תוצאת חיפוש

Kleptomania: Phenomenological, Clinical and Legal Aspects

R. Durst, G. Katz, K. Jabotinsky-Rubin, H.Y. Knobler

Kfar Shaul Mental Health Center, Jerusalem

Kleptomania is currently classified in psychiatric nomenclature as one of the impulse control disorders (DSM-IV, 1994). It is characterized by repeated failure to resist impulses to steal objects, not for personal use or monetary gain. The objects are therefore discarded, given away, or hoarded (ICD-10, 1992). This disorder is known since the early 18th century from the phenomenological and clinical viewpoints, yet is still debated with regard to therapeutic strategies and criminal liability. Although there are usually complications associated with the legal consequences of being caught and arrested, subjects continue to violate the law despite repeated arrests and convictions. In a 28-year old man suffering from kleptomania, years of psychodynamic psychotherapy were ineffective. Only when he was treated as suffering from an impulse control disorder or a variant of obsessive-compulsive disorder, was there significant improvement. The positive response to buspirone (5-HT1A) augmentation of fluvoxamine (SSRI) suggested that disturbed central serotonergic neurotransmission might play an important role in the pathogenesis of kleptomania. This concept is strengthened by the comorbidity of the syndrome with depression and by its compulsive traits. We stress that although kleptomaniacs cannot differentiate between right and wrong, testing shows that their sense of reality is intact, but they act under the influence of drives they cannot resist.

Thoracoscopic Biopsy of Pulmonary Lesions in Nonpulmonary Malignancy following Chemotherapy

Oded Zamir, Myriam Weyl Ben-Arush, Dan Seror, Herbert R. Freund

Surgical Dept., Hadassah-University Hospital, Mount Scopus, Jerusalem and Miri Shitrit Pediatric Hematology and Oncology Unit, Rambam Medical Center, Haifa

The appearance of focal pulmonary lesions in a patient with a nonpulmonary malignancy is worrisome. Apart from metastasis, the differential diagnosis includes benign conditions such as infectious and granulomatous diseases, enlarged lymph nodes, atelectasis, radiation pneumonitis, and bronchiolitis obliterans with organizing pneumonia (BOOP). CT-guided needle biopsy is not always diagnostic and may not be feasible in very small lesions. Since open lung biopsy is associated with considerable morbidity, many physicians tend to postpone tissue diagnosis for a few weeks and perform a biopsy only if repeat chest CT scans show increase in size or number of the lesions. This approach may lead to undesirable delay of appropriate treatment. We report video-assisted thoracoscopic lung biopsy in 7 patients with nonpulmonary malignancy who developed lung lesions following chemotherapy and/or radiation therapy. Histological examination proved metastatic lesions in only 2. There were no operative complications and recovery was rapid and smooth in all patients. Thoracoscopic lung biopsy is an effective, minimally invasive diagnostic tool that obviates the need for thoracotomy in these patients.

Inhaled Budesonide for Chronic Obstructive Pulmonary Disease

Paltiel Weiner, Doron Zamir, Marinella Beckerman

Medical Dept A, Hillel Yaffe Medical Center, Hadera

A significant, large minority of patients with chronic obstructive pulmonary disease (COPD) respond favorably to corticosteroid treatment; but the benefit may be outweighed by its side effects. Long-term administration of inhaled steroids is a safe means of treatment. We hypothesized that treatment with inhaled budesonide would improve clinical symptoms and pulmonary function in subjects with COPD, and that the response to an inhaled B2-agonist would individualize steroid responders. In 44 patients with stable COPD in a double- blind crossover trial, we compared a 6-week course of inhalations of 800 mg/d budesonide with a placebo, separated by a 4-week interval when no medication was taken. In 33 out of 42 responders to the B2-agonist who remained in the study, there was a significant improvement in FEV1 of greater than 20% following budesonide inhalation, as compared to placebo. There was also a significant difference between the 2 periods of treatment as to the mean number of B2-agonist inhalations. We conclude that about 1/4 of patients with stable COPD respond to bronchodilators, and treatment with inhaled steroids improves spirometry data and inhaled B2-agonist consumption in about 3/4.

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.