Israel Medical Association Journal

Background: Technetium-99m sestamibi scintigraphy has become one of the most popular techniques for localization of the parathyroid gland after failure of primary neck exploration.

Objective: To examine the efficacy of sestamibi with the hand-held gamma ray detecting probe for the identification of parathyroid adenomas during revision parathyroidectomy.

Methods: We reviewed six cases of probe-assisted neck exploration for parathyroid lesions following unsuccessful primary exploration.

Results: In all cases, the pathologic glands were successfully detected and removed.

Conclusions: With careful planning, a gamma ray detecting probe can be used optimally at 2–3 hours after technetium-99m sestamibi injection. The probe is efficient, easy and convenient to use.
 

Background: The osteoporosis-pseudoglioma syndrome is a rare autosomal recessive disorder characterized by severe juvenile-onset osteoporosis and congenital or early-onset blindness. Other manifestations include muscular hypotonia, ligamentous laxity, mild mental retardation and seizures. The gene responsible was recently identified to be the low density lipoprotein receptor-related family member LRP5 on chromosome 11q11-12.

Objective: To measure bone density in two siblings with the OPPG[1] syndrome as well as in their family members (parents and siblings).

Methods: Bone mineral density was determined in the lumbar spine (antero-posterior), femoral neck, two-thirds distal forearm (>95% cortical bone) and ultradistal forearm (predominantly trabecular bone) by dual-energy X-ray absorptiometry.

Results: The studies revealed osteoporotic changes both in the patients and the carriers.

Conclusion: The findings demonstrate that OPPG carriers have reduced bone mass, which is a risk factor for development of early osteoporotic changes.

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Background: Bleeding in the first trimester of pregnancy is a common phenomenon, associated with early pregnancy loss. In many instances a subchorionic hematoma is found sonographically.

Objective: To evaluate the possible benefit of bed-rest in women with threatened abortion and sonographically proven subchorionic hematoma, and to examine the possible relationship of duration of vaginal bleeding, hematoma size, and gestational age at diagnosis to pregnancy outcome.

Methods: The study group consisted of 230 women of 2,556 (9%) referred for ultrasound examination because of vaginal bleeding in the first half of pregnancy, who were found to have a subchorionic hematoma in the presence of a singleton live embryo or fetus. All patients were advised bed-rest at home; 200 adhered to this recommendation for the duration of vaginal bleeding (group 1) and 30 continued their usual lifestyle (group 2). All were followed with repeated sonograms at 7 day intervals until bleeding ceased, the subchorionic hematoma disappeared, or abortion occurred. The groups were compared for size of hematoma, duration of bleeding, and gestational age at diagnosis in relation to pregnancy outcome (spontaneous abortion, term or preterm delivery).

Results: The first bleeding episode occurred at 12.6 ± 3.4 weeks of gestation (range 7–20 weeks) and lasted for 28.8 ± 19.1 days (range 4–72 days). The women who adhered to bed-rest had fewer spontaneous abortions (9.9% vs. 23.3%, P = 0.006) and a higher rate of term pregnancy (89 vs. 70%, P = 0.004) than those who did not. There was no association between duration of vaginal bleeding, hematoma size, or gestational age at diagnosis of subchorionic hematoma and pregnancy outcome.

Conclusions: Fewer spontaneous abortions and a higher rate of term pregnancy were noted in the bed-rest group. However, the lack of randomization and retrospective design of the outcome data collection preclude a definite conclusion. A large prospective randomized study is required to confirm whether bed-rest has a real therapeutic effect.

Background: Cystinuria is an autosomal recessive disease that is manifested by the development of kidney stones. Mutations in SLC3A1 cause type I disease, while mutations in SLC7A9 are associated with non-type I disease. In Israel cystinuria is especially common among Libyan Jews who suffer from non-type I disease.

Objectives: To compare clinical manifestations of patients with mutations in SLC3A1 to those with mutations in SLC7A9, and to assess the carrier rate among unaffected Libyan Jewish controls.

Methods: Clinical manifestations were evaluated in patients with mutations in SLC3A1 and in patients with mutations in SLC7A9. Carrier rates for two SLC7A9 mutations were assessed in 287 unaffected Libyan Jewish controls.

Results: Twelve patients with mutations in SLC3A1 were compared to 15 patients with mutations in SLC7A9. No differences were detected between the patients with mutations in SLC3A1 and those with mutations in SLC7A9 in relation to the age of disease onset, the estimated number of stones, the number of invasive procedures, the number of patients receiving drug therapy, or the patients’ urinary pH. Eleven of the unaffected Libyan Jewish controls were found heterozygotes for the V170M mutation, establishing a carrier rate of 1:25. The 1584+3 del AAGT mutation was not found in any of the Libyan Jewish controls.

Conclusion: Mutations in SLC3A1 and SLC7A9 cystinuria patients result in indistinguishable disease manifestations. The high carrier rate among Libyan Jews is a result of a single missense mutation, V170M.
 

The ethical chapter of the Israel Medical Association has recently issued guidelines with regard to exual relationships between doctors and patients or past patients. This paper juxtaposes the paternalistic and severe attitude to doctor-patient sex with the relaxation and individualization of decisions regarding doctors' involvement in assisted suicide, passive and active euthanasia. The discussion bears on our concepts of palliative care and our expectations from it.

Background: The chronic progressive course of peripheral arterial occlusive disease with its limb-threatening and life-threatening potential is associated with physical, psychological and social distress for elderly patients and their families.

Objective: To evaluate the influence of infra-inguinal bypass surgery for limb salvage, and social support, on quality of life in elderly patients (over 60 years old).

Methods: Sixty patients aged 60 years and above diagnosed with limb-threatening ischemia were evaluated using the SF-36 generic questionnaire for quality of life, and the MOS-SS questionnaire for social support. Thirty patients (group I) were evaluated in the hospital prior to reconstructive surgery and 30 postoperative patients (group II) were evaluated at home at least 6 months after infra-inguinal bypass operations. Both groups were comparable in terms of age, gender, prevalence of ischemic heart disease, diabetes, and other atherosclerosis risk factors.

Results: All quality of life parameters were higher among patients who underwent limb salvage surgery (group II) as compared to preoperative patients (group I), yet the obtained values were lower than those in the general population. Patients in the surgical intervention group had higher levels of function, lower pain levels, and higher emotional and social well-being and, in addition, were spared limb amputation. The findings also indicate that the social support dimensions (emotional support, receipt of information, affection and positive social interaction), as measured in terms of perceived availability, do not operate as one entity. Different types of social support were more beneficial along different stages of the disease.

Conclusion: Peripheral arterial occlusive disease causes severe impairment of the quality of life in elderly patients. Arterial reconstructive surgery improves the quality of life though it still remains low compared to the general population. Social support is beneficial in the treatment of these patients, and the social worker in the vascular surgery department has a key role in identifying the various needs of the patients along the path of their chronic illness.
 

Background: While age at death is on the rise, the number of postmortem examinations is declining and is disproportionately low among the elderly population. Research on the subject of gender-associated pathology in the elderly is also scarce.

Objective: To seek eventual gender-related differences in autopsies of elderly patients.

Methods: We analyzed the data extracted from a published report on 93 PMEs[1] performed at a geriatric hospital during the past 20 years.

Results: Ninety-three autopsies, representing 1.2% of the 8,101 deaths during these 20 years, were performed. Forty-five of the deceased were women and 48 were men. The incidence of pulmonary embolism was significantly higher in women (28%) than in men (10%) (P< 0.02). There was no significant difference in the gender distribution of the other diagnoses.

Conclusion: Gender distribution of PME-based causes of death in elderly patients revealed a significant rate of pulmonary embolism in women. A thorough search of the medical literature revealed two previous studies with similar findings. Further research will determine whether pulmonary embolism is more frequent or whether it has a worse prognosis in frail elderly women.

Matrix metalloproteinases are a family of enzymes that degrade different components of extracellular matrix. They play an important role in normal physiologic processes of maintaining tissue integrity and remodeling, as in wound healing, processes of development, and regeneration. However, excessive expression of MMP[1] has been observed in many disease states, including rheumatoid arthritis and osteoarthritis, vascular remodeling in atherosclerosis and aortic aneurysm formation, neoplastic processes, macular degeneration and many others.

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