תוצאת חיפוש

זאב פילדמן¹, זאב קורשון¹, זאב ארינזון¹, רינת פרידמן²

¹מרכז רפואי לגריאטריה, נתניה, ²"נופי השרון", דיור מוגן, נתניה

התלונה על נדודי שינה אופיינית לקשישים ובד"כ מתמידה. שכיחותה עולה עם הגיל ומדווחת אצל נשים, גרושים או אלמנים, המתגוררים לבד, ומשתייכים למעמד חברתי-כלכלי הנמוך. נדודי שינה יכולים להופיע כמחלה בפני עצמה או כביטוי להפרעות פסיכיאטריות, פיזיולוגיות, או על רקע טיפול תרופתי.

המטרה בסקירה: להרחיב את המודעות לנושא נדודי השינה בקרב קשישים ולהרחיב את הנושא, בעיקר בנוגע לשינויים הפיזיולוגיים ולגישה הטיפולית.
 

שי שרוט¹, יואב צפמן¹, יהודה שינפלד²

¹המח' למחלות עצבים, המרכז הרפואית תל-אביב, ²מח' לרפואה פנימית ב' והמרכז למחלות אוטואימוניות, בי"ח שיבא, תל-השומר

תיסמונת האנטיפוספוליפידיים, antiphospholipid syndrome (APS) היא מחלה רב-מערכתית שבה מעורבים נוגדנים ואנטיגנים שונים. הפרעה האוטואימונית מתבטאת קלינית באירועים פקקתיים-תסחיפיים נשנים (עורקיים וורידיים), בהפלות עצמוניות נשנות, בתרומבוציטופניה ובכייל גבוה של נוגדנים כנגד פוספוליפידים ((antiphospholipid-antibodies - aPL וכן של נוגד קרישה זאבתי (lupus anticoagulant - LA). התיסמונת יכולה להתרחש משנית למחלות אוטואימוניות אחרות (כמו זאבת אדמנתית מערכתית systemic-lupus-erythematosus (SLE), לממאירויות או לזיהומים וכן כתגובה לתרופות. כשלא נמצאת סיבה ראשונית מעין אלו להתהוות התיסמונת, היא מוגדרת כראשונית (primary APS).

הנוגדנים הנמנים עם משפחת ה- aPL מאותרים בבדיקה שבה נמדדת תגובתיות (reactivity) חיסונית כלפי קרדיוליפין (aCL) ופוספוליפידים למיניהם הטעונים שלילית, בנוכחות או ללא נוכחות  ביתא 2 – גליקופרוטאין או קופקטורים חלבוניים אחרים, או ע"י תגובתיות חיסונית כלפי ביתא 2 – גליקופרוטאין (הידוע כקופקטור חיוני לקישור ה- aPL) או קופקטורים חלבוניים אחרים לבד, או על ידי יכולתם לעכב את מנגנון הקרישה בתבחיני קרישה התלויים בפוספוליפידים (LA=).

לא כל בני-האדם עם aPL יהיו תסמיניים. בסקר פרוספקטיבי של בנק הדם התגלה, שב- 6.5% מהאוכלוסייה הכללית אובחנו בתבחין ELISA נוגדנים מסוג IgP-aPL. לעתים קרובות, יורד כיל-ה- aPLלטווח התקין עם הזמן, ללא אירועים פקקתיים.

בחולים הלוקים ב- APS, דווח על ביטויים קליניים שונים, הכוללים סיבוכים המאטולוגיים, סיבוכים בעור, מחלת מסתמי הלב והיפגעות הכליות. בנוסף, דווח על ביטויים נירולוגיים שונים המערבים בעיקר את מערכת העצבים המרכזית. בסקירה זו, נדונים ההיבטים הנירולוגיים של תיסמונת הנוגדנים האנטיפוספוליפידיים.
 

למעלה מ- 40,000 נשים נפטרו בשנה האחרונה מסרטן השד בארצות הברית. עובדה זו מעמידה את סרטן השד כסרטן השכיח ביותר בנשים והשני כגורם לתמותה מסרטן בנשים. נשים מעל גיל 60 הן בעלות הסיכון הגבוה ביותר ללקות בסרטן השד ואוכלוסייה זו היא אוכלוסיית המטרה לרוב המחקרים הקליניים שמטרתם טיפול מונע. הסיכון במהלך שנות החיים ללקות בסרטן שד פולשני הוא בשיעור של 12%, ולכן כל טיפול שיפחית או יגדיל את הסיכון הנ"ל, הוא בעל השפעה חשובה על בריאות האשה. טיפולים המשפיעים על עלייה או ירידה בסיכון לסרטן השד בנשים בעת חדלון הווסת כוללים: טיפול הורמוני חלופי, כריתת שד כטיפול מונע, ומתן טמוקסיפן וראלוקסיפן. בשנה האחרונה, פורסמו מספר מחקרים בנושא, אותם נסקור במאמר זה.

Prevention and Treatment of Procedural Pain in Pediatric Wards

R. Gorodischer, L. Herzog, E. Herzog

Depts. of Pediatrics A and Anesthesiology, Soroka University Medical Center; and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Present knowledge and available pharmacological agents allow for adequate prevention and treatment of pain in children. We present guidelines we prepared for the prevention and treatment of procedural pain in children in our general pediatric ward. This followed extensive review of the literature, participation in scientific meetings, discussions with experts and consultation with interested clinicians. Successful implementation of the guidelines requires increased appreciation of the importance of pain prevention, participation of the nursing, as well as medical staff, and ability to evaluate pain in children of various ages.
 

Surgical Repair of Myxomatous Mitral Valve

D. Bitran, O. Merin, I. Dzigivker, D.Rosenmann, S. Od-allah, S. Silberman

Depts. of Cardiothoracic Surgery and of Anesthesiology and Cardiology; Shaare Zedek Medical Center, Jerusalem

Myxomatous mitral valve disease is now the most common cause of mitral regurgitation in the western world. Repair of the leaking valve has become standard surgical procedure during the past 2 decades. Between 1993-1999 we performed 113 repairs of the mitral valve. In 25 patients the etiology was myxomatous degeneration (no mortality). Long-term clinical results depend on patients' functional class at surgery. Based on this fact, and the good surgical results, it is recommended to refer such patients even with severe mitral incompetence for surgery at an early stage, even if symptoms are minimal.

Cholesterol Pericarditis Associated with Rheumatoid Arthritis

B. Knobel, P. Rosman

Dept. of Medicine B, Edith Wolfson Medical Center, Holon; and Sackler Faculty of Medicine, Tel Aviv University

Cholesterol pericarditis (CP) is a rare and unusual disease characterized by chronic pericardial effusion with high cholesterol concentration. Precipitation of cholesterol crystals may occur and induce inflammation and constrictive pericarditis. CP may be idiopathic, but is usually associated with a systemic disease, such as tuberculosis, myxedema, or as in our case, rheumatoid arthritis (RA).

We present a 78-year-old woman with RA, typical deformities of the metacarpo- and metatarso-phalangeal joints and subcutaneous rheumatoid nodules. She was hospitalized with increasing dyspnea and weakness and a 2-dimensional transthoracic echocardiogram showed a large pericardial effusion, without tamponade.

Blood cholesterol was 208 mg/dl, triglycerides 169 mg/dl, LDH 37 u/L and rheumatoid factor 2560 u; glucose, kidney, and thyroid function tests were normal and PPD test negative. Pericardiocentesis yielded 800 ml of opaque, cloudy fluid, with glucose 19 mg/dl, cholesterol 264 mg/dl (normal 20-40 mg/dl), triglycerides 169 mg/dl, LDH 5820 u/L and rheumatoid factor 40 u; viral titers and cultures for bacterial, mycobacterial and fungal infections were negative. The pericardial fluid had a distinctive scintillating, gold-paint appearance and many cholesterol crystals were evident microscopically.

The patient responded to treatment with methotrexate and steroids. Factors responsible for increase in pericardial fluid cholesterol may be its liberation from injured pericardial cells and rheumatoid nodules, lysis of red cells, or lymphatic obstruction and impairment of the absorptive capacity of the pericardium.

Screening for Early Detection of Prostatic Cancer

A. Neheman, Y. Shotland, Y. Metz, A. Stein

Dept. of Urology, Carmel Hospital, Lady Davis Medical Center, Haifa

Prostatic cancer (PC) is second only to lung cancer as a cause of cancer mortality in men word-wide. In Israel it is the most common cause of cancer mortality in men, after lung cancer and colo-rectal cancer.

We screened, for the first time in Israel, for prostatic cancer using serum levels of PSA and a digital rectal examination (DRE). The purpose was not only to diagnose PC but also to increase public awareness of the condition.

300 men in the Haifa area who met statistical criteria for early diagnosis of PC participated. They filled a questionnaire regarding risk factors for PC (age, family history (FH) of prostatic and breast cancer, cigarette smoking, alcohol consumption, previous PSA sampling) and were examined. Those who had out-of-ragne, age-related PSA values, or a pathologic DRE underwent trans-rectal ultrasound (TRUS) examination and guided biopsy of the prostate. Those with a positive biopsy for PC underwent radical prostatectomy or radiation therapy.

41 (14.3%) had out-of-range, age-related PSA levels and 10 (3.5%) had a pathologic DRE. 39 (13.3%) underwent TRUS and biopsy and 6 (2.04%) had clinically significant PC, all early stages (Gleason 4-6).

Correlation between age and PSA has been proven statistically significant (p<0.05). Symptoms of urinary tract obstruction and nocturia were related to a high PSA (p=0.035 and 0.002, respectively). Those with PC had at least 1 symptom of urinary tract obstruction; 6 (15.3%) who underwent TRUS and biopsy and a FH of prostate cancer. However, no subject with a FH of PC had biopsy-proven cancer. Those with PC had PSA values from 4.9 to 31.8 ng/ml (9.6 median). Age-related PSA had a positive predictive value of 17.1%.

Results of our annual screening for early detection of PC using age-related PSA, and DRE are encouraging: cases detected were clinically significant and treatable. It would appear that screening for PC will result in decreasing the incidence of metastatic cancer and therefore mortality. 
 

Folic Acid for Preventing Neural Tube Defects

Ziv Gil, Adi Aran, Orna Friedman, Liana Beni-Adani, Shlomo Constantini

Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba; Division of Pediatric Neurosurgery, Dana Children's Hospital, Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv

Spina bifida and anencephaly are the most common, serious malformations in neural tube defects (NTD). Randomized trials in the last 2 decades have demonstrated that folic acid, 0.4 mg/d, reduces the incidence of NTD by more than 50%. We investigated the use of folic acid and multivitamins containing folic acid in childbearing women.

Of 221 women interviewed, 67 (30%) regularly took pills containing 0.4 mg folic acid. Women with higher educational levels were more likely to take multivitamins with folic acid than were the less educated (p=0.05). Of the women who took folic acid, only 5 (7.5%) used separate folic acid tablets, before and during their pregnancy. The rest used multivitamins containing folic acid. The 5 women who took folic acid separately were college-educated and nonreligious, and they took multivitamins in addition (p>0.05).

Of the women interviewed, 58 (26.2%) were Bedouin of the Negev. 24 (41.4%) of them took pills containing folic acid on a regular basis. This percentage is higher than that in the Jewish women in the study who took folic acid for prevention of NTD (17%; p=0.038).

Most of the women took folic acid after the first trimester. Only a minority took daily periconceptional folic acid. Multivitamins containing 0.4 mg of folic acid were more popular than folic acid tablets alone. This study emphasizes the need for continuing efforts to increase consumption of folic acid and awareness of its benefits among women of childbearing age.

Atrophic Gastritis Presenting with Pulmonary Embolism

Muhammad A. Abdul-Ghani, Rima Feldman, Moshe Shai, Jacob Varkel

Dept. of Medicine C, Western Galilee Hospital, Naharia

Atrophic gastritis is an autoimmune gastropathy in which there is destruction of gastric parietal cells. This results in intrinsic factor deficiency and disturbance in vitamin B12 absorption. Its clinical manifestationa are therefore the consequences of B12 deficiency and include anemia and neurological defect. In addition, lack of B12 results in metabolic changes, including disturbances of methionine metabolism and accumulation of homocysteine.

In recent years, there has been increasing evidence suggesting that hyperhomocysteinemia is a risk factor for thrombo-embolic disease. We describe a 51-year-old man with atrophic gastritis, severe B12 deficiency and hyperhomocystein-emia. The initial clinical manifestation was pulmonary embolism, without either anemia or neurological signs. B12 deficiency should therefore be considered in patients being investigated for hypercoagulability.

Histoacryl Vs Dermabond Cyano- Acrylate Glue for Closing Small Operative Wounds

Zvi Steiner, Jorge Mogilner

Dept. of Pediatric Surgery, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa

Acrylate glues used in a childrens' day care unit to close small surgical wounds were compared. In 157 children, aged 12 weeks to 3.7 years, either Histoacryl or Dermabond was used (respectively, H: Ethicon Inc., Johnson & Johnson, NJ or D: Dermabond, Braun Surgical Gmbh, Melsungen, Germany). Operations were for inguinal hernia (110 cases), hydrocele (25), undescended testis (16), umbilical hernia (13) and funiculocele (3).

1 week after surgery the wounds were evaluated in terms of integrity of closure, redness or infection, need for antibiotics, wound granuloma, and parental satisfaction with instructions and actual method of wound caring. 3 months after surgery the wound/scar was reexamined.

The margins of the wounds were separated partially or completely in 8 of 85 in group H (9.4%) while in the D group, 2 wounds (2.4%) had partially opened (p<0.05). There were no differences between the glues with regard to wound infection or cosmetic results. Parental satisfaction was higher with D (96%) than H (82%) but the difference was not statistically significant.

It is convenient to use glue to close operative wounds in children after ambulatory surgery. The use of D significantly reduced wound ruptures compared to H. Long-term cosmetic results were similar.

Advantages of Standardized Protocol for Oral Rehydration in Acute Pediatric Gastroenteritis

Avi Weizman, Ahmed Alsheikh, Laura Herzog, Asher Tal, Rafael Gorodischer

Pediatric Depts. A and B, Soroka Medical Center; and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Oral rehydration (OR) for acute gastroenteritis in infants and children has been shown to be as effective as IV therapy, with less discomfort and lower costs. In this retrospective study we compared 2 pediatric wards, in 1 of which only a standardized, simplified, bedside protocol, based on American Academy of Pediatrics guidelines, was used.

There were no significant clinical characteristics in the 208 patients. In the ward which used the above protocol, OR utilization was significantly more frequent than in the other ward (48% versus 15%), thus saving equipment costs of nearly $1,000/3 months. There were no significant differences in outcome between the wards.

We conclude that introducing a standardized management protocol may increase OR utilization in hospitalized children with acute diarrhea.
 

Penile Reconstruction after Complete Glans Amputation during Ritual Circumcision

Ofer Z. Shenfeld, Dean Ad-El

Depts. of Urology and of Plastic and Reconstructive Surgery, Hebrew University-Hadassah Medical Center, Jerusalem

Circumcision, so commonly performed, is considered a safe procedure rarely associated with significant complications. A case of complete amputation of the glans penis during neonatal circumcision is reported. The glans was successfully reimplanted, with good post-operative functional and esthetic results.

Burch Laparoscopic Procedure for Repairing Proven Stress Incontinence

Moshe Bustan, Shabtai Romano, Raed Salim, Jacob Rosenman, Eliezer Shalev

Depts. of Obstetric and Gynecology and of Urology, HaEmek Medical Center, Afula

There are more than 200 procedures for repairing stress urinary incontinence. We evaluated the safety and efficiency of the Burch laparoscopic procedure in 32 women with urodynamically proven genuine stress incontinence.

Mean operating time was 40 minutes and mean hospitalization time after the procedure was 30 hours. The cure rate was 97%, similar to that rin other studies (80-95%). The major complications w2 cases (6.2%) of unintended bladder injury, diagnosed and repaired laparoscopically. Although follow-up has only been for 3-42 months, the high cure rate and safety and advantages of laparoscopy over laparotomy, make laparoscopic Burch colposuspension the procedure of choice for repairing stress incontinence.

Thrombocytopenic Purpura as Sole Manifestation of Brucellosis in a Child

Ronen Marom, Dan Miron, Herzel Gabriel, Yosef Horowitz

Pediatric Dept. A, Pediatric Infectious Disease Service, and Pediatric Hemato-Oncology Unit, HaEmek Medical Center, Afula and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Thrombocytopenic purpura associated with brucellosis has rarely been described in children. The thrombocytopenic purpura is usually part of the array of manifestations of brucellosis, such as fever, malaise, arthralgia, arthritis, hepatosplenomegaly and lymphadenopathy.

We describe a 4-year-old girl in whom severe thrombocytopenic purpura was the only manifestation of brucellosis which resolved after appropriate antibiotic therapy. We conclude that brucellosis should be included in the differential diagnosis of thrombocytopenic purpura in areas endemic for brucellosis, and when there is a history of exposure to infected food products.