, Psychiatric Division, Rambam Medical Center, Haifa

Nocturnal eating disorder (NED) is a rare syndrome that includes disorders of both eating and sleeping. It is characterized by awakening in the middle of the night, getting out of bed, and consuming large quantities of food quickly and uncontrollably, then returning to sleep. This may occur several times during the night. Some patients are fully conscious during their nocturnal eating, while some indicate total amnesia. The etiology of NED is still unclear, as research findings are contradictory.

Those suffering from NED exhibit various levels of anxiety and depression, and many lead stressful life-styles. Familial conflict, loneliness and personal crises are commonly found. Recently, a connection has been discovered between NED and unclear self-definition, faulty interpersonal communication, and low frustration threshold. Several authors link it to sleepwalking, leg movements during sleep, and sleep apnea. Treatment is still unclear and there have been trials of pharmacotherapy, psychotherapy, or a combination of both. However, pharmacological treatment has generally been found to be the most effective, although each case must be considered individually.

In 1998, 7 women referred to our Eating Disorders Clinic, 5% of all referrals, were subsequently diagnosed as suffering from NED. Of these, 3 suffered from concurrent binge-eating disorder and 4 also from bulimia nervosa. 2 case studies representative of NED are presented.

Referrals and Self-Referrals to an Emergency Department

Sasson Nakar, Shlomo Vinker, Yaacov Or, Mordechai Schadel, Yosi Niego, Gavriel Plotkin

Central District of General Sick Fund and Family Medicine Dept., Sackler Faculty of Medicine, Tel Aviv University, and Emergency Dept., Kaplan Medical Center, Rehovot (Affiliated with Hebrew University-Hadassah Faculty of Medicine, Jerusalem)

The Israeli health system has been undergoing major changes in recent years. Considerations of cost containment have led sick funds to open new out-of-hours services in the community to reduce visits to hospital emergency departments.

Referred and self-referred visits to our emergency department during a 1-month period were studied. Patients after trauma or whose visits resulted in hospitalization were excluded. Of the 505 encounters 56.3% were of women; the average age was 52.5±19.3 years (range 18-96). 57.4% visits were during working hours of primary care clinics ("working hours"), while the others were "out-of-hours" visits. Only 52.7% had a referral letter, 75% of them from the family physician. The quality of the handwriting in 46% was good, in 44% fair and the remaining 10% were illegible. A specific clinical question was asked in only 16% of the letters. A third of "working-hours" visits were self- referrals, rising to 64% in "out-of-hours" visits (p<0.001).

The most common diagnoses in discharge letters were: chest or abdominal pain, asthma, back pain, headache, nephrolithiasis and upper respiratory tract infection. The rate of self-referrals was relatively high throughout the day. Cost-containment efforts did not seem to eliminate self-referrals with "primary care" problems. The quality of referral letters should be improved both with regard to format and content.

Can Police Car Flashing-Light Induce Encephalographic Discharges and Seizures?

G. Vainstein, V. Yofe, N. Gadoth

Dept. of Neurology, Meir General Hospital, Sapir Medical Center, Kfar Saba

The new police car flashing-light device (930 Heliobe Lightbar) has recently been implicated as potentially epileptogenic. We exposed 30 epileptic patients, 30 nonepileptic patients who suffered from headache and 15 normal volunteers to this light source. All had routine EEGs with standard intermittent photic stimulation, followed by 3-minute stimulation with the Lightbar. In none were either seizures or EEG changes induced. In 1 epileptic spike-and-wave activity induced by standard photic stimulation was enhanced with the Lightbar.

We could not confirm that the Lightbar is epileptogenic.

Symptom Severity among Chronic Schizophrenics in Hospital and in the Community

Haim Y. Knobler, Dorit Ben Ami, Orna Intrator, Shlomit Katz, Daniela Moshe, Yaacov Lerner

Jerusalem Mental Health Center, Falk Institute of Psychiatric and Behavioral Studies, and Dept. of Statistics, Hebrew Universitry of Jeruselam

We compared severity of symptoms of chronic schizophrenics in a psychiatric hospital with those treated in its outpatient clinics.

The Positive and Negative Syndrome Scale and the Mini-Mental State examination were used to assess the schizophrenic symptoms and cognitperformance, respectively, of 25 chronic schizophrenic inpatients matched for gender, age and education with 25 chronic scoutpatients. The Global Assessment Scale and the Clinical Global Impression Scale were used to test global functioning. Assessment included psychiatric and medical history and treatment and demographic characteristics.

In-patients had significantly more positive, negative and general psychiatric symptoms. Their cognitive and general functioning were impaired. Most in-patients also had medical problems. Age of onset of schizophrenia among the in-patients was younger.

Results show a marked difference in severity of symptoms and level of functioning between chronic schizophrenic in-patients and out-patients. These differences should be considered in the planning of discharge of chronic in-patients from psychiatric hospitals into the community.

Malignant Eccrine Poroma

R. Silfen, A. Amir, M. Feinmesser, D.J. Hauben

Dept. of Plastic and Reconstructive Surgery, and Pathology Dept., Rabin Medical Center (Beilinson Campus), Petah Tikva

Malignant eccrine poroma (MEP) is rare and both clinical and histologic diagnosis is often difficult. Therefore, diagnosis is sometimes delayed or even incorrect. We report a case in a 70-year old man with MEP of the leg. He demonstrated typical MEP behavior and the problems of differential diagnosis.

ACE Gene Polymorphism in a Diabetic Cohort and Diabetic Nephropathy

Orna Levinson, Shmuel Oren, Chana Yagil, Marina Sapojnikov, Alexander Wechsler, Rosanna Bloch, Yoram Yagil

Laboratory for Molecular Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba and Barzilai Medical Center, Ashkelon

The renin-angiotensin system is thought to play an important role in the pathophysiology of kidney disease in diabetes. Previous studies have shown a possible association between the D allele of the angiotensin converting enzyme (ACE) gene, known to be associated with higher circulating levels of ACE, and increased risk of developing nephropathy in NIDDM. The present study investigated the distribution of ACE gene genotypes in the general population and patients with NIDDM, the association between the D allele and diabetic nephropathy, and the association between the ACE genotype and involvement of other target organs in NIDDM. The ACE genotype (insertion/deletion I/D) was determined in all subjects, subsequently divided into 3 groups based on their polymorphism (DD, DI and II). The presence of nephropathy was defined by an albumin-creatinine ratio of 30 mg/g or greater (mean of 2 first morning urine samples).

In the general population most had the D allele (DD or ID) and a minority the II genotype. There was no association between genotype and hypertension, ischemic heart disease, hyperlipidemia, and cerebrovascular or peripheral vascular disease. In diabetics the genotype distribution was not different from that in the general population. Within the diabetic group, there was no association between genotype and hypertension, hyperlipidemia, duration of diabetes, or HbA1C levels. Nephropathy, found in 81 of the 156 with NIDDM, was not associated with genotype. Diabetic nephropathy was not associated with retinopathy, neuropathy, or ischemic heart, cerebrovascular or peripheral vascular disease. We conclude that in the population sampled, there was no association between the D allele of the ACE gene and the risk of developing nephropathy in NIDDM.

Smoking and Incidence of Lung Cancer, 1981-1995

Orna Baron-Epel, Helena Andreev, Micha Barchana, Manfred S. Green

Israel Center for Disease Control, Ministry of Health, Tel Hashomer, Israel; Cancer Registry, Ministry of Health, Jerusalem, and Dept. of Epidemiology and Preventive Medicine, Faculty of Medicine, Tel Aviv University

Smoking is the dominant risk factor for lung cancer. We compared trends in smoking with those of the incidence of lung cancer in Israel. The proportion of smokers has declined during the past 20 years; the decrease is greater in men than in women, and more marked in the elderly. Since 1980 the age-adjusted incidence of lung cancer in Jewish men has decreased slightly, but in women it has remained constant. Among Arab men there was an increase in age-adjusted incidence of lung cancer and since 1986 it has been higher than in Jewish men.

The largest decrease in lung cancer incidence was among Jewish men aged 75 and over. This may be explained by data on the age of smoking cessation in the population. It was observed that the main decrease in smoking occurred among men over the age of 55 in the past 20 years, which correlates with the decline in lung cancer observed in the older age group. Lung cancer rates in Israel are lower than in other western countries despite the similar prevalence of smoking, for unknown reasons.

The Israel Teratogen Information Service: A 10-Year Report 

A. Ornoy, S. Shechtman, J. Arnon

Hebrew University - Hadassah Medical School and Israel Ministry of Health, Jerusalem

The Israel Teratogen Information Service (TIS) was established 10 years ago with the help of the Ministry of Health and the Hebrew University-Hadassah Medical School. During these 10 years we have had 20,631 calls. We describe the results of our experience in counseling.

There was a gradual increase in the number of calls, which in 1997 reached 4,447. Most calls (84.5%) were during pregnancy, while 12% were prior to pregnancy. In 75.7% the calls were due to drug exposure during pregnancy; 10.9% were due to exposure to X-rays; there was maternal infection in 6.6% and in 5% immunization during pregnancy. The callers were: physicians in 46.6%, nurses 18.9%, pregnant women 39.5%, and 4.8% others.

In 76.6% there was no additional risk to the embryo or fetus and in 17.4% there was a small additional risk of less than 1%; a significant additional risk to the fetus was expected in only 6%. In 3625 pregnant women with known outcome there were 8.9% spontaneous and 9.2% induced abortions. Of the 2968 live-born children, 2.3% were malformed, a rate similar to that among controls.

The information provided by the TIS alleviated the fears most pregnant women have, and reduced unnecessary terminations of pregnancy planned because of unjustified fear of the teratogenic effects of agents to which women were exposed. It reduced the number of children born with congenital anomalies, since pregnancies were interrupted whenever there was a high risk for congenital anomalies.