תוצאת חיפוש

Evolving Role of Radiation Therapy in Nonmalignant Disorders

Rami Ben-Yosef

Bone Marrow Transplant Dept., Hadassah Hospital, Jerusalem

Various nonmalignant disorders have traditionally been treated with radiation therapy. It has almost completely been discontinued due to reports of secondary malignancy. During the past 15 years there has been an evolving role for radiation therapy in various nonmalignant disorders such as meningioma, A-V malformation, prevention of vascular restenosis and heterotopic bone formation. Appropriate follow-up of such patients for diagnosis of secondary malignancy is recommended. Radiation therapy should be carefully considered in diseases not successfully treated with conventional means.

Primary Subclavian Vein Thrombosis after Intensive Physical Exertion

Ora Shovman, Jacob George, Yehuda Shoenfeld

Dept. of Medicine B and Autoimmune Disease Research Unit, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Subclavian vein thrombosis accounts for approximately 1-2% of recorded deep venous thromboses. It may be primary or secondary, and insertion of a central venous catheter is the most common cause of secondary subclavian vein thrombosis. Traumas, anatomic abnormalities and carcinoma are important additional risk factors for secondary thrombosis. Primary thrombosis of the subclavian veins is known as Paget-Schroetter syndrome. New criteria for its diagnosis include a history of increased upper extremity use prior to onset of symptoms, the presence of a venographically demonstrated thrombus and absence of any definable causes. We describe a 42-year-old woman with a history of intensive physical exertion admitted with swelling, pain and difficulty moving her arm. The diagnosis of primary subclavian vein thrombosis was established from the history of physical effort, results of Doppler ultrasound, and exclusion of other causes of subclavian vein thrombosis. This case suggests that primary subclavian vein thrombosis should be considered in young patients with subclavian vein thrombosis after exclusion of secondary disease.

Trauma Registry Database

Moshe Michaelson, Eran Tal-Or

Trauma Unit, Rambam Medical Center, Haifa

Trauma registry is vital for every trauma center. In 1995, data on all injured patients who reached our trauma unit were collected. 3.040 patients were hospitalized, of whom 415 were transferred from other hospitals. We describe the distribution of the patients to in-patient wards and present the relationship between mortality and injury severity score. 1102 hospitalized patients underwent a total of 1599 operations with an overall mortality of 2.63%.

ATLS Course for Surgery Residents - Should it be Mandatory?

Ron Ben-Abraham, Michael Stein, Yoram Kluger, Gideon Paret, Avraham Rivkind, Joshua Shemer

Medical Corps, Israel Defense Forces; Sourasky Medical Center and Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University; and Hadassah Medical Center, Jerusalem

Senior surgeons were asked about mandatory participation of general surgery residents in the advanced trauma life support (ATLS) course. Although trauma care in Israel is given by surgical residents, in the opinion of their senior mentors the course should continue to be mandatory for them.

Limited Axillary Thoracotomy for Recurrent Spontaneous Pneumothorax

I. Bar, M. Simha, A. Nissan, Y. Shargal, M. Kramer, G. Merin

Depts. of Cardiothoracic Surgery and of Surgery, and Pulmonary Institute, Hadassah--University Hospital, Ein Karem; and Dept. of Surgery, Hadassah--University Hospital, Mt. Scopus, Jerusalem

Recurrent spontaneous pneumothorax often requires surgical intervention. Recently, less invasive thoracic surgical techniques, such as video-assisted thoracoscopy (VAT) and limited axillary thoracotomy (LAT), have been developed and used for different thoracic procedures. We describe our results with limited axillary thoracotomy, as compared with those of video-assisted thoracoscopy as reported in the literature. From October 1994 to May 1996, 14 patients with recurrent spontaneous pneumothorax, aged 16-33 years, underwent limited axillary thoracotomy, resection of blebs and apical pleurectomy, using multifire GIA 80 staplers (Auto Suture Inc.). There were no complications or recurrences during 5-17 months of follow-up. Mean operative time was 52.2 minutes and mean hospital stay 2.3 days postoperatively. Full activity was regained within 12.1 days. In comparison with over 75 cases of VAT from the literature, LAT is safe and offers the potential benefits of decreased operative time, hospital stay and cost.

Carnitine Deficiency in Inborn Errors of Metabolism

B.-A. Sela, T. Lerman-Sagie, M. Berkovitz

Institute of Chemical Pathology, Chaim Sheba Medical Center and Section of Clinical Biochemistry, Sackler School of Medicine, Tel Aviv University; Pediatric Neurology Unit, Wolfsohn Medical Center, Holon; and Children's Ambulatory Clinic, Assaf Harofeh Medical Center, Zrifin

Several conditions, considered as inborn errors of metabolism, involve severe deficiencies in carnitine in both plasma and muscle. In the absence of evidence suggesting primary carnitine deficiency due to a biosynthetic enzymatic defect in the liver, the various diseases with carnitine deficiency are related to genetic defects in organic acid metabolism leading to blocked mitochondrial b oxidation. We describe a 4.5-year-old boy and 2 female infants with glutaric aciduria type I, isovaleric acidemia, and long-chain acid dehydrogenase deficiency, in whom severe carnitine deficiency was apparent. In all 3, long-term carnitine treatment proved to be vital and eliminated most of the symptoms.

Identification of Sentinel and Axillary Node Involvement in Breast Cancer

M.Z. Papa, D. Bersuk, M. Koler, E. Klein, M. Sareli, G. Ben-Ari

Dept. of Surgical Oncology and Breast Unit, Chaim Sheba Medical Center, Tel Hashomer

Axillary node dissection for breast cancer is important for staging and prognosis. "Sentinel nodes" are the first nodes into which primary cancer drains. Identification, removal and pathological examination of those nodes indicates whether completion of axillary lymphadenectomy is required. The sentinel nodes are identified using a vital dye injected at the primary tumor site. With this technique we were able to identify sentinel nodes in 46 of 48 (95%) women examined. An average of 2.7‏1.2 nodes were identified as sentinel nodes. In 81% of cases there was a correlation between involvement of sentinel nodes and of other axillary nodes as well. In 10% of patients sentinel nodes were involved with tumor while other axillary nodes were negative. The major problem in routine application of this is relationship in surgical decisions is reliable real time pathological identification of lymph node involvement by tumor.

Analgesia in Breast Surgery with Interpleural Bupivacaine

Z. Crystal, Y. Katz

Dept. of Anesthesiology, HaEmek Medical Center, Afula and B. Rappaport Faculty of Medicine, Technion, Haifa

A control group of 15 patients undergoing breast surgery was given general anesthesia. In 15 other patients an interpleural block with 0.4 ml/kg bupivacaine, 0.5%, was performed 20 minutes before induction of general anesthesia for pre-emptive analgesia. This was extended further by continuous administration of bupivacaine 0.25%, 0.125 ml/kg/hr by automatic infusion pump, with supplements of opiates for postoperative pain management. The combined technique was associated with significantly reduced perioperative opiate requirement with better emergence from anesthesia, fewer side effects, a prolonged pain-free period, and overall better quality of postoperative recovery.

Fear of Personal Death among Hospital Physicians

Y. Hamama-Raz, Z. Solomon, A. Ohry

School of Social Work and Dept. of Neuro-Rehabilitation, Chaim Sheba Medical Center, Tel Hashomer (Both affiliated with Tel Aviv University)

Many studies have tried to explain why professionals experience difficulty when dealing with, and in treating efficiently situations connected with death. We studied levels of personal fear among physicians in general hospitals and addressed 2 questions: Does exposure to death on professional and personal levels, affect the level of the fear of personal death which physicians experience? Is there a relationship between personality variables, represented by the repression-sensitization dimension, and level of fear of personal death? A sample of 233 physicians from 22 general hospitals who specialized in oncology, internal medicine, surgery, psychiatry or pediatrics was studied. Each answered 4 questionnaires with regard to demographic information, fear of personal death, level of repression-sensitization and exposure to the death of relatives and significant others. There were no differences in level of fear of personal death of physicians according to specialization, but those who had been exposed to death on the personal level, feared less their own death. With respect to the personality variable, tendency to sensitization, it was found that those who were sensitized exhibited a higher level of the fear of their own death compared to those who were repressive. Of the various demographic variables examined (sex, level of religiouobservance, age, number of children, health, professional experience) it was found that those: with many years of professional experience, who were relatively older, who were nonobservant religiously and who were in good health, had lower levels of personal fear of death; gender was not a factor.

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.

Fatal Multiple Organ System Dysfunction Associated with Germanium Metal

Micha Shamir, Charles L. Sprung

Dept. of Anesthesiology and Critical Care Medicine, Hadassah--University Hospital and Hebrew University-Hadassah Medical School, Jerusalem

The element germanium is widely distributed in nature. It is used in industry as a semiconductor and there have been a few attempts to use it in medicine. In the past few years 20 patients have been described in the literature as suffering from germanium overdosage. Like laboratory animals affected by the element, they suffer from renal failure and injury to other organs. We describe a 52-year old man given germanium to prevent recurrence of a brain tumor. He developed multiple organ dysfunction syndrome and died of intractable hyperdynamic shock. We call for caution regarding morbidity resulting from treatments believed safe.

Participation of Patients with Uret-Eral Calculi in Clinical Decision Making, and Level of Anxiety

Ilana Margalith, Amos Shapiro

Hadassah-Hebrew University School of Nursing, and Dept. of Urology, Hadassah Medical Center, Jerusalem

In a study examining the relationship between patient participation in clinical decision making and levels of anxiety, patients were offered a choice of treatment for ureteral calculus. 42 received information about 2 treatment options, ultrasound fragmentation of the stone through a ureteroscope and extracorporeal shock wave lithotripsy (ESWL), and were asked to choose the method that they preferred. 54 received treatment decided on by the physician without their participation in the decision making process. Anxiety was measured before meeting with the physician, immediately after the meeting and on hospitalization for treatment. The contribution of the patient's perception of participation in the decision- making process and level of education was also examined. There was a decrease in level of anxiety after meeting with the physician only among those who did not actually participate in the decision-making process (p<0.05). There was no change in the level of anxiety among those offered choice of treatment. However, a decrease in anxiety was evident among patients who perceived that they had received information about their illness and its treatment (p<0.01). This was not the case for patients who perceived themselves as participants in decision making unless they had a relatively high-level of education (p=0.05).

Macroenzymes: an Interesting Laboratory Finding, without Clinical Relevance

C. Perry, H. Peretz, E. Graf, O. Ben-Tal, A. Eldor

Hematology Dept. and Biochemistry Laboratory, Tel Aviv-Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

Macroenzymes are complexes of serum enzymes with proteins which have a higher molecular weight and longer plasma half-life than the normal enzyme. The presence of macroenzymes is suggested by finding increased serum enzyme activity, not associated with symptoms. Thus, macroenzymes can cause diagnostic errors and the performance of unnecessary tests or invasive procedures. We describe 2 patients with highly elevated serum levels of lactate dehydrogenase (LDH) and creatine kinase (CK) due to formation of complexes with immunoglobulin G. 1 patient had LDH of 4500 u/L but was otherwise normal and in the second CK was elevated with no evidence of ischemic heart disease. Awareness of the phenomenon of macroenzymes may save the patient long and sometimes invasive investigation.

Quality of Life in Younger Adults after First Stroke

Shenka Alfassa, Revital Ronen, Haim Ring, Aida Dynia, Ada Tamir, Reuben Eldar

Fleischman Unit for Study of Disability, Neurological Ward, Loewenstein Hospital, Ra'anana

To study the effect of stroke on the quality of life in younger adults, 199 patients 17-49 years of age who had sustained a first stroke between 1.11.92 and 31.10.93 were followed up. They were interviewed by telephone at 3, 6, 12 and 24 months after the event. 2 died during the first year of follow-up, and 8 had recurrent strokes. After 2 years, 8 additional patients had died and 4 had sustained recurrent events. Gradual improvement was reported within all age groups and in all areas. During the 3-6 months period, a mean of 4% improvement occurred in functional capability, 15% in social and recreational activity and 8% in return-to-work. The 6-12 month period showed an increase of 3% in improvement in mean functional capability, 10% in social and recreational activity and 2% in return-to-work. 1 year after the stroke 27% remained with moderate to severe disability, but over 86% were functionally independent in their daily living activities. There were no significant changes during the second year of follow-up in these statistics. 67% of those employed prior to their stroke returned to work and approximately 70% reported a return to prestroke social and recreational activity. These results demonstrate that the relatively high recovery rate and functional improvement during a year of follow-up were not accompanied by similar rates of improvement in emplyment and in social integration. They indicate the need for increased emphasis on long-term psychosocial rehabilitation services within the community.

Epidemiological Characteristics of Outbreaks of Diarrhea and Food Poisoning in the Israel Defense Forces

I. Grotto, Y. Mandel, I. Ashkenazi, J. Shemer

Army Health Branch, IDF Medical Corps and Sackler Faculty of Medicine, Tel Aviv University

Acute infectious diseases of the gastrointestinal tract and food poisoning are problems of great importance in the Israel Defense Force (IDF). They involve individual and epidemic morbidity, with impairment of health of individual soldiers and in the activities of units. Outbreaks of gastrointestinal infectious diseases must be reported to the IDF army health branch, which conducts epidemiological investigation. This study is based on data from yearly epidemiological reports for 1978-1989, and from a computerized database for the years 1990-1995. The incidence of outbreaks is characterized by an unstable trend, It was highest at the end of the 80's (68.3 per 100,000 soldiers on active duty) and lowest for the last 2 years (1994-1995, 36.3 per 100,000). The incidence of soldiers involved in food-borne outbreaks has been more stable, constantly declining during the course of the years. There was marked seasonality with a peak in the summer months. Sporadic morbidity was constant in 1990-1995, with a yearly attack rate of 60% in soldiers on active duty. Shigella strains were the leading cause of outbreaks until 1993, while in 1994-1995 their proportion decreased, with an increase in the proportion of Salmonella strains. As to Staphylococcus aureus, its role in causing food poisoning has been characterized by marked changes. Shigella sonnei replaced Shigella flexneri as the leading strain. 73.3% of outbreaks were small, with fewer than 40 soldiers involved, while 5.4% of outbreaks affected more than 100 soldiers. Outbreaks in which a bacterial agent was identified or which occurred in new-recruit bases were larger than those in which a bacterial agent was not identified, or which occurred in active field unit bases. In conclusion, the rates of infectious disease of the gastrointestinal tract are still high, although there has been a marked decrease since 1994. The incidence of outbreaks has also decreased, as well as the role of Shigella as a leading causative agent.