תוצאת חיפוש

The Homeless and the Health System: Profile of the Homeless Patient

J. Posen, N. Tanai, S. Spiro, D. Frumer

Social Work Dept., Ichilov Hospital, Tel Aviv and Faculty of Social Work, Tel Aviv University

The homeless population is mobile and does not use ambulatory health care services. Thus the major contact between the homeless and the medical establishment occurs primarily when they are treated for acute symptoms in hospital. We describe the clinical and sociodemographic profile of the homeless who require hospital services. The research population included 50 homeless treated in the emergency room and various departments of our medical center between October 1994 and August 1995. Social workers used a questionnaire relating to clinical, sociodemographic and social factors. Most patients were men, 76% under the age of 50. The most common diagnosis was alcoholism; other diagnoses included back, limb and joint injuries, infections, skin diseases, and general exhaustion. There were subgroups with differing needs within this homeless population for which appropriate rehabilitation programs are proposed.

Seminiferous Tubule Cytological Pattern in Infertile, Azoospermic Men in Diagnosis and Therapy

David B. Weiss, Shoshana Gottschalk-Sabag, Elchanan Bar-On, Zvi Zukerman, Yigal Gat, Benjamin Bartoov

Male Infertility and Cytology Units, Shaare Zedek Medical Center, Jerusalem; Andrology Unit, Rabin Medical Center (Beilinson Campus), Petah Tikva and Male Infertility Laboratory, Dept. of Life Sciences, Bar-Illan University, Ramat Gan

We determined spermatogenic patterns of seminiferous tubules in azoospermic infertile men and evaluated the prevalence of bilateral testicular homogeneity. 185 azoospermic men underwent bilateral testicular fine-needle aspiration (TFNA) in which each testis was punctured at 3 different positions. Aspirated material was stained and classified according to the most mature spermatogenic cell type present or whether only Sertoli cells were present. 35.7% had spermatozoa in their testes, 36.2% had spermatogenic maturation arrest, and 28.1% had only Sertoli cells in their seminiferous tubules. In 15.6% of all patients, the diagnosis in 1 testis differed from that in the other. In only 73.2% of those with testicular spermatozoa was it bilateral. In the remaining 26.9%, only Sertoli cells, spermatocytes or spermatids were found as the most mature cell type in the other testis. The study definitely indicates that fertilization with retrieved testicular spermatozoa should not be offered to azoospermic patients without prior evaluation of the seminiferous tubue spermatogenic pattern in both testes.

Liver Allografts from Donors older than 60: Benefits and Risks

Eytan Mor, Dan Shmueli, Ziv Ben-Ari, Nathan Bar-Nathan, Ezra Sharabani, Alexander Yussim, Boris Dorfman, Ran Tur-Kaspa, Zaki Shapira

Transplantation Dept. and Institute of Liver Diseases, Rabin Medical Center, Beilinson Campus; and Sackler School of Medicine, Tel Aviv University

With limited organ resources and an increasing number of candidates for liver transplantation, the world-wide trend is towards using liver allografts from donors older than 60 years. This strategy, however, may be hazardous because of the known correlation between advanced donor age and graft dysfunction. Since January 1996, each of 5 patients received a liver allograft from a donor older than 60 years. Preservation time in these cases was shortened as much as possible and liver allografts were used only if there were no other potential risk factors for primary nonfunction. Mean cold ischemic time was significantly shorter in this donor group (7.8 hrs) than for livers from 28 younger donors (10.2 hour; p<0.01). 3 of the 5 grafts from older donors had normal function immediately. The other 2 initially had biochemical features of preservation injury, but graft function returned to normal within the first week after transplantation. All 5 patients currently have normal graft function, with follow-up ranging from 3-8 months. There was no difference between the 5 recipients of grafts from older donors and 28 adult recipients of grafts from younger donors in extent of preservation injury and in immediate graft function. We conclude that in countries with limited organ resources, such as Israel, liver allografts from older donors can be used within defined limits and minimal preservation time.

Magnetic Resonance Imaging for Suspected Femoral Neck Fractures

M. Kligman, M. Roffman

Dept. of Orthopedic Surgery, Carmel Medical Center, Haifa

Painful hip as a result of injury, with or without a history of trauma, is a common reason for referring elderly patients to the emergency room. The diagnosis of femoral neck fracture requires the combination of a physical examination, X-rays, and in problematic cases, a bone scan. However, even this combination does not always provide a diagnosis. We present 50 patients with painful hip who complained of limp and reduced hip joint motion, but had no evidence of fracture, either on X-ray or bone scan. After conservative treatment, 5 patients with no history of trauma underwent hemiarthroplasty of the hip for displaced subcapital fracture. In addition, we present a case of subcapital fracture which was diagnosed only by MRI, in whom both X-rays and bone scan were considered normal.

Treatment of Open Fractures due to Dog Bite

A. Dimant, M. Liebergall, S. Porat R., Mosheiff

Orthopedic Dept., Hadassah-University Hospital, Ein Kerem, Jerusalem

2 patients aged 12 and 19, respectively, sustained open fractures of the wrists due to dog bites. Both were bitten on a wrist by Rotweiller dogs, but with different magnitudes of injury to bone and soft tissue. Treatment, clinical course and recovery are described, together with recommendations for dealing with open fractures due to animal bites. In the presence of considerable injury to soft tissue and bone, and of exposure to canine oral flora, open fractures due to dog bites should be dealt with as high grade open fractures.

Osteoid Osteoma of the Patella

I. Cohen, A. Aner, V. Rzetelny

Dept. of Orthopedics, Edith Wolfson Medical Center, Holon

Osteoid osteoma is a primary, benign, bone tumor with a typical X- ray appearance. The diagnosis is usually straightforward when it involves the long bones of the leg. However it may occur in unusual locations, such as in flat and cancellous bones. The following case demonstrates the difficulty in diagnosing it in an extremely rare site. A 25-year-old woman with long-standing anterior, right knee pain had had 3 interventions: 2 diagnostic arthroscopies and a distal, femoral biopsy. Since there had been no improvement in her condition, the diagnosis of osteoid osteoma of the patella was suggested, supported by recent X-ray and scintigraphicfindings. This rare condition was confirmed by biopsy of the upper pole of the patella, a procedure that was followed by complete recovery. 6 years later, she is now completely free of pain and has no clinical or X-ray evidence of recurrence.Review of the literature revealed only 5 previously reported cases of osteoid osteoma of the patella. All were diagnosed relatively late and in 1 the tumor was diagnosed only after total patellectomy. Diagnosis of these rare cases that mimic much more common causes of patello-femoral pain demands a high index of suspicion.

Glenoid Fossa Fracture

M. Kligman, M. Roffman

Dept. of Orthopedic Surgery, Carmel Medical Center, Haifa

4 patients with displaced intra-articular glenoid fossa were treated either surgically or conservatively. After an average follow-up of 7 years, the clinical and radiographic results were satisfactory in all. The 2 treated surgically required shorter follow-up than those treated conservatively. Conservative treatment should be considered a good option for displaced intra-articular glenoid fossa fracture.

Ct-Guided Core Needle Biopsy Of Abdominal, Pelvic And Retroperitoneal Masses

M. Sklair-Levy, A.I. Bloom, Y. Sherman, S. Fields, J. Bar-Ziv, Y. Libson

Depts. of Radiology and Pathology, Hadassah-University Hospital, Jerusalem

CT-guided core needle biopsy of abdominal, pelvic and retroperitoneal masses is accurate and safe and can be performed on an outpatient basis. Between 1987 and 1995, 809 patients (age range 1-87 years) underwent 851 biopsies (minimal lesion diameter 1 cm). Cutting needles were always used, facilitating both cytological and histological diagnosis while minimizing risk of complications. A positive result (malignant, inflammatory or infectious) was obtained in 69% of the 809 and a negative result (normal tissue) in 17.4%, while in 13.6%, material for diagnosis was insufficient. Biopsy was repeated in 42 of them in whom radiological or clinical suspicion of malignancy was high. In 24 (60%) a positive result was obtained after the second biopsy.

Significant complications occurred in 7 (0.8%). 1 hemo-rrhaged following liver biopsy and required blood transfusion. Pancreatitis occurred in 6 (2.6%) following pancreatic biopsy. An intra-abdominal fluid collection in 1 necessitated percutaneous drainage. There was no mortality following the procedure and no documented case of needle-tract seeding of tumor. All outpatients were discharged within 3 hours of completion of the biopsy, without ill effects.

Recurrent Late Hemarthrosis after Total Knee Replacement

David Hendel, Gad J. Velan

Dept. of Orthopedics, Rabin Medical Center, Golda Campus, Petah Tikva

A patient who had a successful total knee replacement for severe degenerative osteoarthritis of the right knee had an excellent functional result. 2 years after the operation there was spontaneous intra-articular bleeding that was treated successfully conservatively. Recurrent hemarthrosis 2 months later was treated similarly and also resolved without residual functional impairment after a follow-up of over 1 year. Recurrent late hemarthrosis in the knee is a fairly rare complication following total knee arthroplasty, but is amenable to conservative measures. Frequently, persistent recurrent hemarthrosis requires debridement of the bleeding synovium of the knee.

Femoral Fracture following Total Hip Replacement

M. Kligman, M. Roffman

Dept. of Orthopedic Surgery, Carmel Medical Center, Haifa

Between January 1990 and May 1996 we performed 500 total hip replacements, 6 of which were complicated by ipsilateral femoral fracture. Treatment was either by skeletal traction or by internal fixation, with or without revision-total hip replacement. Results of surgical treatment were superior to those of conservative treatment. This study supports use of Mennen plate-fixation. Further studies are necessary for final evaluation of the efficacy of this method.

Acute Fungal Endocarditis Due To Trichosporon Beigelli

Nahum Nesher, Alon Erez, Doron Nezer, R. Finkelstein, Y. Barel

Dept. of Cardiac Surgery, Rambam Medical Center, Haifa and Technion Faculty of Medicine

We report a 59-year-old woman with acute fungal endocarditis of a prosthetic valve caused by the endogenic organism, Trichosporon beigelli. This slowly developing disease mainly effects drug addicts who use intravenous narcotics. In nonaddicts it is rare, with mortality as high as 50%. There are only sporadic reports of T. beigelli as a complication long after open heart surgery. The ongoing infection is undetected for even several years after the primary infection, due to its prolonged latent phase. We present the difficulties of diagnosis, and of treating the disease with a combination of surgery and of long-term chemotherapy.

Hyperbaric Oxygen for Carbon Monoxide Poisoning

A. Abramovich, A. Shupak, Y. Ramon, O. Shoshani, Y. Bentur, G. Bar-Josef, U. Taitelman

Israel Naval Medical Institute, Israel Defense Forces Medical Corps, Haifa and Israel Poison Information Center, Intensive Care Unit and Pediatric Intensive Care Unit, Rambam Medical Center, Haifa

Severe cases of carbon monoxide (CO) poisoning from all over Israel are treated at the Israel Naval Medical Institute with hyperbaric oxygen (HBO). Between 1.11.94 and 15.2.95, 24 cases of CO poisoning were treated. Poisoning was usually due to domestic gas-fired heating systems, CO being the only toxin involved. Since delay between termination of CO exposure and arrival at the emergency department averaged 55 minutes, the level of carboxyhemoglobin measured on presentation did not always reflect the true severity of the poisoning. Poisoning was defined as severe and requiring HBO treatment when 1 or more of the following indications was present: evidence of neurological involvement, cardiographic signs of acute ischemic injury, metabolic acidosis, carboxyhemoglobin level greater than 25%, and pregnancy. 20 (84%) recovered consciousness during the course of 1 session (90 min.) of HBO treatment (p2 2.8 ATA) or immediately thereafter, with resolution of other signs of CO poisoning. 3 required a second treatment session before their symptoms resolved. A patient who arrived in deep coma with severe cerebral edema died. HBO is an important element in the combined treatment of severe CO poisoning. There should be greater awareness of the danger of CO poisoning and the means of preventing it, both among medical staff and the population as a whole, mainly in areas in which cold weather requires use of heating systems, which may be gas-fired.

Volume Reduction Surgery in Emphysema

M.R. Kramer, I. Bar, I. Eidelman, M. Bublil, I. Nitzan, C. Sprung, S. Godfrey, G. Merin

Depts. of Cardiothoracic Surgery and Anesthesiology, and Institute of Pulmonology, Hadassah-University Hospital and Hebrew University-Hadassah Medical School, Jerusalem

Volume reduction surgery (VRS) is a new procedure based on the concept that relieving hyperinflation in emphysema improves diaphragmatic and chest wall mechanics and ventilation perfusion mismatch. We present our early experience with 16 patients who underwent VRS from August 1995 to June 1996. Patient selection was based on: PFT, CT scan, V/Q scan, ABG's and 6-min walk. After pulmonary rehabilitation, operation was by median sternotomy and bilateral lung shaving. Pulmonary function improved significantly. FEV1 increased from 0.68 ± 0.2 to 1.0 ± 0.2 L (p<0.01) and FVC increased from 1.7 ± 0.5 to 2.7 ± 0.5 L (p<0.017). Total lung capacity decreased from 129% ± 24% to 108% ± 20% (p<0.03). 6-min walk increased from 221 ± 90 to 404 ± 123 meters (p<0.001). Complications included 1 death, prolonged air leak in 7 cases and infection in 2. Quality of life improved substantially in 12 of the 16 cases; in 3 cases there was only slight improvement and in 1 the condition became worse. Volume reduction surgery is a promising surgical solution in selected patients with advanced emphysema.