תוצאת חיפוש

Cyclic Vomiting Syndrome in Children

G. Ben-Amitay, Y. Nevo, D. Lieberman, R. Mester, S. Harel

Ness Ziona Mental Health Center, Institute for Child Development and Pediatric Neurology Unit, Tel Aviv-Sourasky Medical Center, and Tel Aviv University Medical School

Cyclic vomiting syndrome in children is a manifestation of various etiologies, including gastroenterological and renal disorders, central and autonomic nervous system abnormalities, as well as metabolic and endocrine dysfunction. Frequently no organic cause is found. Personality profiles of children with cyclic vomiting reveal perfectionism, competitiveness, and aggressive behavior. Vomiting attacks have been induced by anxiety and excitement in patients with cyclic vomiting. We describe an 8-year-old girl with cyclic vomiting, frequently associated with occipital headaches, photophobia or dizziness. Psychiatric evaluation indicated a generalized anxiety disorder.

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.

Primary Dermatology Who is the Gate Keeper?

A. Biton, D. Vardy, S. Naimer

Regional Dermatology Clinic, Kupat Holim Clalit, and Ben-Gurion University of the Negev, Beer Sheba

For several years health funds in Israel have allowed patients to see dermatologists, gynecologists, orthopedic surgeons and ENT specialists without being referred by their primary care physician. There is heated debate about whether this practice is justified and if it is cost effective. Is it better medicine for the patient? What are the roles of the primary care physician and of the primary dermatologist in the care of skin diseases? What do patients want? We examined the practices of 4 dermatology clinics and discuss the issues involved.

Intradermal Hepatitis B Vaccination in Those Not Responsive to Intra-Muscular Vaccination

Hanna Bauer, Israel Potasman, Neora Pick

Infectious Disease Unit, Bnai Zion Medical Center and Faculty of Medicine, The Technion, Haifa

Health care workers are at continuous risk of hepatitis B infection. Currently recommended intramuscular vaccination confers immunity in only 85-90%. We examined the immunogenicity and safety of intradermal vaccination of hepatitis B vaccine in nonresponders. 400 hospital employees who had been immunized as recommended were screened for anti-HBs antibodies and 50 were found seronegative. Each received an intramuscular booster injection and antibody level was measured a month later. Excluded were 33 employees, including 24 late responders, 2 HbsAg carriers and 7 uncooperative employees. 17 employees (mean age 47.1 yrs) then received a series of 3 intradermal injections of Energix B, 0.25 ml in the forearm, 2-3 weeks apart. The mean number of previous intramuscular injections was 4.6±1.4 month later there was a mean titer of 315.4±347.0 miu/ml of antibody in 16/17 workers. Side effects were minimal. Intradermal injection of hepatitis B vaccine for nonresponders seems effective for inducing seroconversion. Its cost-effectiveness for the health care system warrants assessment.

Clinical Characteristics of those who Leave the Emergency Room Against Advice

A. Carmel, H. Amital, Y. Shemer, A. Sahar

Emergency Dept. and Dept. of Medicine B, Gertner Institute for Medical Service Research, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

The object of this study was to characterize those who leave the emergency department agmedical advice and to examine the short-term consequences. The study was conducted retrospectively 1992 and prospectively during May-August 1993 by telephone interviews. About 0.5% of all the patients who applied to the emergency department left against medical advice. Their main characteristic was that they were mostly young, single men. A wide range of complaints had brought them to the emergency department, very similar to that of the control group, but with a higher tendency to abuse drugs and alcohol. Most of those who left against medical advice had less severe disease than the controls. However 10% of them had to be hospitalized within the subsequent 2 weeks, in comparison with 4% of the controls. This study suggests that improving the efficiency of the emergency department will decrease the number leaving against advice.

Effect of Alpha-Alpha Esterol on Plasma Cholesterol and Antioxidants

Y. Levy, E. Paster, G. Dankner, A. Ben-Amotz, J.G. Brook

Lipid Research Unit, Medical Dept. D, Rambam Medical Center; Rappaport Faculty of Medicine, The Technion; and Israel National Oceanographic Research Institute, Haifa

16 patients with hypercholesterolemia were treated with an extract of alpha-alpha leaves (esterol) while on a low-fat, low-cholesterol diet. Esterol is believed to inhibit the absorption of cholesterol and bile acids and may interfere with the absorption of essential nutrients. As oxidative modification of lipoproteins is required for the process of atherosclerosis, plasma antioxidant vitamins were followed. After 4 months of treatment, plasma cholesterol decreased by 10% from 282 to 250 mg/dl (p<0.001) and LDL cholesterol by 13%, from 203 to 177 mg/dl (p<0.001). Plasma antioxidant vitamins E, A and β-carotene were unchanged. Thus, esterol has a cholesterol-lowering effect but apparently does not lower fat-soluble, plasma antioxidant vitamins. Both cholesterol-lowering and plasma antioxidant vitamins are important for the primary prevention of coronary artery disease in hypercholesterolemia.

Effects of Vertical Banded Gastroplasty on Weight, Quality of Life and Nutrition

Iris Shai, Shimon Weitzman, Izhak Levy

Depts. of Epidemiology and Surgery, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

We examined the long term results of vertical banded gastroplasty 3-10 years after operation. They were assessed by weight lost, incidence and severity of untoward effects and improvement in diet and in quality of life in 75 of 122 who had had the operation. Average weight lost was 28.5±14.9 kg (p<0.001) in 5 years and 58.6±30.4% of excess weight, which brought patients to within 32±25.2% of ideal weight. According to these measures, in 63-76% the operation had been successful in causing weight loss. The 2 criteria for successful weight loss were loss of more than 50% of weight in excess of ideal body weight and residual body weight less than 50% greater than ideal body weight. There was a greater risk of failure in unmarried subjects older than 45 (odds ratio for not losing weight was 6; in those weighing more than 120 kg it was 9). We saw evidence of this mostly 4 years after operation (odds ratio 11). The degree of success in weight loss was correlated with texture of food (softness) preferred and length of operation. Of those interviewed, only 65% were satisfied with their results. The greatest improvement in quality of life measurements was in physical activity, perception of health, and frequency of feeling depressed. Side-effects were vomiting, reflux and fatigue. Only 34.7% were able to digest solid foods, so that subjects are at risk for nutritional deficiencies.

* Based on MS thesis in epidemiology of Iris Shai.

Recurrent Tuberculosis in a Psychiatric Hospital

A. Zeenreich, B. Gochstein, A. Grinshpoon, M. Miron, J. Rosenman, I. Ben-Dov

Pulmonary and Radiology Institutes, Chaim Sheba Medical Center, Tel Hashomer and Tel Aviv University; Israel Ministry of Health; and Gan Meged Hospital

During 1987-1996, 39 of 720 patients hospitalized (most for severe schizophrenia) were diagnosed as having active pulmonary tuberculosis (5.4%, 975 per 105 per year). In 1992-1993, after a cluster of 5 cases was found, all patients were screened by PPD skin test and chest X-ray and 16 more cases were identified. Diagnosis was confirmed bacteriologically in only 10 of them but there were typical radiological findings in the others. 39 were treated with a multi-drug regimen. In addition, 333 exposed patients and 21% who had converted their skin tests were given isoniazid preventive therapy. A small increase in levels of liver enzymes was common, but significant abnormality (over 4 times the upper limit of normal) was found in only 7 patients, in whom therapy was therefor stopped or changed. During a follow-up period of 4 years, 2 more developed tuberculosis and 33 converted their PPD reactivity status. We conclude that an outbreak of tuberculosis in a psychiatric hospital can be controlled with a relatively low rate of side-effects by using systematic diagnostic and therapeutic measures. However, single step screening is not sufficient. Routine screening of all new patients, a high index of suspicion and contact investigation are needed.

Clinical Characteristics of Crohn's Disease in Children and Adults

Yoram Menachem, Zvi Weizman, Chaim Locker, Shmuel Odes

Gastroenterological Institute and Pediatric Gastroenterology and Nutrition Unit, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

There are few reports contrasting the clinical characteristics of Crohn's disease in different age groups. We therefore compared retrospectively children and adults with Crohn's disease. 23 children (mean age: 12.8±2.5 years) and 66 adults (mean age: 27.0±4.0 years) were studied. Presenting symptoms of abdominal pain and diarrhea were significantly more common in adults, while in children anorexia and weight loss were more frequent. Children tended to present with extra-gastrointestinal tract symptoms as well, mainly anemia and joint involvement. Common symptoms during active disease did not differ between groups, except that weight loss, evident in all children, was found in only 70% of adults. Anemia was present during active disease in all pediatric cases but in only 62% of adults. There were no significant differences between groups regarding disease location, gastrointestinal complications and extra-intestinal manifestations. We conclude that in children Crohn's disease may differ significantly, mainly presenting with nonclassical symptoms, such as anemia and joint involvement. The primary care physician should be aware of these differences.

Hepatocellular Damage after Using Ecstasy

E. Shiloach, E. Zecler, M. Horowiz, E. Scapa

Depts. of Medicine C and Gastroenterology, Assaf Harofeh Medical Center, Zerifin (Affiliated with Sackler Faculty of Medicine, Tel Aviv University)

Ecstasy is a stimulant used mainly by youngsters to get 'high.' There are few reports of acute injury of the liver due to ecstasy. We describe a 37-year-old woman who presented with the clinical picture of recurrent hepatitis following ingestion of the drug. After several months she developed liver cirrhosis shown by biopsy and CT scanning. This case emphasizes the potential danger of ecstasy. Every patient with hepatitis of unknown origin must be questioned about ingestion of the drug.

Progression of Diabetic Retinopathy after Cataract Extraction

Y. Raniel, Y. Teichner, Z. Friedman

Annette and Aron Rozin Dept. of Ophthalmology, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

A prospective study of the effect of cataract extraction with intraocular lens implantation on the course of diabetic retinopathy (DR) in 44 patients (59 eyes) was carried out. It showed that in the 1-3 years following surgery, there was progression of DR (including development of newly formed retinopathy) in 35% of the patients (28.8% of eyes). Progression was more marked in patients with pre-operative bilateral DR compared to those without bilateral DR (77% and 16% respectively). Insulin dependence did not play a role in progression. Final visual acuity was better in patients without pre-operative DR, as well as in eyes without progressive retinopathy.

Continuous Quality Improvement in Anesthesia

Luis Gaitini, Sonia Vaida, Shahar Madgar

Depts. of Anesthesia and of Urology, Bnai-Zion Medical Center, Haifa

Slow continuous quality improvement (SCQI) in anesthesia is a process that allows identification of problems and their causes. Implementing measures to correct them and continuous monitoring to ensure that the problems have been eliminated are necessary. The basic assumption of CQI is that the employees of an organization are competent and working to the best of their abilities. If problems occur they are the consequences of inadequacies in the process rather that in the individual. The CQI program is a dynamic but gradual system that invokes a slower rate of response in comparison with other quality methods, like quality assurance. Spectacular results following a system change are not to be expected an the ideal is slow and continuous improvement.

A SCQI program was adapted by our department in May 1994, according to the recommendations of the American Society of Anesthesiologists. Problem identification was based on 65 clinical indicators, reflecting negative events related to anesthesia. Data were collected using a specially designed computer database. 4 events were identified as crossing previously established thresholds (hypertension, hypotension, hypoxia and inadequate nerve block). Statistical process control was used to establish stability of the system and whether negative events were influenced only by the common causes. The causes responsible for these negative events were identified using specific SCQI tools, such as control-charts, cause-effect diagrams and Pareto diagrams. Hypertension and inadequate nerve block were successfully managed. The implementation of corrective measures for the other events that cross the threshold is still in evolution. This program requires considerable dedication on the part of the staff, and it is hoped that it will improve our clinical performance.

Incidence, Antimicrobial Resistance and Mortality in Bloodstream Infections in the Critically Ill

Lavi Oud, Shelly Krimerman, Isaac Srugo

General Intensive Care Unit and Clinical Microbiology Dept., Bnai-Zion Medical Center, Haifa

Bloodstream infections (BSI) are 7-fold more common in patients admitted to the intensive care unit (ICU) rather than to other hospital wards. The epidemiology of BSI in critically ill patients in Israel has not been systematically addressed. We examined the annual trends in BSI in patients in a general ICU of evolving patterns of antimicrobial resistance and associated mortality rates for the years 1994-1996. The presence of the systemic inflammatory response syndrome (SIRS) when the first positive blood cultures are taken was a prerequisite for its definition as clinically significant. The unit site, staff, practice guidelines, and type of patient were unchanged during the study period. Blood cultures were positive in 220.7-332.0 patients per 1000 ICU admissions, 18-22-fold more common than in regular ward patients. SIRS was a universal finding in these ICU patients. There was multi-drug resistance for the majority of species cultured, reaching 100% in some cases. Crude hospital mortality of ICU patients, with and without positive blood cultures, was 31-54% and 5-14%, respectively. The introduction of a new blood culture system (Bactec 9240) in 1996 was associated with a 61% increase in the rate of patients with positive blood cultures, accounted for mostly by increased isolation of coagulase-negative staphylococci. However the mortality rate for the latter decreased by 59%, suggesting the possibility of a selective increase in detection of contaminated cultures. Although highly prevalent in the study population and generally defining a patient group with high mortality risk, the specificity of SIRS-associated positive blood cultures may be species and culture-system dependent. These findings re-emphasize the need for both improved control measures for the epidemic proportions of BSI and multi-drug antimicresistance, as well as more specific indicators of the clinicaof positive blood cultures in critically ill patients.

Fungus-Ball in a Preterm Infant Successfully Treated with Fluconazole

Mirit Hershman-Sarafov, Orora Tubi, Isaac Srugo, David Bader

Neonatal and Radiology Depts., and Microbiology Laboratory, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Very-low-birth-weight premature infants are at high risk for invasive candidiasis. The most commonly involved organ is the kidney. Renal candidiasis may present as fungus-ball obstructive uropathy. We describe unilateral renal obstruction secondary to fungus-ball in a premature infant. Noninvasive, systemic antibiotic treatment, including amphotericin B and fluconazole, resulted in disappearance of the finding.

Onchocerca in Israel

A. Pressman, Y. Kandelis, Y. Bachar, G. Mogilner

Depts. of Pediatric Surgery and Pathology, Bnei-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

The parasite Onchocerca volvulus is well-known in its endemic areas in South and Central America and West Africa. It is transmitted to man by simulium flies and causes systemic infection with skin, lymphatic and ophthalmic manifestations and can cause blindness (river blindness). Treatment with Ivermectin is effective but sometimes there is need for surgical intervention to prevent or treat complications. We describe an 11-year-old girl, a new immigrant from Ethiopia, who had a firm mass in her left thigh, caused by Onchocerca volvulus. It was completely excised. This is a very rare condition in Israel, which must be considered in patients coming from endemic areas.