תוצאת חיפוש

Treatment of Hypertension with Losartan

R. Zimlichman

Dept. of Medicine and Hypertension, Wolfson Medical Center, Holon

The efficacy, safety and side-effects of treatment with losartan (Ocsaar) was studied for the first time in Israel in a large group of patients with mild to moderate hypertension in several community clinics. The 421 patients (51% men) aged 30-86 years (mean 58.6) received 50 mg of losartan daily, increased when necessary to 100 mg, and/or a second antihypertensive drug was given. After 4 weeks blood pressure was normalized in 344 and after 12 weeks in 363. Side-effects were minimal and treatment was effective in all age groups.

Malaria in Travelers Returning from Endemic Areas

Andre Matalon, Amos Yinnon

Kupat Cholim Klalit, Dan-Petah Tikva District, and Dept. of Family Medicine, Tel Aviv University; and Infectious Disease Unit, Shaare Zedek Hospital and Hebrew University-Hadassah Medical School, Jerusalem

2 cases of malaria in family practice are described in a 26- and a 50-year-old woman. Both probably could have been prevented had common chemoprophylactic drugs been taken. The risk of malaria is greater than the risk of possible side-effects of the drugs commonly used by travelers for prevention. Family physicians must be aware of the possibility of malaria in young people with fever, especially those who have travelled to equatorial areas and special attention should be given to encourage chemoprophylaxis.

Low Prevalence of Hepatitis G Infection in Dialysis Patients

Doron Zamir, Shimon Shtorch, Chen Zamir, Zvi Fireman, Hilkiau Zonder

Internal Medicine Dept. A, Liver Clinic, Dialysis Unit and GI Unit, Hillel Yaffe Hospital and Hadera Subdistrict Health Office

Prevalence of hepatitis G virus (HGV) infection in the general western population ranges from 0.2-1.5%. In high-risk groups, such as patients with chronic liver disease, hematologic disorders and drug addicts, prevalence is as high as 10%-15%. Dialysis patients have increased rates of HGV infection (6%-50%).

We evaluated prevalence of HGV infection among dialysis patients, and the association between HGV infection and hepatitis C virus (HCV) infection. Serum samples were screened for HGV infection by RT-PCR. Screening for HCV infection was performed by an EIA test and confirmed by RIBA and RT-PCR for HCV. Sera were also tested for HBV markers.

The study group included all 78 hemodialysis patients and 7 of the 12 peritoneal dialysis patients in our unit during September to November 1997. 4 (5.2%) were HGV-positive but none were peritoneal dialysis patients. 1 of the 12 HCV-positives was also infected with HGV. HGV infection was not associated with duration of dialysis, number of blood transfusions or levels of transaminases.

Prevalence of HGV infection among our hemodialysis patients was low (5.2%), but higher than reported for the general population. Prevalence of HGV/HCV infection in hemodialysis patients was low and unrelated to duration of dialysis, number of blood transfusions and levels of transaminases.

Patient Satisfaction and Hospital Services Evaluation by Regular and Private Patients

Sara Carmel, Jonathan Halevy

Dept. of the Sociology of Health, Faculty of Health Sciences, Ben-Gurion University of

the Negev, Beer Sheba; Sha'are Zedek Medical Center and Hebrew University-Hadassah Medical School, Jerusalem

"Sharap" is a private medical service integrated within our public clinic and hospital services. Clients may choose their physician by paying a fee in addition to what their health insurance agency (Kupat Holim) pays for. All other hospital services are supplied to all patients alike. The main purpose of this study was to evaluate the extent to which this declared policy is maintained in practice.

During 5 months in 1997, 198 Sharap patients and 198 regular patients were interviewed in the the general surgery, cardiac surgery, ENT, cardiology, newborn and gynecology wards of this hospital. Both groups were similar in regard to cause of hospitalization, gender, age group (10-year age ranges), and length of hospitalization (at least 24 hours).

Similar levels of satisfaction with hospitalization in general and with the nursing service and with supportive services were found in both groups. However, Sharap patients were more satisfied with their physicians than regular patients (87% vs 74%, respectively). Similar results were also found using indirect measures of satisfaction. About 86% in both groups reported having achieved the goal of improvement in health. A high proportion of respondents from both groups (82% and 88%, respectively) could not distinguish between Sharap and regular patients in the ward. However, a greater proportion of regular patients (35% vs 21%) wanted more extensive explanations from their physicians regarding their treatment.

Sharap patients belonged to higher socio-economic classes than regular patients. Our evaluation indicates that although the Sharap service enables the affluent to choose their preferred physician, resulting in a different doctor-patient relationship, the service does not create a significant feeling of discrimination among hospitalized patients, and does not interfere with the high level of health services available to the public at large.

Apomorphine for "Off-Periods" in Parkinson's Disease

J. Zoldan, D. Merims, A. Kuritzky, I. Ziv, E. Melamed

Dept. of Neurology, Rabin Medical Center, Beilinson Campus, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University

After 3-5 years of continuous use of 1-dopa preparations for Parkinson's disease, 25%-50% of patients develop side-effects such as the "on-off" phenomenon and involuntary movements that markedly impair function. One cause of these manifestations is evidently a disturbance in the absorption of 1-dopa.

We attempted to avoid this problem by using subcutaneous injections. Apomorphine is a rapid-acting dopamine agonist which causes a return from "off" to "on" within minutes.

We present the results of a trial of subcutaneous injections of apomorphine in 22 Parkinsonian patients (12 males, 10 females) with severe motor fluctuations. During 5 days prior to the apomorphine all received Motilium (domperidone, 60 mg/d) to prevent nausea and vomiting. All were hospitalized initially to determine optimal dosage and to teach them the technique of self-injection.

2 to 4 mg of apomorphine were injected 1 to 3 times daily for 2 to 12 months. In 17 patients (80%) "off" periods were reduced without significant side-effects. Apomorphine seems to be effective, tolerable treatment for shortening 1-dopa induced "off" periods.

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.

Clozapine in the Treatment of Schizophrenia

M. Mark, R. Magnezi, O. Luxenburg, M. Siebzehner, J. Shemer

Israel Center for Technology Assessment in Health Care, Sackler Faculty of Medicine, Tel Aviv University

Schizophrenia is associated with brain abnormalities and is typically evidenced by disorganized speech and behavior, delusions, and hallucinations; it usually requires extended hospitalization. Its incidence in the western world is estimated at 4-7 cases/10,000/year.

A method of shortening hospitalization and improving level of functioning is the use of unique medication, including clozapine, which has been in use in Israel for the past 6 years.

We report 327 patients who participated in a community rehabilitation program and were treated with clozapine. They were compared with 417 patients who corresponded to the guidelines of the Director of Mental Health Services for treatment with clozapine, but were not treated with it for reasons not defined in the guidelines.

The study included those 25-44 and 45-64 years of age and according to the division of the population of patients hospitalized in both government and private hospitals. The project demonstrates the savings from use of clozapine as opposed to the alternative of hospitalizing these patients. It also shows the complexity and difficulty in assimilating new technologies, in relation to the influence of social considerations and supplier/insurer accounting on the patterns of technological assimilation.

Ferritin in Adult Still's Disease

E. Flatau, N. Reichman, N. Kaufman

Dept. of Medicine B, Central Hospital of the Emek, Afula and Technion Faculty of Medicine, Haifa

Adult-onset Still's disease (AOSD) is characterized by a spiking fever and diverse clinical findings; the diagnosis is often delayed for months or even years. The only positive laboratory finding is neutrophilic leukocytosis. Since 1987, the diagnostic importance of elevated serum ferritin levels has been discussed in numerous papers, but is not yet among the diagnostic criteria for AOSD. We describe a case in which the finding of extreme hyperferritinemia enabled prompt diagnosis and treatment.

Relapse of Sarcoidosis after Alternative Medical Treatment

Georgy Edelson, Yair Levy, Yehuda Shoenfeld

Dept. of Medicine B, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Reference to alternative medicine frequently appears in newspaper headlines, advertisements and in articles in medical journals. The practice of alternative medicine has increased, even as the number of critical articles warning of deleterious effects have also increased. Public demand is strong and growing, but there are no clear rules as to what is not permissible, particularly when treatment is not by qualified physicians. There are still no clear indications and contra-indications for complementary (not alternative) medicine in patients with organic injuries and life-threatening conditions. However, it is obvious that in these patients complementary medicine should not be substituted for conventional therapy.

We present a 32-year-old man with sarcoidosis who discontinued conventional therapy on his own initiative and began alternative medicine (homeopathy) with subsequent deterioration in his condition. He was hospitalized for a relapse of his sarcoidosis which required large doses of corticosteroids.

Nephron-Sparing Surgery - Initial Experience with 50 Patients

Sarel Halachmi, Alexander Kastin, Boaz Moskovitz, Ofer Nativ

Urology Dept., Bnai Zion Medical Center, Haifa

During recent years the use of the new imaging techniques, ultrasonography and computerized tomography, has increased. The accessibility to these methods has changed the pattern of detection of renal lesions. Over 90% of renal masses are now discovered incidentally, while investigating nonurological symptoms. Therefor, most lesions are discovered in their early stages.

The gold-standard procedure for removing renal masses is radical nephrectomy, which ensures complete removal of an organ-confined lesion, but involves loss of functional tissue. This might be critical in patients with a single kidney, or reduced nephron function. There are several diseases characterized by multiple renal lesions, such as Von Hippel-Lindau and tuberous sclerosis in which radical treatment may lead to chronic dialysis in young patients.

Nephron-sparing surgery was developed in order to preserve as much functional tissue as possible while removing safely any suspicious renal lesion. This new technique, not involving radical surgery, should be evaluated in cases of renal tumors for its ability to achieve the same cancer cures rates. We present our experience with our first 50 patients who underwent nephron-sparing surgery for removal of renal lesions.
 

Adjuvant Therapy of Large Bowel Carcinoma

G. Ezekiel, S. Walfisch, Y. Cohen*

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

The National Institutes of Health (NIH) held a consensus conference which recommended 5-FU and levamisole as adjuvant chemotherapy for colon cancer MAC (Modified Astler Coller) stage C.

From 1991-1994, 37 such patients diagnosed here were treated with 5-FU (intravenous dose of 450/mg/m²/d for 5 days and from day 29, once a week for 48 weeks) and oral levamisole (50 mg 3 times/d. for 3 days, every 2 weeks for a year), as suggested by NIH guidelines.

16 patients were males and 21 were females, mean age was 62 years and median 64. Cancer locations were: right colon (in 16, 43%), left colon (19, 51%), multiple colon primaries (2, 1%). 25 (68%) had 1-3 positive lymph nodes and 12 (32%) had 4 or more positive lymph nodes.

Only 20 (54%) finished treatment as prescribed. In the others, 1 or both drugs caused side-effects for which the drugs had to be stopped. 6 patients relapsed while on treatment.

The most common side-effects were diarrhea, stomatitis and bone marrow suppression. 3 were hospitalized due to neutropenic fever. 5-year actuarial survival of all patients was 61%; 5-year relapse-free survival was 61%; 5-year relapse-free survival of right versus left colon was 41% and 82%, respectively (p<0.01). There was no significant difference in 5-year survival of those with 1-3 positive lymph nodes as compared to those with 4 or more (62% and 56%, respectively). 5-year survival in those who finished or did not finish treatment (excluding those who stopped treatment because of progressive disease) was 83% and 70%, respectively (NS).

The 5-year survival of our series was similar to that of patients treated similarly elsewhere. The 5-FU and levamisole treatment was not tolerated well by our study population. It has recently been replaced in our service by a 5-FU and leucovorin regimen given for 6 months.

* Jules E. Harris Chair in Oncology.

Acute, Painful, Swollen Testis

Dan Leibovici, Simon Strauss, Ahuva Sharon

Dept. of Urology, Ultrasound Unit, Institute of Diagnostic Imaging and Medical Dept., Assaf Harofeh Medical Center and Sackler Faculty of Medicine, Tel Aviv University

An acutely painful and swollen testis mandates urgent diagnostic and therapeutic measures since this symptom complex may indicate torsion of the testis. Prompt scrotal exploration is necessary if the testis is to be saved from ischemic necrosis.

Polyarteritis nodosa (PAN) is a vasculitis involving mainly medium and small sized arteries and may damage any organ. In PAN, the presentation of an acutely painful and swollen testis raises a perplexing diagnostic problem since the symptoms may be related to vasculitis involving the testis on the one hand, or represent primary testicular pathology unrelated to the underlying PAN. A 31-year-old man with PAN who presented with acute pain and swelling in a solitary testis is reported.

1000 Cardiac Catheterizations in Congenital Heart Disease

Benjamin Zeevi, Galit Bar-Mor, Michael Berant

Cardiac Catheterization Unit, Schneider Children's Medical Center, and Sackler School of Medicine, Tel Aviv University

Over the past 15 years, percutaneous therapeutic cardiac catheterization has become increasingly important in the treatment of congenital heart disease. We describe our experience in 1000 such catheterizations between 1993-1997. 55% were in 1-12-year-olds; only 20% were in patients younger than 1 year old and 11.3% were in adults with congenital heart defects. In about 50% it was at least a second cardiac catheterization. Overall, there were 425 therapeutic cardiac catheterizations, increasing from 33% in the first 200 procedures, to 63% in the last 200.

We performed 30 different types of therapeutic catheterizations: 23.3% were valvular dilations, 21.4% vessel angioplasties, 36.9% closure procedures, 9.2% electrophysiological procedures, and 9.2% miscellaneous. In 31.3% of therapeutic catheterizations we used 12 new procedures. Minor complications occurred in 8.5% and major in 0.6%; most complications were successfully treated or were self-limited and there was no residual damage.

In this report the current role of each type of major catheterization is discussed on the basis of our experience. Further development of technology for lesions not amenable to currently available transcatheter methods, and longer follow-up for current techniques will consolidate the role of therapeutic cardiac catheterization in congenital heart disease.

Home Palliative Care of Terminal Cancer Patients, with Family Feedback

Hana Arad, Hana Geva, Valery Rosin, Ruth Kibrik, Isaac Kersz

Home Care Unit of Kupat Holim Haklalit, HaEmek Medical Center, Afula and Quality Improvement Unit, Rambam Medical Center, Haifa

Palliative care of terminal cancer patients is one of the tasks of our Home Care Unit. Increasing hospitalization costs have brought forward the decision to treat them at home, assuming that they would prefer to return and die in their natural surroundings, among family.

Most of our patients are aged, recent immigrants from the Soviet Union, of low socioeconomic status; most live with their close families. Our care model combines social, cultural, economic, medical and nursing aspects. More patients choose to die at home, and that is where costs are minimal. Care management and characteristics of 44 terminal cancer patients, who died between January and October 1996, are described. Living with a family was not required for treatment at home. Length of care by the unit ranged from 1-48 weeks, with an average of 8.5 and a median of 6. 55% of patients were hospitalized, most (58%) for 5-9 days for noncancerous diseases, and then discharged home. 54% died at home, a third were hospitalized for 2-17 days before death. Compared to the average length of stay in palliative care oncology wards, 1044 days and more than NIS 500,000 were saved.

A telephone survey examined families' satisfaction with various components of care. 92% were satisfied with the home treatment. 79%-82% felt that the nurse and doctor of the team met their needs and expectations. Half the families were satisfied with the treatment of pain. Families in which treatment was 24 weeks or more were generally less satisfied than those with shorter treatment at home. We learned that an early entry into treatment is necessary; hospital referral criteria should consider to a greater extent the coping ability of families; nursing aid hours should be increased and professional emotional support added; additional pain control methods should be used. All these would strengthen families, improve quality of care, and contribute to additional savings by decreasing hospital stay.

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.