תוצאת חיפוש

Skeletonized Internal Mammary Arteries for Coronary Bypass Grafting

Jacob Gurevitch, Yosef Paz, Menachem Matsa, Amir Kramer, Dimitri Pevni, Oren Lev-Ran, H. Locker, Raphael Mohr

Dept. of Thoracic and Cardiovascular Surgery, Sourasky-Tel Aviv Medical Center

The skeletonized internal mammary artery (IMA) is longer, and its immediate spontaneous blood flow is greater than that of the pedicled IMA, thus providing increased versatility for complete, arterial myocardial revascularization without the use of saphenous vein grafts. From April 1996 to May 1997, 583 patients underwent coronary artery bypass grafting here and in 415 (71%) complete arterial revascularization was achieved using bilateral skeletonized IMA. The right gastroepiploic artery was used in 57 (13%); there were 329 males (79%) and 86 women (21%); average age was 64 (30-87) and 175 (36%) were older than 70; 131 (32%) were diabetics. Average number of grafts was 3.2 (range 2-6 grafts). At 30 days, 5 (1.2%) had died and there had been 6 perioperative infarcts (1.4%), 5 CVA's (1.2%), and 6 had sternal wound infections (1.4%). Up to 1-12 months of follow-up was achieved in 409 (99%). Late mortality was 1.4% (of which 3 were noncardiac). 394 (97%) were angina-free at latest follow-up. We conclude that arterial revascularization using bilateral skeletonized IMA is safe, as postoperative morbidity and mortality are low, even in old and diabetic patients.

Screening Tests for Detecting Breast Cancer: Performance Rates and Characteristics of Patients

Netta Bentur, Revital Gross, Ayelet Berg

JDC-Brookdale Institute of Gerontology and Human Development, Jerusalem

Screening tests including mammograms for early detection of breast cancer are in the basket of services provided under the National Health Insurance Law. The law also defines the population groups entitled to mammograms, and sets the frequency of the test as once every 2 years. The aim of this study was to examine the screening rates for early detection of breast cancer at the inception of the law, in order to monitor future changes in performance rates, and identify the characteristics of those unlikely to undergo these tests, in order to promote the use of screening tests by them. This study is part of a comprehensive survey examining the effect of the National Health Insurance Law on the Israeli population.

The survey, carried out in the summer of 1995, included a sample of 1,400 Israeli residents aged 22 and over. To determine performance rates for clinical breast examinations a subgroup of 515 women aged 30 and over was sampled. To determine performance rates for mammograms, 173 women were aged 50-74 (the entitlement ages under the law), were sampled. 54% of women aged 30+ reported having had at least 1 clinical breast examination during their lifetime, and 56% of women aged 50-74 reported having had a mammogram during the past 2 years. Variables with an independent effect on the likelihood of having had a clinical breast examination by a physician during the past 2 years were: being over the age of 50, having at least 9 years of education, being a veteran resident of Israel (as opposed to a new immigrant), and being Jewish. Variables with an independent effect on the likelihood of having a mammogram during the past 2 years were: being a veteran resident of Israel, and having a high income צ which was found to have a borderline effect. The findings of the survey emphasize the importance of changing the behavior patterns of both women and physicians, informing women about their entitlement to the tests, and raising consciousness of the importance of having repeated clinical examinations by a physician, as well as mammograms.

Israel's ATLS Program: Summary and Outlook

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

Medical Dept., Israel Defense Forces and Israel Trauma Society

In recent years a vigorous effort has been made to improve quality of primary trauma care in Israel. Advanced trauma life support courses (ATLS) were given to physicians throughout the country, regardless of their specialties. In 7 years 4229 physicians participated in 202 courses with an average success rate of 76%. In the future, issues such as mandatory vs. voluntary training, language barriers, and continuous decline of knowledge should be addressed if momentum is to be maintained.

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.

Characteristics of Adults with Emotional Distress, and Patterns of Mental Health Services Use

Revital Gross, Dina Feldman, Yonathan Rabinowitz, Miriam Greenstein, Ayelet Berg

Health Policy Research Unit, JDC-Brookdale Institute and Mental Health Division, Ministry of Health, Jerusalem and School of Social Work, Bar Ilan University, Ramat Gan

We sought firsthand data on the extent of perceived mental health needs and on patterns of use of mental health services among Israelis aged 22 and over. The data are from a national survey conducted in 1995. A random sample of phone numbers from the telephone company's computerized listings yielded 1,395 completed questionnaires (response rate, 81%).

At some point in their lives, 27% had experienced emotional distress or mental health problems with which they had difficulty coping alone; 13.4% reported that they had such an experience during 1995. According to multivariate analysis, those more likely to report mental health problems were women, those with a chronic disease, Russian immigrants, divorced or widowed adults, those with a low level of education, and members of the Clalit sick fund. 38% of those who had ever had emotional or mental health problems had asked for help. The proportion of those seeking help was high among respondents aged 35-55, Hebrew speakers (compared to speakers of Russian or Arabic), and city dwellers, and the rate was low among members of the Clalit sick fund. Of those who did seek help, 39% went to a psychologist or a psychiatrist, 25% to their family doctor, 19% to a family member or friend, 7% to a social worker or social service agency, 6% to other medical personnel, and 4% to a psychiatric hospital. 30% turned for assistance to the private sector and 70% to the public sector.

These findings have special significance in view of the impending reform of the mental health services. As mandated by the new National Health Insurance Law, mental health services are to be included in the basket of health services provided by the sick funds. The data can be of use in the management of sick funds and for physicians working in the community, as they prepare for this change. In addition, the data will be of aid to national policy makers in planning services suited to the needs of different population groups and to allocate resources more rationally.

Fibrosarcoma after Silicone Breast Augmentation: Associated?

Anabel Aharon-Maor, Yair Levy, Yehuda Schoenfeld

Medical Dept. B, Chaim Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University

We describe a 42-year-old woman in whom bilateral fibrosarcoma of the breast was diagnosed 15 years after bilateral breast augmentation with silicone implants. 3 years prior to admission the implants were replaced and 2 years prior to admission mammography showed a nodule in the left breast which biopsy showed to be fibrosarcoma. The implants were removed from both breasts and she was given chemotherapy but later that year underwent bilateral mastectomy. Despite chemotherapy, as well as adjuvant radiotherapy, the disease progressed, with involvement of the lungs and the skin of the left hemithorax. She was admitted repeatedly for severe anemia caused by bleeding from the malignant skin lesions, and died less than 2 years after diagnosis of the disease.

Not all reports in the literature find a significant connection between silicone implants and subsequent development of breast cancer, but there are reports that do connect them. Breast fibrosarcoma is not significantly more frequent after silicone augmentation, but still there is controversy as to whether there is a connection between silicone implants and breast malignancy. In the patient we present, the prolonged exposure to silicone may have been a predisposing factor for the development of bilateral fibrosarcoma, since other known risk factors for breast cancer were denied.

Pelvic Lytic Lesion and Osteoporosis-Related Fractures

Yaron Weisel, Ehud Rath, Nissim Ohana, Dan Atar

Orthopedic Dept., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Insufficiency fractures of the pelvis may be overlooked as a cause of hip or groin pain. These fractures occur in the elderly, usually those with pronounced osteopenia of the pelvis. Predisposing factors include corticosteroids, local irradiation and postmenopausal osteoporosis. These fractures are difficult to detect clinically and plain radiographs and other studies may be misleading, delaying diagnosis and treatment. A 65-year-old woman had left groin and hip pain for 2 months with no history of trauma. Plain radiographs showed lytic lesions in the left pubic rami. Bone scan revealed increased uptake in that region, suggesting metastatic bone disease. Computed tomography and magnetic resonance imaging demonstrated fractures in the left superior and inferior pubic rami, with callus formation with no involvement of soft tissues. Quantitative computed tomography indicated low calcium concentration, below fracture threshold. The diagnosis of insufficiency fractures of the pelvis was confirmed by the favorable clinical and radiographic outcome. It is therefore important to be familiar with the appearance and location of these fractures.

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.

Recurrent Syncope as a Presenting Symptom of Systemic Mastocytosis

Iris Barshack, Ginette Schiby, Ofer Shpilberg, Yechezkel Sidi

Pathology Dept., Hematology Institute and Medical Dept. C, Chaim Sheba Medical Center, Tel Hashomer

A 48-year-old man presented with recurrent syncope which was preceded by facial edema and difficulty in breathing. Physical examination, laboratory tests, abdominal CT and bone scan were all within normal limits. Bone marrow biopsy was consistent with mastocytosis. Systemic mastocytosis consists of a spectrum of disorders characterized by aberrant proliferation of tissue mast cells, and are mainly related to mast cell mediator release.

Correlation between Success in Specialty Examinations and Learning Methods of Family Medicine Residents

Netta Notzer, Dahlia Megiddo, Ruth Abramowitz, Michael Weingarten

Medical Education Unit, Family Medicine Section, Sackler Faculty of Medicine, Tel Aviv University

Learning methods chosen by residents in family medicine during their residency and the correlation between them and achievement in the written specialty exams (Stage 1) were investigated. The learning patterns studied were: structured learning (certification course, study with a tutor, staff meetings, conferences) and self-learning (textbooks, journals, the Hebrew publication "Update," and audio tapes). Of 184 residents who took the examination in 1994-5, 104 responded to a questionnaire as to preferences for the various learning aids and satisfaction with their use. There was no correlation between use of a given learning method and success in the examination. Significantly more candidates preferred self-learning, especially among those who were successful, but also among some who failed the examination. There was no direct connection between the examination and the high level requirements of the residency program, for which up-to-date, integrated knowledge based on self-learning is needed.

Orthostatic Hypotension as a Manifestation of Malignant Lymphoproliferative Disease

H. Semo, A. Adunsky, E. Grossman

Depts. of Geriatric Medicine and of Medicine D, Chaim Sheba Medical Center, Tel Hashomer

An 85-year-old man was admitted with 6-month history of incapacitating orthostatic hypotension. Investigation led to the discovery of sympathetic dysautonomia, sensorimotneuropathy and malignant lymphoproliferative disease. Several attempts to treat the orhypotension or the neoplastic disease failed to improve his condition. Orthostatic hypotension precipitated by sympathetic dysautonomia may be an infrequent effect of early malignant lymphoproliferative disease.

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.

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.

Experience with Under-Water Birth

Eylon Lachman, Zvi Finelt

Dept. of Obstetrics and Gynecology, Yoseftal Hospital, Eilat

Underwater birth is now deemed an acceptable type of delivery. Safety is a recurring consideration, the main concern being that of drowning. But in reports of 19,000 underwater births no untoward events were noted. Also, need for pain relief and of intervention during labor were both reduced. The short term indicators of neonatal outcome were good. A recent review explains 5 different physiological factors which inhibit initiation of fetal breathing under warm water. Many studies have shown no increase in risk of infection of either mother or baby. We report our experience with 26 women, 23 of whom actually delivered in the pool with excellent results. We believe that birth under water is safe and beneficial if done properly for low-risk patients.

Six Cases of Acute Rheumatic Fever in One Year

George Habib, Ramiz Abu-Ahmad

Rheumatology Clinic and Dept. of Medicine, Nazareth Hospital; and Medical Dept. B, Carmel Medical Center, Haifa

During 1995, 6 cases of acute rheumatic fever were diagnosed here. Taking into account differences in total admissions, this appears to represent an increase over 1994. Most of the cases were males, with average age at diagnosis 19.5 years. All were of low socioeconomic status. 50% had cardiac involvement, and 1 needed treatment with corticosteroids. Most had pharyngeal symptoms prior to the acute attack, and 1 patient had 2 prior episodes of rheumatic fever. A thorough epidemiological study should be done in the Nazareth area to assess the real incidence of acute rheumatic fever, and to determine whether there is a true increase in incidence.