תוצאת חיפוש

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.

Necrotizing Soft Tissue Infection

E. Rath, I. Shelef, E. Avinoah, Y. Lichtman, O. Levy, D. Atar

Depts. of Orthopedics, Diagnostic Radiology and General Surgery C, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

The dramatic course of necrotizing soft tissue infection represents a medical emergency, since it is limb - and life-threatening. Most necrotizing soft tissue infections are caused by mixed aerobic and anaerobic Gram-negative and Gram-positive organisms. Most case have been reported in immunocompromised hosts after penetrating trauma or surgery. We describe a unique series of cases of necrotizing soft tissue infection. The mainstay of treatment is early and daily debridement of devitalized tissue and broad-spectrum antibiotics. Hyperbaric oxygen therapy should be considered.

Conversion Total Hip Replaceafter Failed Internal Fixation of Intertrochantric Fracture

M. Kligman, M. Roffman

Dept. of Orthopedic Surgery, Carmel Medical Center, Haifa

Between 1933-1995, 16 patients underwent conversion-total hip replacement after internal fixation of an intertrochanteric fracture failed. Clinical results were unsatisfactory compared to primary total hip replacement. There was a high incidence of intra- and postoperative complications, including femoral fracture, wound infection, and aseptic loosening. This study should increase the surgeon's awareness of the difficulties encountered in conversion of failed intertrochanteric fractures to total hip replacement.

Living-Related Liver Transplantation

N. Bar-Nathan, Z. Shapira, E. Shaharabani, A. Yussim, Y. Ben-Ari, T. Sheinfeld, I. Zehavi, R. Shapira, G. Dinari, Z. Ben-Ari, R. Tur-Kaspa, E. Mor

Dept. of Transplantation and Liver Institute, Rabin Medical Center (Beilinson Campus), and Pediatric Intensive Care and Pediatric Gastroenterology Units, Schneider Children's Medical Center, Petah Tikva

Our experience with living-related liver transplantation is described. In 2 boys and 1 girl, aged 4-4.5 years with acute, fulminating hepatitis A, the presence of very severe jaundice (bilirubin levels > 18 mg%) associated with severe coagulopathy (INR>10) and encephalopathy indicated the need for urgent liver transplantation. In all 3 cases the left lateral hepatic segment of a matched blood type parent was transplanted. None of the donors suffered a serious complication postoperatively and all returned to full activity in 6-16 weeks. The post-transplantation course was uneventful in 1 child, but in the other 2 there was hepatic arterial thrombosis in 1 at 1 day and in the other at 8 days post-transplantation. Early detection of arterial thrombosis by Doppler sonography permitted salvage of the 2 hepatic grafts after thrombectomy and re-anastomosis. In 1 of these 2 children an anastomotic biliary stricture was found 2 months after transplantation. It was corrected at surgery and a percutaneous stent was inserted. All 3 children are alive with normal graft function at 2, 7 and 8 months post-transplantation, respectively. This initial experience indicates that living-related liver transplantation is feasible in Israel. The technique might help to solve our severe organ shortage for children awaiting liver transplantation.

Cardiac Failure following Sting of Yellow Scorpion in an Adult

C. Kristal, I.Y. Shemesh, Y. Mishal, A. Bourvin

Intensive Care Unit, Dept. of Anesthesia and Medical Dept., Barzilai Medical Center, Ashkelon

3 men, aged 18, 29, and 47 had severe cardiovascular disturbances following the sting of the yellow scorpion (Leiurus quinquestriatus hebraeus), which is considered the most dangerous scorpion in Israel. Cardiovascular complications are common in children after scorpion sting, but are rare in adults. Pulmonary edema developed in 1 of those being reported and hypertension and arrhythmias in the other 2. Severe deterioration in left ventricle function was confirmed by echocardiographic measurement of diminished ejection fraction. All patients recovered completely. This is the first report of severe cardiac involvement in adults following scorpion sting. We therefor recommend that even adults who develop cardiac symptoms after scorpion sting, particularly those with chronic cardiac disease, be monitored and treated in an intensive care unit.

Patient Satisfaction with Care in Acute-Care Hospitals

Ayelet Berg, Dan Yuval

JDC-Brookdale Institute of Gerontology and Human Development, Jerusalem

Patient satisfaction with the hospitalization process is an important element in the measurement of quality of care. Information from a survey of patients' experiences could therefore help hospitals improve their service, and provide decision-makers with relevant information. We present the findings of a study of some 4,500 patients, aged 18+, released from hospitals in the fall of 1993 and of 1995 from the wards of 9 acute care hospitals, psychiatric and geriatric wards excluded. Self-administered questionnaires were sent and returned by mail, with an overall response rate of 82%.

Despite the many changes in Israel's health system in general and its hospital system in particular, and the social and demographic changes between those 2 periods, patient satisfaction remained constant. Of those discharged from medical or surgical wards, 70% were satisfied to a "great" or "very great" extent with their hospital experience. There was improvement in most areas of hospitalization in the course of the 2 years. The greatest improvement was with regard to admission, nursing staff, hotel services, in patient satisfaction food and supplies. On the other hand there was deterioration in visiting conditions and hours. Satisfaction with physicians, nurses and hotel services had the strongest links with general satisfaction.

Characteristics of Adults with Emotional Distress, and Patterns of Mental Health Services Use

Revital Gross, Dina Feldman, Yonathan Rabinowitz, Miriam Greenstein, Ayelet Berg

Health Policy Research Unit, JDC-Brookdale Institute and Mental Health Division, Ministry of Health, Jerusalem and School of Social Work, Bar Ilan University, Ramat Gan

We sought firsthand data on the extent of perceived mental health needs and on patterns of use of mental health services among Israelis aged 22 and over. The data are from a national survey conducted in 1995. A random sample of phone numbers from the telephone company's computerized listings yielded 1,395 completed questionnaires (response rate, 81%).

At some point in their lives, 27% had experienced emotional distress or mental health problems with which they had difficulty coping alone; 13.4% reported that they had such an experience during 1995. According to multivariate analysis, those more likely to report mental health problems were women, those with a chronic disease, Russian immigrants, divorced or widowed adults, those with a low level of education, and members of the Clalit sick fund. 38% of those who had ever had emotional or mental health problems had asked for help. The proportion of those seeking help was high among respondents aged 35-55, Hebrew speakers (compared to speakers of Russian or Arabic), and city dwellers, and the rate was low among members of the Clalit sick fund. Of those who did seek help, 39% went to a psychologist or a psychiatrist, 25% to their family doctor, 19% to a family member or friend, 7% to a social worker or social service agency, 6% to other medical personnel, and 4% to a psychiatric hospital. 30% turned for assistance to the private sector and 70% to the public sector.

These findings have special significance in view of the impending reform of the mental health services. As mandated by the new National Health Insurance Law, mental health services are to be included in the basket of health services provided by the sick funds. The data can be of use in the management of sick funds and for physicians working in the community, as they prepare for this change. In addition, the data will be of aid to national policy makers in planning services suited to the needs of different population groups and to allocate resources more rationally.

Diagnosis of Cerebral Embolism by Transesophageal Echocardiography

A. Mahagney, D. Sharif, B. Weller, E. Abineder, B. Sharf

Depts. of Neurology and Cardiology, Bnai Zion Hospital, Haifa

Cerebrovascular events have high mortality and morbidity, especially in the elderly. Ischemia is the main cause and 30% of the ischemic events are embolic and of cardiac origin. The clinical picture is not always typical of the type of stroke, but diagnosis of the mechanism of the event determines treatment. Transesophageal echocardiography (TEE) is a sensitive procedure more appropriate for diagnosing emboli of cardiac origin than transthoracic echocardiography (TTE). We therefor compared TEE and TTE in the determination of the source of emboli in 65 patients with ischemic stroke but without significant atherosclerotic changes in their carotid arteries, and compared these findings with those in 50 patients without stroke. 68% of the patients had potential sources of emboli according to TEE, compared to only 15% according to TTE. In the control group only 24% had potential sources of emboli by TEE. The findings were: clots in the left atrium, severe aortic atheroma, patent foramen ovale with paradoxical shunt, spontaneous echocardiography contrast, vegetations and mitral valve prolapse. The study showed that TEE is better than TTE in detecting the etiology of embolic stroke in those with normal carotid arteries, thus determining appropriate management.

Correlation between Success in Specialty Examinations and Learning Methods of Family Medicine Residents

Netta Notzer, Dahlia Megiddo, Ruth Abramowitz, Michael Weingarten

Medical Education Unit, Family Medicine Section, Sackler Faculty of Medicine, Tel Aviv University

Learning methods chosen by residents in family medicine during their residency and the correlation between them and achievement in the written specialty exams (Stage 1) were investigated. The learning patterns studied were: structured learning (certification course, study with a tutor, staff meetings, conferences) and self-learning (textbooks, journals, the Hebrew publication "Update," and audio tapes). Of 184 residents who took the examination in 1994-5, 104 responded to a questionnaire as to preferences for the various learning aids and satisfaction with their use. There was no correlation between use of a given learning method and success in the examination. Significantly more candidates preferred self-learning, especially among those who were successful, but also among some who failed the examination. There was no direct connection between the examination and the high level requirements of the residency program, for which up-to-date, integrated knowledge based on self-learning is needed.

Paroxysmal Nocturnal Hemoglobinuria

Haim Ben-Ami, Yehuda Edoute

Medical Dept. C, Rambam Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired disorder of blood cells which originate from an abnormal hematopoietic stem cell. The condition is characterized by nocturnal hemoglobinuria, chronic hemolytic anemia, and thrombosis. We describe a 60-year-old woman with PNH admitted with abdominal pain and jaundice, who had dark urine on arising after a night's sleep. The diagnosis was established by the typical clinical story and a positive Ham test. She was successfully treated with Halotestin and folic acid. Although PNH is rare, it should be considered in the differential diagnosis of hemolytic anemia. Early diagnosis and treatment are important.

Mixed Uterine Mesodermal Tumors: Clinical and Pathological Characteristics

Samuel Ariad, Alexander Rabinovitz, Ilana Yanai-Inbar, Benjamin Piura

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

During 1971-1996, 17 patients with mixed mesodermal uterine tumors were treated. Average age at diagnosis was 67.3 years, 12/17 were of European and 5/17 of Afro-Asian extraction. The overall 5-year survival was 21%. 10/17 patients had mixed mesodermal tumors with a heterologous mesenchy-mal element, and 7/17 had a homologous mesenchymal element (carcinosarcoma). 6/17 had another primary malignancy, including breast cancer (3/17), bilateral metachronous breast tumor (2/17), and malignant lymphoma of the neck region (2/17). All 3 with breast cancer had previously been treated with tamoxifen. 1 had simultaneous mesodermal tumor and ovarian thecoma. Simultaneous autoimmune manifestations occurred in 2/17, including thrombocytopenic purpura in 1, and myasthenia gravis in another. Mesodermal tumor of the uterus is a relatively rare malignancy with aggressive behavior and poor prognosis. It also had unusual associations with other primary tumors, hormonal treatment, and autoimmune manifestations.

Circadian Fluctuations of the Signal-Averaged ECG

Ehud Goldhammer, Edward Abinader

Cardiology Dept., Bnei-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Circadian periodicity for the time of onset of acute myocardial infarction has been shown; the early morning peak of infarction coincides with the onset of other related phenomena, including sudden cardiac death, ventricular arrhythmias, thrombotic stroke, etc. Late potentials detected by the signal-averaged ECG are considered to be independent markers of vulnerability to ventricular arrhythmias. The signal-averaged ECG enables the amplifying and recording of small bioelectric signals of cardiac origin, while eliminating extraneous electrical "noise." To determine whether late potentials are themselves subject to circadian influence, 31 patients (age range 41-79) who had had an old or recent myocardial infarction underwent late potential assessment by the signal-averaged ECG. 4 indices were studied: duration of late LPD potentials (LPD), total QRS duration (TQRS), and root mean square voltage of the last 40 msec, and of the last 50 msec (RMS 40 and RMS 50). These indices were assessed 3 times, during the early morning hours, at noon and during the evening. Morning LPD differed significantly from noon and evening LPD and the morning RMS 40 similarly differed from noon and evening values. TQRS and RMS 50, even though remaining in the normal range, also showed a tendency to abnormal values during morning hours. These findings could possibly be related to the early morning incidence peaks of severe ventricular arrhythmia and sudden cardiac death, since abnormal late potentials constitute the physiopathological basis for certain ventricular arrhythmias.

Radiotherapy of Localized Prostatic Carcinoma

Eliahu Gez, Yael Netzer-Horowitz, Einat Waiman, Raphael Rubinov, Yoram Cohen, Abraham Kuten

Northern Israel Oncology Center and Oncology Dept., Rambam Medical Center and Lin Medical Center, Haifa; and Soroka Medical Center, Beer Sheba

112 patients with localized prostate cancer, clinical stage A2-C, were treated by definitive radiotherapy between 1982-1988. Radiation volume encompassed the prostate, seminal vesicles and pelvic lymph nodes. The 10-year actuarial survival figures were: overall 51%; stage A2 87%; stage B 50%; stage C 36%; well differential tumors 67%; moderately differentiated 50%; poorly differentiated 32%; patients with local tumor control 55%; and patients with minimal local control 36%. It is concluded that external beam irradiation is effective in localized prostatic cancer. Stage and grade are prognosticators of survival.

Technetium 99-M Sestamibi Bone Scan in Musculo-Skeletal Neoplasms

Dror Robinson, Lena Pinkas, Lilia Mindlin, Nahum Halperin, Tifha Horn

Dept. of Orthopedics and Nuclear Medicine, Assaf Harofeh Medical Center, Zerifin

It is often difficult to assess accurately the nature of a skeletal lesion. Problems include differentiating a malignant from a benign bone tumor, as well as determining the cause of a pathologic fracture. Such fractures may occur through osteoporotic bone as well as through neoplasm-affected bone. Thus, development of an imaging modality capable of distinguishing between such lesions is of importance. During 1996, we ran a prospective study in which results of Tc-99m-methyl-diphosphate (MDP) bone scans were compared with those of sestamibi (MIBI) bone scans and with subsequent biopsy and clinical course. The results of the bone scans were assessed by 2 independent "blinded" observers, and the ratios of counts in lesions to those in normal tissue (L/N ratios) were calculated. In cases of malignant (7) and benign (8) tumors, intensity of uptake in MDP scans were not predictive of degree of aggressiveness. On the other hand, MIBI bone scans demonstrated significant difference in intensity of uptake between benign and malignant bone tumors (L/N ratios 2.05 vs 2.75). In 5 of 8 benign lesions the L/N ratio was 1. In the others, increased uptake was minimal. In 2 patients changes in uptake in MIBI bone scan following chemotherapy appeared to be related to the degree of tumor necrosis achieved. While the MIBI bone scan cannot replace tissue biopsy as a definitive diagnostic modality in bone neoplasms, it does appear to allow better preoperative assessment and prognosis.

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.