Israel Medical Association Journal

Background: The implantable loop recorder (ILR) is an important tool for the evaluation of unexplained syncope, particularly in cases of rarely occurring arrhythmia.

Objectives: To review the clinical experience of two Israeli medical centers with the ILR. Methods: We reviewed the medical records of patients with unexplained syncope evaluated with the ILR at Rabin Medical Center (2006–2010) and Wolfson Medical Center (2000–2009).

Results: The study group included 75 patients (44 males) followed for 11.9 ± 9.5 months after ILR implantation. Patients’ mean age was 64 ± 20 years. The ILR identified an arrhythmic mechanism of syncope in 20 patients (17 bradyarrhythmias, 3 tachyarrhythmias) and excluded arrhythmias in 12, for a diagnostic yield of 42.7%. It was not diagnostic in 17 patients (22.7%) at the time of explant 26 patients (34.7%) were still in follow-up. In two patients ILR results that were initially negative were reversed by later ILR tracings. The patients with bradyarrhythmias included 9 of 16 (56.3%) with surface electrocardiogram conduction disturbances and 2 of 12 (16.7%) with negative findings on carotid sinus massage. All bradyarrhythmic patients received pacemakers the seven patients for whom post-intervention data were available had no or mild symptoms.

Conclusions: The ILR has a high diagnostic yield. Pre-ILR findings correlating with the ILR results are conduction disturbances (positive predictor of arrhythmia) and negative carotid sinus massage results (negative predictor of arrhythmia). Proper patient instruction is necessary to obtain accurate results. Caution is advised when excluding an arrhythmia on the basis of ILR tracings, and long-term follow-up is warranted.

Background: Infants with severe intraventricular-periventricular hemorrhage (IVH) have higher absolute nucleated red blood cell counts (aNRBC) at birth (a marker of intrauterine hypoxia) than controls. Periventricular leukomalacia (PVL) is known to be associated with prenatal and postnatal events. Whether PVL is also linked to intrauterine hypoxia is unknown.

Objectives: To test the hypothesis that infants with PVL have higher aNRBC counts at birth than controls.

Methods: We studied 14 very low birth weight infants with PVL and compared them with 14 pair-matched controls without PVL. Head ultrasound scans were performed in all infants on days 3–5 and 21–25 of life. Paired tests, Fisher exact tests and stepwise logistic regression were performed for analysis.

Results: Groups were similar for gestational age (GA), birth weight (BW), prolonged rupture of membranes (PROM), Apgar scores, IVH, and aNRBC counts. PVL correlated significantly with low partial pressure of CO2 (pCO2) and IVH (P < 0.01). In logistic regression, when GA, gender, PROM, antenatal steroid therapy, 1 (or 5) minute Apgar scores, IVH grade, nosocomial sepsis, patent ductus arteriosus, necrotizing enterocolitis (NEC), need for pressors, aNRBC counts and lowest pCO2 were used as independent variables, pCO2 (P = 0.002), IVH grade (P = 0.001), GA (P = 0.038), NEC (P = 0.061) and use of dopamine (P = 0.010) remained in the analysis (total R2 = 68.2%).

Conclusions: In contrast to severe IVH, aNRBC counts do not predict the development of PVL.

Background: While myoclonus and ataxia are considered common in patients with familial Creutzfeld-Jakob disease (fCJD), other movement disorders are less prevalent.

Objectives: To systemically evaluate the frequency of extrapyramidal signs and movement disorders in patients with fCJD.

Methods: A detailed neurological examination, with special emphasis on movement disorders and extrpyramidal signs, was conducted in 43 consecutive symptomatic CJD patients (26 males and 17 females mean age 58.7 ± 8.9 yrs, range 43–77 years) carrying the E200K mutation in the PRNP gene.

Results: Limb or gait ataxia was noted in 38 patients (88%) (37 patients, 86%, had ataxia at presentation). Myoclonus was evident in 25/43 patients (58%) (21 patients, 49%, at presentation). In 95% of the patients (41/43) (37/43, 86% at presentation) at least one extrapyramidal sign throughout the disease course was noted, the most prevalent being rigidity (28/43, 65% of the patients and 22/43, 51% at presentation), followed by the glabellar sign (24/43, 56% of the patients and 22/43, 51% at presentation), bradykinesia (19/43, 44% and 15/43, 35% at presentation), dystonia (15/43, 35% 12/43, 28% at presentation) and tremor (13/43, 30% 12/43, 28% at presentation).

Conclusions: In this unique population of fCJD patients, myoclonus was less prevalent than previously reported while other extrpyramidal signs were common and occurred at a relatively early stage of the disease. The high prevalence of movement disorders can be added to other phenomena characteristic of this familial disorder among Libyan Jews. Whether this is attributable to the E200K mutation itself or to some other mechanism has still to be elucidated.

The phenomenon of hair pulling has been recognized for centuries, yet the true prevalence of trichotillomania (TTM) is largely unknown and the topic has been sparsely studied. TTM is classified as an impulse-control disorder despite much debate about its etiology. In this review we summarize the different hypotheses, including impulse-control disorders, obsessive-compulsive disorders, behavioral problems and addiction, and the appropriate treatment methods. The combination of selective serotonin reuptake inhibitors and antipsychotic medications are shown to be most effective. Treatment with anti-addiction drugs seems relevant. Further research is needed to increase our knowledge regarding the etiology of TTM.