תוצאת חיפוש

Traumatic Brain Injury: The National Trauma Registry*

Einat Peles, Vita Barell, Valentina Boyko, Arnona Ziv, Giora Kaplan

Health Services Research Unit, Ministry of Health, Sheba Medical Center Tel-Hashomer

Background: Traumatic Brain Injury (TBI) has been established as a category in reporting systems. Uniform data systems case definition has been suggested for hospital discharge data surveillance systems cases based on ICD-9-CM diagnostic codes. These include fractures and specific mention of intracranial injuries such as contusion, laceration, hemorrhage, and concussion. Inspection of data from the Israel National Trauma Registry suggested that two diagnostic groups of very different severity and outcome were being unjustifiably combined.

Aim: To evaluate the validity of categorizing TBI into two discrete groups, using the presence of specific mention of intracranial injury and/or loss of consciousness for more than one hour as the definition of definite TBI. Possible TBI includes skull fractures with no mention of intracranial injury and/or concussion with no loss of consciousness.

Methods: The study population includes all traumatic injuries admitted to hospital, dying in the ER or transferred to other hospitals and recorded in the 1998 Trauma Registry in all 6 level I trauma centers in Israel and two level II centers.

Results: The significant difference in severity between groups supports the validity of sub-dividing the TBI classification into definite and possible subcategories. As a result, we obtain two different severity groups without measuring specific severity scores which are limited in the reporting system.

Conclusion: The groups were significantly different in severity, hospital resource use, immediate outcome, demographic and injury circumstances.

*           Level I: Rambam, Beilinson-Schneider, Sheba, Ichilov (Tel Aviv Sourasky Medical Center), Hadassah Ein Karem and Soroka.

            Level II: Hillel Yaffe and Kaplan

Antidepressive Effect of Pyridoxine (Vitamin B₆) in Neuroleptic-Treated Schizophrenic Patients with Co-Morbid Minor Depression - Preliminary Open-Label Trial

Roni Shiloh¹, Abraham Weizman¹, Nechama Weizer¹, Pnina Dorfman-Etrog¹, Hanan Munitz¹ 

¹Geha Psychiatric Hospital, Felsenstein Medical Research Center, Rabin Medical Center, Beilinson Campus, Petah Tikva; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Background: Minor depression is reported in 20-60% of schizophrenic patients during various stages of their disorders; impairing patients' compliance, response to treatment and worsening their overall prognosis. Various anti-depressive treatments have been proposed for such cases but response rates are usually poor. Pyridoxine (Vitamin B⁶) in essential for the proper metabolism of various neurotransmitters that are considered relevant to the pathophysiology of depression and/or schizophrenia and it has been reported beneficial in ameliorating depressive symptoms as part of major depression, premenstrual syndrome or 'Chinese restaurant syndrome'. We hypothesized that addition of pyridoxine to on-going neuroleptic treatment could improve minor depression in schizophrenic patients.

Method: Nine schizophrenic patients with co-morbid minor depression participated in this study. All participants had a stable unchanged clinical state (changes in Brief Psychiatric Rating Scale (BPRS). Scale for the Assessment of Positive Symptoms (SAPS), and Scale for the Assessment of Negative symptoms (SANS) scores <5%) and all were maintained on unchanged doses of anti-psychotic drugs for at least 4 consecutive weeks prior to initiation of the study.

Participants received, open-label, pyridoxine 150 mg/day in addition to their anti-psychotic treatment for 4 consecutive weeks. Mental status was evaluated before, during, and at the end of 4 weeks of pyridoxine administration using the BPRS, SAPS, SANS and HAM-D.

Results: Two of the nine patients (22%), characterized by higher initial HAM-D and SANS scores, and by older age and longer duration of illness, experienced marked improvements in depressive symptoms (23% and 28% decrease in HAM-D scores) following 4 weeks of pyridoxine administration. In one of these two, the improvement in depressive symptoms was accompanied by a parallel decrease in SANS Scores.

Conclusion: A subgroup of schizophrenic patients with co-morbid minor depression may benefit from pyridoxine addition to their on-going anti-psychotic treatment.

בן עמי סלע

המכון לכימיה פתולוגית, מרכז רפואי שיבא, תל-השומר; החוג לביוכימיה קלינית, הפקולטה לרפואה סאקלר, אוניברסיטת תל-אביב

מדי שנה, כ-40% מכלל המעשנים מנסים, או לפחות מצהירים על רצונם להיגמל מעישון, אך רק כ-6% מתוכם אכן מצליחים במשימה זו לטווח ארוך. גם שיטות הגמילה עם תחליפי-הניקוטין, כגון טבליות הלעיסה או הדיסקיות המוצמדות לעור, העלו את שיעור הנגמלים פי 1.4 עד 2.6 בהשוואה לנוטלי האינבו, אך 80%-70% מבין אלה שחדלו לעשן באמצעות תחליפי-ניקוטין, חזרו תוך שנתיים לשיגרת העישון.

ניסויים לגמילה מעישון באמצעות תרופות נוגדות-דיכאון נמצאים לאחרונה בקו-עלייה. כך לדוגמה, התכשיר nortriptyline התלת-ציקלי, נמצא מכפיל את שיעורי הגמילה, ותוצאות מבטיחות התקבלו עם doxepin ו-fluoxtein. ייתכן, שההצלחה היחסית של נוגדי-דיכאון בגמילה מעישון, מקורה בקשר הגורדי בין דיכאוניות ועישון: מעשנים עם רקע דיכאוני תלויים יותר בניקוטין והצלחתם בגמילה פחותה, שכן דיכאון הוא אחד מתסמיני הגמילה הבולטים אצלם. עישון סיגריות מביא גם כן להפחתת פעילות האנזים monoamine oxidase B במוח במנגנון שאינו שאינו קשור לניקוטין, ובכך משתמרת יותר רמת הדופאמין, בעלת השלכות נוגדות-דיכאון.

Malignant Humoral Hypercalcemia Associated with Angiotropic Large B Cell Lymphoma: Case Report

Boleslaw Knobel, MD;^1,5 Ilan Sommer, MD;¹ Pauline Petchenko, MD;² Dorit Lev, MD; ³ Elimelech Okon, MD;^4,5

¹Department of Medicine "B", ²Department of Hematology, ³Institute of Genetics, Edith Wolfson Medical Center, Holon ⁴Department of Pathology, Rabin Medical Center, Petach Tikva and 5Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Angiotropic large B cell lymphoma (angiotropic LCL) or intravascular large cell lymphoma (IVLCL) was diagnosed by liver and bone marrow biopsies and immunohistochemical studies in a 52 year old Caucasian male.

IVLCL is a very rare disease characterized by widespread intravascular proliferation of lymphoma cells. Although it most commonly affects the central nervous system or skin and occasionally bone marrow, angiotropic LCL may be present without evidence of localized disease, as seen initially in our patient.

To date, only a few cases of intravascular malignant lymphomatosis associated with parathyroid hormone related protein (PTH-rP) induced humoral hypercalcemia have been published.

Our extraordinary case was diagnosed mainly by liver biopsy. The neoplastic lymphoid cells stained diffusely and strongly positive with CD-20 (Pan B) and were negative for CD-3 (Pan T) immunostain.

The most significant, initial clinical finding was severe, unexplained hypercalcemia (until 18.6 mg/dl). Plasma PTH-rP showed a ten-fold increase at 8 pmol/L (normal value less than 0.8 pmol/L). Very unusual cytogenic abnormalities were found.

The patient received the massive third generation combination chemotherapy comprising of Methotrexate, Doxorubicine, Cyclophosphamide, Vincristine, Prednisone and Bleomycin and developed, complete although temporary, clinical, humoral and cytogenetic remission.

ענבר צוקר¹, לאה סירוטה¹, נחמה לינדר¹

¹המח' לטיפול נמרץ פגים, מרכז שניידר לרפואת ילדים בישראל, פתח-תקווה

ילודים, ובמיוחד פגים במשקל לידה נמוך, נמנים עם קבוצות החולים הנזקקות בשכיחות גבוהה לערויי-דם ותוצריו. על פי הערכות, כ- 80% מהילודים השוקלים פחות מ- 1500 ג', יקבלו מספר ערויי-דם בשבועות הראשונים לחייהם. ערויים אלה ניתנים כדי לתקן אנמיה תסמינית, הנגרמת כתוצאה ממישלב של חסר ייצור מספיק של דם ע"י הילוד ובמיוחד הפג הגדל, ושל איבודי דם מישניים לבדיקות. לעיתים, ניתנים ערויים במסגרת פעולות טיפוליות מיוחדות, המצריכות מתן ערויי דם בכמות גדולה, כגון ניתוחי לב וערוי חלופין. הטיפול בערויי דם יכול לגרום לשורה של סיבוכים מיידיים ומאוחרים. חלקם יכולים לחול בכל קבוצת גיל וחלקם ייחודיים לילודים. המטרה בסקירה זו היא לדווח על הסיבוכים האפשריים של ממתן ערוי-דם בילודים, תוך התייחסות למאפיינים הייחודיים לתת-אוכלוסייה זו של חולים.
 

עבד אלנאסר עזב, יורי ירוסלבסקי,

המח' לפארמאקולוגיה קלינית, אוניברסיטת בן-גוריון בנגב, המרכז לבריאות הנפש, באר-שבע

כיום, מצויה ספרות רחבת יריעה המתבססת על עבודות קליניות המצביעה על כך, שליתיום (litium) לא יוכל לתת מענה לכל החולים הלוקים במחלה אפקטיבית דו-קוטבית (מא"ד), ומכך נבע הצורך בחיפוש אחר אפשרויות טיפוליות נוספות. התרופות הראשונות שיעילותן הוכחה במחקרים קליניים מבוקרים (כפולי-סמיות) הן התרופות נוגדות הכיפיון (תנ"כ), קארבאמזפין חדישות, כגון לאמוטריגין (lamorigine), שגם לגביו קיימת עדות קלינית מצטברת והולכת שהוא עוזר לטיפול במחלה אפקטיבית דו-קוטבית.

את מנגנון הפעולה של התנ"כ (המשמשות כיום לטיפול במא"ד) ניתן לסווג באופן כללי לשלושה סוגים: 1) הגבלת הירי החשמלי המתמשך (היח"מ, sustained repetitive firing) של הנירונים, המושגת דרך הארכת תקופת האיבטול של תעלות נתרן. 2) הגברת השפעת (GABA) הגורמת להשפעה מעכבת באותן סינאפסות. 3) חסימה של תעלות סידן, בעיקר של תעלות בעלות סף נמוך (T-type). עם זאת, המנגנון שעומד מאחורי היות התנ"כ הנ"ל תרופות שעוזרות לטיפול במא"ד, עדיין אינו ברור.

חשוב לציין, שהמשותף לכל התנ"כ הללו הוא יכולתן לחסות את תעלות הנתרן (voltage-activeted sodium channel blockade), אך למרות זאת, התרופה פניטואין, החוסמת ביעילות אותן תעלות נתרן, עדיין לא ניתנה כטיפול במא"ד, על אף העובדה שהיא משמשת כתרופה נוגדת כיפיון כבר קרוב לשישה עשורים. לכן, היה עניין רב לבדוק את ההפעה הנטימאנית של פניטואין ובסקירה זו, יובאו התוצאות של עבודה ראשונית שנעשתה לבדיקת השפעות אלו של התרופה בקרב חולים עם מא"ד ובחולים סכיזואפקטיביים, שבהם נמצאה השפעה חיובית של התרופה.
 

Photodynamic Therapy of Nasal Basal Cell Carcinoma

R. Haddad, M. Cohen, O. Kaplan, R. Greenberg, H. Kashtan

Dept. of Surgery, Tel Aviv-Sourasky Medical Center

Photodynamic therapy (PDT) is a noninvasive modality used topically for several skin cancers. We evaluated the effects of PDT on basal cell carcinoma (BCC) of the nose, using aminolevulinic acid (ALA) as a photosensitizer and a non-laser light source (Versa-LightTM). The advantages of this light source are synergistic, hyperthermia and fewer side effects.

A paste of 20% ALA was applied topically to biopsy-proven BCC of the nose. Lesions were covered with occlusive light-shielding dressing and after 18 hours they were submitted to 10 minutes of exposure to the light. Initial evaluation was made after 21 days and every 3 months thereafter. Patients who did not respond after 2 treatments were referred for surgery.

Mean follow-up in 31 patients was 19 months (range 6-36). There were no significant side-effects. There was complete response in 24/27 (88.9%), in whom there was recurrence in 2/27 (7.4%).
 

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.

Burch Laparoscopic Procedure for Repairing Proven Stress Incontinence

Moshe Bustan, Shabtai Romano, Raed Salim, Jacob Rosenman, Eliezer Shalev

Depts. of Obstetric and Gynecology and of Urology, HaEmek Medical Center, Afula

There are more than 200 procedures for repairing stress urinary incontinence. We evaluated the safety and efficiency of the Burch laparoscopic procedure in 32 women with urodynamically proven genuine stress incontinence.

Mean operating time was 40 minutes and mean hospitalization time after the procedure was 30 hours. The cure rate was 97%, similar to that rin other studies (80-95%). The major complications w2 cases (6.2%) of unintended bladder injury, diagnosed and repaired laparoscopically. Although follow-up has only been for 3-42 months, the high cure rate and safety and advantages of laparoscopy over laparotomy, make laparoscopic Burch colposuspension the procedure of choice for repairing stress incontinence.

Nutritional Status and Vitamin B⁶ Supplementation in the Institutionalized Elderly

Felicia Stern, Yitshal N. Berner, Zeev Polyak, Sophya Bernadiner, Margarita Komarnitsky, Ben Ami Sela, Ram Doolman, Yoseph Dror

Institute of Biochemistry, Food Science, and Nutrition, Hebrew University of Jerusalem; Subacute Dept. and Clinical Nutrition, Hartzfeld Geriatric Hospital, Kaplan Medical Center, Gedera; and Institute of Chemical Pathology, Sheba Medical Center, Tel Hashomer

Nutritional status and vitamin B⁶ status were assessed in 18 men and 32 women, average age 84, living in a home for the aged. Average proportion of energy derived from protein was higher than the recommended; fiber intake was very low. Also low were intakes of calcium, magnesium, zinc, copper, vitamins D and E, thiamin, folic acid and vitamin B⁶.

Supplementation with vitamin B⁶ (10mg/d) for 28 days in those with the lowest B⁶ status assessed by B⁶ intake, activation coefficient of aspartate transaminase and plasma pyridoxamine concentrations led to improved B⁶ status (marked decrease in activation coefficient) and increased synthesis and decreased degradation of many short-lived neutrophil proteins. Though our elderly enjoy a variety of foods, some have marginal deficiencies that can be improved. Therefore, in the institutionalized elderly, micronutrient supplementation should be administered at a level low enough to be safe (below recommended upper level of intake) but high enough to be effective.

רונית חיימוב-קוכמן¹, ראובן ברומיקר², אריאל מילויצקי¹

¹מחלקת נשים ויולדות ²והמחלקה לטיפול נמרץ בילוד, בי"ח הדסה הר הצופים, הפקולטה לרפואה, האוניברסיטה העברית, ירושלים

Psychological Treatment for Paruresis (Bashful Bladder)

Baruch Elitzur

Psychiatric Clinic, Ichilov Hospital, Tel Aviv Medical Center

Paruresis, or bashful bladder, is a functional disorder that involves inability to urinate in the presence of others. The symptom meets the DSM-IV diagnostic criteria for simple phobia or social phobia. Although the prevalence of paruresis is relatively high (7% in 1 study and 32% in another), there are few reports of its treatment. The treatment of choice presented in the literature is cognitive-behavioral.

We describe a multidimensional model used in treating 3 men who suffered from paruresis. Promotion of relaxation, mental imagery, paradox, gestalt, metaphor, cognitive-behavioral and psychodynamic techniques were used. After 5 treatment meetings, 2 younger men, 18- and 24-years old, respectively, were able to overcome the condition, while a 50-year-old got only partial relief.

The Gift of Breastfeeding 

Dorit Nitzan Kaluski, Alex Leventhal

Dept. of Nutrition, Public Health Services, Israel Ministry of Health, Jerusalem

Breast milk is the optimal food for infant growth and development, the prevention of infectious diseases and mother- child bonding. From the economic perspective, breastfeeding is cost-effective both for the family and society as a whole. The Israeli Ministry of Health encourages breastfeeding as the exclusive source of nutrition for infants in the first 4-6 months of life, with gradual addition of complementary foods thereafter. The promotion of breastfeeding in Israel requires comprehensive national activity with involvement of all the stakeholders. This includes implementation of the International Code of Marketing of Breast Milk Substitutes and joining the international "Baby Friendly Hospitals" project. Knowledge of breastfeeding should be spread, health professionals should be encouraged to become agents of change, support by breast counselors should be encouraged, post-delivery vacations from work should be prolonged and empowerment of women implemented.

High Dose Endobronchial Brachy - Therapy for Malignant Airway Obstruction

Alex Yarmolovsky, Alan Katz, Eyal Fenig, G. Fink, Daniel Bendayan, Aaron Sulkes, Mordechai R. Kramer

Institutes of Pulmonology and Oncology, Rabin Medical Center, Beilinson Campus, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University

Brachytherapy is especially suitable for palliative treatment of endobronchial tumors adjacent to internal organs that might be damaged by intensive external beam radiation, but are easily accessed with a flexible bronchoscope. This treatment is mostly palliative.

30 patients underwent such palliative high-dose endobronchial brachytherapy to alleviate malignant airway obstruction. With the aid of a flexible fiberoptic bronchoscope an endobronchial catheter was inserted adjacent to the tumor and treatment delivered using a 192Ir remote afterloader for 5-10 min, in 2 or 3 sessions.

There was symptomatic improvement in 26 (86%) and objective improvement in 27 (90%). 1 patient died of hemoptysis.

Cortical Blindness Following Coronary Angiography 

Addie Ron, Simcha Meisel, Myra Shapiro-Feinberg,Herman O. Klein

Depts. of Medicine, Cardiology and Diagnostic Imaging,Meir Medical Center, Kfar Saba

Cortical blindness has been occasionally reported as a complication after cerebral angiography, but is rare after coronary angiography. The contrast agent is believed to be responsible for the sudden development of blindness. Although the exact mechanism is unknown, it appears that the contrast agent disrupts the blood brain barrier, mostly in the occipital areas.

We report a 77-year-old man who suddenly developed transient, bilateral cortical blindness 4 hours after coronary angiography. Using contrast enhancement, the CT scan showed typical, symmetrical involvement of both occipital lobes. There were no other neurological deficits. Vision and CT findings returned to normal within 48 hours.