תוצאת חיפוש

Influence of Warning Labels on Medicines and Physicians' Orders on Patient Behavior

Yehuda Limony, Pesah Shwarzman

Child Health Center of Kupat Holim Klalit, Kiryat Gat and Dept. of Family Medicine, Ben-Gurion University of the Negev, Beer Sheba

Compliance of 40 mothers with a warning label, "for external use," on a medicine package was checked in a survey in a primary care clinic for children. We also checked parents' attitudes to giving a medicine to their child when instructions given by the physician or by a friend contradicted the printed warning on the label. All mothers who were told that the medicine was recommended by their physicians accepted the recommendation without hesitation. Another group included 20 mothers who were told that the medicine was recommended by a friend. 9 of 20 mothers in this group refused to use the medicine. Talking with the nurse about the potential risk of medicine in general, some mothers, after second thought, refused to give the medicine to their child. At the end, 65% of recommendations made by a friend were rejected by mothers as compared to only 15% of the physicians' recommendations.

35 of 40 mothers (87%) understood the meaning of the warning label, but only 13 (32%) had noticed it at all. We conclude that patients may accept their physicians' recommendation to use a medicine despite a contradictory warning label much more readily than when it was recommended by a friend. Therefore, any intervention program intended to promote a more cautious use of medicines should include not only the explanations of the various warning labels but should also promote a change in the patient's behavior to a more active search for warning labels.

Radiologic Appearance of "Falling Gallstones" during Laparoscopic Cholecystectomy

E. Alkalay, D. Yaffe, Z. Spindel

Eyn Vered Clinic and Depts. of Radiology and Surgery, Sapir Medical Center, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University

Laparoscopic cholecystectomy is the "gold standard" in treating cholelithiasis. Stones are frequently lost in the peritoneal cavity during the procedure, but "missing stones" have been regarded as insignificant. However, there is accumulating evidence that untreated "lost" stones may cause complications even years after operation.

We present a 65-year-old woman who presented with vague complaints, anemia and an elevated ESR. CT scan showed an infiltrating process in extra-abdominal muscles compatible with sarcoma. At operation, 2.5 years after previous laparoscopic cholecystectomy, an abscess was found which contained biliary stones. Because of their small size they were not visible on CT scan. We discuss the possible ways of handling "falling stones."

Bowel-Lengthening in a Newborn with Short Bowel Syndrome

Schmuel Katz, Ilan Erez, Ita Litmanovitz, Ludwig Lazar, Arie Raz, Zipora Dolfin

Depts. of Pediatric Surgery, Neonatology and Pediatrics; Meir Hospital, Kfar Saba

Advances in parenteral nutrition and supportive therapy have led to improvement in survival of babies with short-bowel syndrome. Those whose intestinal mass is very unlikely to be adequate should have surgical therapy as soon as possible, before they develop the complications of long-term parenteral nutrition or significant enteritis.

We present a newborn with short-bowel syndrome due to prenatal midgut volvulus. At operation the remaining viable jejunum, 15 cm long, was anastomosed to the cecum. All feeding attempts failed, and the infant suffered from malabsorption. Calories and proteins had to be supplied by intravenous total parenteral nutrition.

At 3 months of age there was significant widening of the remaining bowel and Bianchi's bowel-lengthening procedure was performed. The postoperative course was uneventful and there was gradual improvement in intestinal absorptive capacity. The patient was weaned from parenteral nutrition at 3 years of age. Now, 2 years later, she eats a normal diet.

Methotrexate Treatment in Refractory Juvenile Rheumatoid Arthritis

R. Brik

Pediatrics B Dept., Rambam Medical Center, Haifa

The mean time from initiation of methotrexate (MTX) treatment of juvenile rheumatoid arthritis (JRA) to partial remission of clinical symptoms and total clinical remission was assessed. 9 girls and 8 boys, from 3 to 18 years of age (mean 11.4±5.4) with active JRA by American College of Rheumatology (ACR) criteria (5 systemic, 8 polyarticular and 4 pauciarticular disease onset), who failed to respond to adequate courses of non-steroidal anti-inflammatory drugs (NSAID), steroids or disease-modidrugs were studied.

Clinic visits were scheduled at monthly intervals for physical and laboratory assessment disease activity and drug safety. Partial response to MTX was defined a 25% reduction of the active joint count and/or articular severity score. Total clinical remission was defined as in adult rheumatoid arthritis. The duration of disease activity until enrollment ranged from 6 months to 14 years (4.5±3.7 yr); duration of therapy was 3 months to 3 years (14.6±9.3mo) and dosage ranged from 5 to 15 mg/m²/week. Prednisone in doses below 10 mg/day and NSAID were permitted.

14 of 17 patients (82%) had a 25% reduction in joint activity after 6 weeks to 4 months (9.2±3.2 weeks); 10 (59%) went into full clinical remission after 5 to 26 months (14.3±9 months); 3 relapsed after an initial response to treatment, and 4 (23%) did not respond to MTX. The non-responders were males who required higher doses of prednisone (p<0.0001).

MTX appears to be effective therapy for children with JRA. An initial response can be expected in most patients after 9 weeks of treatment, and full clinical remission occurs after a mean of 14 months.

Aphthous Stomatitis as a First Manifestation of Crohn's Disease in a Child

Y. Gold, S. Reif

Dana Children's Hospital, Tel Aviv Medical Center

The incidence of Crohn's disease has risen dramatically over the past few years. The peak age of onset is in late adolescence, but it rarely occurs in the first few years of life. We describe a 5-year-old boy with recurrent bouts of fever, aphthous stomatitis, and anemia which did not respond to routine antibiotic therapy. It was only after a few months, when the characteristic symptoms of inflammatory bowel disease (IBD): abdominal pain and diarrhea appeared, that the diagnosis of Crohn's disease was made.

This case illustrates the difficulty in diagnosing IBD in young children. The presenting symptoms of IBD in children are often nonspecific and extra-intestinal. There is usually a low index of suspicion by the physician as to the possibility of IBD in a young child.

Concept Management in Penetration of Unusually Shaped Foreign Bodies into Extremities

I. Dudkiewicz, M. Salai, A. Chechik

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

During routine emergency room work penetration by foreign objects is frequently encountered, some of which may be very irregular in shape. These may cause further damage if inappropriately removed. It is important to perform a proper X-ray survey.

Multiple Angiodysplastic Lesions of the Colon - a Therapeutic Challenge

Nir Hilzenrat, Edit Liberty

Division of Gastroenterology and Dept. of Medicine E, Soroka Medical Center and Ben-Gurion University, Beer Sheba

Colonic angiodysplasia is one of the most frequent causes of recurrent lower gastrointestinal tract bleeding, mainly in the elderly. In 50% of patients multiple angiodysplastic lesions were reported when they were the cause of rectal bleeding. Bleeding from angiodysplasia is more severe and less responsive to treatment in those with coagulation disorders. A 74-year-old woman with an artificial mitral valve who was treated with coumadine is reported. A few years after operation she began to develop severe recurrent rectal bleeding because of multiple angiodysplastic lesions along the right colon, proven by colonoscopy. She was frequently hospitalized for blood transfusions; endoscopic treatment was not feasible and the surgical risk of colectomy was very high. Treatwith estrogen and progesterone significantly decreased recurrent episodes of bleeding.

Art Therapy for Hospitalized Children (Inspired by Elizabeth Kuebler-Ross's Approach)

Edna Pinchover*

Pediatric Wards School, Hadassah Hospital (Ein Karem and Mt. Scopus), Jerusalem

This paper presents a combined strategy for coping with the emotional condition of hospitalized children, and reports the results of its implementation in pediatric wards. The strategy combines art therapy methods with the spiritual-psychological approach developed by Elizabeth Kuebler-Ross. Art therapy uses art for therapeutic and diagnostic purposes; in this study it was employed to encourage the child-patients to express their feelings, and lead them to processes of understanding of and adjustment to their conditions. Kuebler-Ross' methods, known for dealing with difficult emotional situations at the bedside of the seriously ill, were enlisted to build a relationship of trust and respect between patient and therapist.

The population dealt with consisted of children (age 3-13) injured in road accidents, and cardiac and oncological cases. 7 case studies are brought to demonstrate the integrated therapeutic process. The process starts from the child-patient's artwork, which allows the therapist better insight into emotional conditions and to relate closely to issues brought up by the work. Through conversation with the therapist in an atmosphere of empathy and honest consideration, the patient becomes aware of her/his reactions, behavior, intentions and ambitions.

The belief underlying this study is that the patient derives from these contacts new abilities which moderate anxieties and strengthen healthy energies. Better collaboration and sounder ways of coping with intrusive medical treatment, as well as more trust and hope seem to emerge from the relationships created by these contacts.

* Principal of School.

Rupture of Pectoralis Major Muscle: Operative Treatment of an Uncommon Sport Injury

Moshe Weisbort, Gad J. Velan, David Hendel

Orthopedics Dept., Rabin Medical Center (Golda Campus), Petah Tikva

Rupture of the pectoralis major muscle in an athlete is rare, but is said to be common in weight lifters. The muscle usually ruptures at the musculotendinous junction during forceful contraction of the muscle in adduction, forward flexion and internal rotation of the arm. We describe an athlete who suffered such a major tear during a rugby game. It was treated surgically and after adequate rehabilitation, athletic activities were resumed.

Vacuum Phenomenon in the Hip Joint: Diagnostic Value

S. Iordache, E. Rath, D. Atar, A. Vindzberg

Orthopedics Dept., Soroka Medical Center, Beer Sheba

Vacuum phenomenon is well known in degenerative spinal disease in the elderly, but is seldom seen in other joints, especially in children. The phenomenon does not represent a pathological finding, and can be used for imaging of the articular facets, mainly in the hip and knee joints. We report a patient with this phenomenon in the hip joint.

Attitudes of Family Physicians to Alternative Medicine

Amiram Sarel, Jef Borkan, Ralph L. Carasso, Judith Bernstein, Uri Rozovsky

Brull-Tel Aviv Community Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba; and Dept. of Neurology, Hillel Yaffe Medical Center, Hadera

80 Israeli family physicians (51.25% men and 48.75% women) participated in a telephone survey concerning attitudes, practices and experience with alternative medicine. 23.75% reported practicing 1 or more alternative techniques, most commonly acupuncture28%) and hypnotherapy (24%). 55% had referred at least 1 patient to an alternative practitioner during the preceding month. Physicians who studied in Israel or Western countries referred more patients than graduates of medical schools of Eastern Europe. Specialists referred patients more often than residents. The most common reason for referral was back pain.

Background Music in the Family Physician's Surgery: Patient Reactions

S. Zalewsky, S. Vinker, I. Fiada, D. Livon, E. Kitai

Family Medicine Clinics and Dept. of Family Medicine, Sackler School of Medicine, Tel Aviv University

Music is a universal language, and its effects on pain relief and stress reduction are well known. We evaluated patients' opinions of the effects of background music in their family doctors' surgery. Low volume, background, classical music was played in the doctors' surgery on 5 consecutive clinic days. All patients were asked to fill a short anonymous questionnaire on leaving. Among the 135 consecutive patients offered the questionnaire, there was 87.4% compliance. Among the 118 who completed the questionnaire, 95% said that the background music did not disturb them, 89% thought it made them feel better and 80% thought that it aided the doctor's performance. We conclude that low volume, background music in the doctors's surgery may contribute to better doctor-patient interaction, although larger studies are needed to confirm our findings.

Urgent, Unscheduled Self-Referrals by Ambulatory Patients

S. Vinker, S. Nakar, Z. Alon, H. Abu-Amar, G. Sadovsky, E. Hyam

General Sick Fund, Central District and Dept. of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University

Direct self-referral to a consultant is common in the Israeli health system. Yet patients' reasons for their urgent, unscheduled self-referrals for ambulatory consultations (UUSR) have not been explored. We studied such consultations in an urban multi-disciplinary consultation center serving a population of approximately 100,000. Over a 3-month period such consultations in ophthalmology, ear-nose-and-throat and dermatology clinics were treated by a duty family physician (FP). The FP was instructed to focus on the urgent complaint and either to give definitive treatment and schedule a consultation when needed, or refer the patient for immediate specialist consultation. Patients treated by the FP were asked to fill an anonymous questionnaire, which 347/645 (55.4%) did.

Among the reasons for UUSR were that the patient thought that his/her complaints should be treated by a consultant (29%), the patient was sent by the FP without a consultation note (13.9%), the FP was not available (10.4%), or the patient wished to see the consultant for a second opinion (8.2%). In only 7.8% had the patient noted that his complaint needed urgent consultation. Duration of complaints, but not prior efforts to schedule a consultation, were associated with different reasons for asking for an UUSR. For various reasons patients preferred an UUSR rather than seeing their own FP. Patients' opinions regarding self-referrals are important in planning primary care facilities and FP training.

Pains and Pleasures of a Family Physician: 10 Years of Caring for a Family

Andre Matalon

Family Medicine Dept., Tel Aviv University and Kupat Cholim Klalit, Machoz Dan, Petah Tikva

One of the major characteristics of family medicine is the duration of the doctor-patient relationship over a continuum of time. Physician and family contribute to establishing a relationship that is both therapeutic and gratifying. This mutual bond and involvement was called by Balint "a mutual investment company," in which understanding and trust grow over the years. This paper deals with these contributions and investments, and the positive and negative emotions evoked in the family physician by the patient and family. After 20 years of caring for the family presented, it was possible to address more specifically the analysis of the pains and pleasures of this continuity of care, and the sources of the complex bonding between the family and the family physician.

Osteoid Osteoma of the Hand: a Rare Location

Nahum Rosenberg, Shalom Stahl

Dept. of Orthopedics A, and Hand Surgery Unit, Rambam Medical Center, Haifa

Osteoid osteoma is a benign bone tumor. It is rare in the hand where it may cause local swelling and pain. Marginal resection is almost always curative, without residual functional disability. Because it is rare in this location, osteoid osteoma is not usually considered in the differential diagnosis of painful lesions of the hand, which may delay treatment. Osteoid osteoma in the hand has characteristic clinical, roentgenologic and scintigraphic features. Early diagnosis of this lesion may be improved by recognition of these features. An algorithm for decision-making that may help is proposed. We describe our experience in 3 cases involving, respectively, the capitate bone, a proximal, and a distal phalanx, in which cases marginal resection was curative.