תוצאת חיפוש

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.

Antioxidant Profile of Human Saliva and its Biological Significance

R. M. Nagler, A. Z. Reznick

Dept. of Oral and Maxillofacial Surgery, Salivary Clinic and Oral Biochemistry Laboratory; Rambam Medical Center and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Saliva is the first biological medium to come in contact with materials entering the body through the oral cavity. These materials are contained in food and drink (or inhaled as volatile ingredients). Accordingly, saliva contains various defense mechanisms which have been thoroughly investigated. They include immunological and enzymatic systems aimed at pathological microorganisms. Saliva also can protect the mucosa against mechanical insults and when required, promote its healing via agents such as the epidermal growth factor.

Another defense mechanism in saliva which has been gaining increased attention and seems to be of paramount importance is its antioxidant system. We discuss both the molecular and enzymatic components of the salivary antioxidant system in respect to mixed, parotid, submandibular and sublingual saliva and under various physiological conditions of secretion.

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. 
 

Diagnosis and Therapy in Acute Stroke: A Rehabilitation Center Viewpoint

M. Motin, J. Streifler, A. Tsur, H. Ring

Neurological Rehabilitation Dept., Loewenstein Rehabilitation Center, Ra'anana; Neurological Unit, Rabin Medical Center, Golda Campus, Petah Tikva and Sackler School of Medicine, Tel Aviv University, Ramat Aviv

The extent of the diagnostic work-up of patients with acute stroke was evaluated in 101 patients admitted for rehabilitation during a 4-month period in 1997. This included specific blood tests and neuro- and cardiac imaging, and compared the extent of work-up in a community hospital versus a rehabilitation center. Comparisons were also made with similar investigations 10 and 20 years earlier.

Results demonstrated that the trend to admit younger stroke patients (<50 years) to neurological (as opposed to medical) departments observed between 1977-1987 persisted in 1997.

The use of CT scan increased dramatically from 1977 to 1987 (19% vs 78%), and in 1997 was actually 100% The use of carotid duplex and echocardiography increased steadily during the 3 decades reaching 26% and 28% respectively. Tests for thrombophilia were seldom done. However, in neurological departments it was done in about 50% of the younger stroke patients. In neurology departments carotid duplex was done 2 to 3 times more often than in medical departments.

During rehabilitation imaging tests were done once or more in almost half the patients. The results and those of additional blood tests, have led to modification of antithrombotic treatment in 14% of the younger group and 4% of the older group.

We have clearly shown that while stroke work-up has become more comprehensive in recent years, there is still much to do in this field. Stroke units or teams in our general hospitals will increase stroke awareness, improve work-up and hasten definitive treatment.
 

Eosinophilic Pneumonia induced by Minocycline

Eli Rosen

Medical Dept. B, Hillel Yaffe Hospital, Hadera

Eosinophilic pneumonia is a rare adverse effect of minocycline. To date there are about 70 chemical compounds that cause drug-induced, eosinophilic lung disease.

A 20-year-old woman who developed eosinophilic pneumonia due to minocycline is described. Diagnosis was established by history, signs and symptoms, peripheral eosinophilia, chest x-rays and response to combined cessation of treatment and a short course of steroids.

Physicians should be aware to this rare adverse effect of the drug. Attention to the possibility of minocycline-induced eosinophilic pneumonia can prevent unnecessary, expensive investigation. Cessation of intake is usually sufficient for cure.

Prematurity: Interplay between Psychological and Biological Risk Factors Leading to Infant Psychopathology

Miri Keren, Galia Tyano, Leah Sirota

Community-based Infant Mental Health Unit, Geha Hospital; Sackler School of Medicine, Tel Aviv University; Kibbutz Seminar, Ramat Aviv; Neonatal Intensive Care Nursery, Schneider Children's Hospital, Petah Tikva; and Sackler School of Medicine, Tel Aviv University

Concepts such as risk factor, vulnerability, protective factor and resiliency have become central in the field of developmental psychopathology. The birth of a very-low-birth weight premature baby can be used as a paradigm of the interplay between these factors. Indeed, prematurity implies for both infant and parents, biological as well as psychological risk factors. They may interact in such a way that the child's emotional, cognitive and social development will deviate from normal. Understanding the psychological impact of premature birth includes reference to both the normal psychological processes that characterize pregnancy that are jeopardized by a premature, often traumatic delivery, and to the special significance of being a parent in the Special Care Nursery.

The contrast between the expected appearance of the baby and that of the sick-looking, tiny premature, together with uncertainty about its medical status, often affect the parents' bonding process. In addition, must learn quickly to cope with issues such as total dependence on a verybusy team, loss of control of the care of their baby, and their unclear roles as parents. Added to these risk factors are the specific neurobehavioral characteristics of premature babies, which often make it hard for parents to read their cues and respond to them properly.

A clinical vignette illustrates the chain of psychological and biological events that lead to severe disturbance of the early parent-child relationship. It also brings up the question of psychosocial intervention in the Special Care Nursery, both in terms of early detection of families at risk and the types of intervention.

Assisted Reproductive Technologies Reported in Israel National Registry, 1995 and 1996

V. Insler, O. Gonnen, D. Levran, Y. Lotan, B. Fish, G. Potashnik, A. Kogosovsky, R. Ron-El

Committee of the Israel National Registry Assisted Reproductive Technologies*

National registration of the results of assisted reproductive technology (ART) is maintained by many countries. The Israel Committee for Registry of ART asked 19 in-vitro fertilization (IVF) units in 1995 and 20 in 1996 to report on their activities and results.

Data were collected by questionnaires and analyzed by computer. The most common ovarian stimulation was the combination of GnRH agonist and gonadotropins. There were 10,89 treatment cycles in 1995, of which 45% were with intracytoplasmic sperm injection (ICSI). In 1996, of 12,72 cycles, 54% were with the ICSI procedure. Embryos were transferred into the uterine cavity in 90% of the conventional IVF cycles and in 95% of the ICSI cycles. The overall pregnancy rate was 22% per embryo transfer in the conventional IVF and ICSI cycles. The delivery rate was 13.7% and 15.4% per embryo transfer in the conventional IVF and ICSI cycles, respectively. The rates for abortion and tubal pregnancy were 24% and 1.3%, respectively.

These results are better than in previous years and are comparable with results in some western European countries. Efforts are being made to convert the registry into a real-time computerized system.

Committee of the Israel National Registry of ART.

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.

Pneumomediastinum Following Drug Abuse

Z.G. Fridlender, A. Bloch

Medical Division, Hadassah Hospital, Ein Kerem, Jerusalem

Pneumomediastinum is termed spontaneous when not associated with trauma or other identifiable pathological process. There are several reports of pneumomediastinum following narcotic drug inhalation or smoking while applying positive pressure. We describe a 37-year-old male drug addict, hospitalized after having being found unconscious with shortness of breath. CT scan demonstrated bilateral pneumonia with pneumomediastinum. After a day of mechanical ventilation he gradually recovered and the mediastinal air disappeared.

Pneumomediastinum may occur in addicts but usually has no dangerous clinical consequences. If there is respiratory deterioration another cause should be sought.

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.
 

Pulmonary Adenocarcinoma in Myasthenia Gravis - Auto-Immunity and Late Development of Malignancy

Yitzhak Rosen, Yair Levy, Yehuda Shoenfeld

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

We report a 75-year-old man with myasthenia gravis for many years, who was hospitalized because of cough, fever, and dyspnea. Chest x-ray revealed a bilateral pleural effusion. Adenocarcinomatous cells were found in the pleural fluid. Computerized tomography of the chest showed widespread pulmonary dissemination of the tumor.

The relationship between myasthenia gravis, an autoimmune disease involving the motor end-plate, and malignancy (thymoma) has been widely recognized. Current literature documents few reports of lung malignancies with concurrent development of myasthenia gravis. A tentative explanation, based on current research, is provided for the possible role of myasthenia gravis and the late development of lung cancer. Moreover, a model for the autoimmune phenomenon and the development of late malignancies will be provided with explicit explanations. It is important to search for occult, developing malignancies in newly diagnosed autoimmune diseases.