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.
 

Breaking Bad News - A Structured Course for Primary Care Physicians 

Lea Ungar, Mordechai Alperin, Gilad Amiel, Zvi Behrier, Shmuel Reiss

Family Medicine Dept., Kupat Holim Klalit Health Services, Western Galilee District; Medical Education Unit, Bruce Rappaport Faculty of Medicine, Technion Institute of Technology; and Urology, Dept., Bnei-Zion Medical Center, Haifa

Physicians are frequently required to break bad news to their patients. Previous research has shown that inconvenience, incompetence, and difficulty in dealing with patients' feelings are the main complaints expressed by physicians after such an encounter. Current educational programs dealing with breaking bad news are usually short, given in lecture format, and are inadequate in addressing essential issues such as knowledge, personal beliefs and attitudes, and previous personal experiences of physicians in such situations.

In the past 8 years our Dept. of Family Medicine has implemented a course in breaking bad news that addresses these issues. A senior family practitioner and a medical social worker conduct 14 sessions of discussions and role-playing for small groups of residents and primary care physicians. The program is based on: theory dealing with methods of managing stress and crisis intervention, clarifying personal attitudes, discussions of previous personal encounters of the participants, various modalities of communication, methods of addressing patients' feelings and emotions, and coping with the emotions of the one breaking the bad news.

On a 1-5 Likert scale questionnaire the course received an overall score of 4.47 (SD 0.51). Participants noted that they gained relevant communication skills for future patient encounters. A reliable examination of practitioners' competence in breaking bad news is mandatory in order to assess the efficiency of such courses.

Gastrointestinal Hemorrhage of Obscure Origin

Yoel Siegel, David Ergaz, Oscar Liphshitz, Felix Gottesfeld, Zev Sthoeger

Depts. of Medicine B and Surgery, and Gastroenterology Unit, Kaplan Medical Center, Rehovot (Associated with Hebrew University-Hadassah Medical School, Jerusalem)

Gastrointestinal bleeding of obscure origin consists of recurrent bouts of acute or chronic bleeding for which no definite source is discovered in routine endoscopic and barium contrast studies of the upper and lower gastrointestinal tracts. Usually its cause is angiodysplasia of the intestine, but many cases are due to tumors, mostly of the small bowel, which may be malignant.

In patients under the age of 50, the proportion with malignancy is relatively high (up to 14%) as compared to older patients. We describe a 45-year-old woman who suffered from gastrointestinal bleeding for 3 years. The cause of bleeding was not found despite extensive work-up.

In her last admission for acute gastrointestinal hemorrhage she was given a total of 30 units of blood. A tumor of the small intestine found by angiography was excised and found to be a stromal tumor of uncertain malignant potential. 1 year after operation she is asymptomatic without bleeding and her hemoglobin is stable without treatment.

Concomitant Coronary Artery Bypass Surgery and Pulmonary Lobectomy 

Amit Korach, Uzzi Izhar, Ehud Rudis, Amir Elami

Dept. of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem

Coronary artery disease amenable to percutaneous interventions or coronary artery bypass grafting, and resectable lung cancer are major causes of morbidity and mortality. We present our experience in the treatment of 3 patients (men aged 64 and 66 and a woman of 77) who each had significant coronary artery disease and a resectable lung tumor. They underwent combined coronary artery bypass grafting and pulmonary lobectomy.

We conclude from our experience and review of the literature that concomitant surgery in such cases is safe and effective, decreases suffering, and decreases the cost of 2 separate invasive procedures.

Thallium Scan and Pulmonary Carcinoma 

Adam Mor, Amit Segev, Rami Herskoviz, Yoseph A. Mekori

Dept. of Medicine B, Meir General Hospital, Kfar Saba Affiliated with Sackler Faculty of Medicine, Tel Aviv

A 70-year-old man was admitted for exacerbation of congestive heart failure. In his assessment thallium scan of the heart was performed. An incidental finding was a focus of absorption in the right lung. The lesion was later diagnosed as adenocarcinoma based on the cytological findings.

Tracheoesophageal Puncture after Total Laryngectomy

Roy Landsberg, Frida Korenbrot, Dov Ophir

Depts. of Otolaryngology and of Head and Neck Surgery, Meir Hospital, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University; and the Israel Cancer Association Voice Rehabilitation Program

Total laryngectomy due to malignant laryngeal tumors is followed by loss of speaking ability. Voice restoration in laryngectomized patients is the main target in their rehabilitation. Until the late 70's, esophageal speech was considered the most effective rehabilitation method. In 1980 Singer and Blom introduced a prosthesis for tracheoesophageal speech which has been gaining popularity. Tracheoesophageal puncture (TEP) can be performed either at the time of total laryngectomy, or later.

30 of our patients underwent TEP between 1991 and 1999, 15 at the time of total laryngectomy and 15 as a delayed secondary procedure. Mean follow-up was 36 months (range 6 months to 8 years) during which all regained speaking ability.

Over the long range, speech rehabilitation with the prosthesis was successful in 24 (80%). In only 1 in the primary TEP group did treatment fail, as the prosthesis had to be removed due to local recurrence of the tumor. Long range failure in 5/15 patients after secondary TEP stemmed from difficulties some patients had in handling the prosthesis and from psychological difficulties in adapting to the new speech device. Complications were mostly minor and occurred mainly in the secondary TEP group.

TEP performed at the time of total laryngectomy, or later as a secondary procedure, is effective for speech rehabilitation after laryngectomy.

Unconventional Treatment of Severe Heart Failure in the Elderly

Z. Fidelman, Z. Korshun

Geriatric Medical Center, Natanya

In the elderly, congestive heart failure is common and associated with significant morbidity and mortality.

Comprehensive management of heart failure improves functional status and decreases mortality. Diuretics remain the mainstay in treating congestive heart failure. However, some patients are resistant to diuretics. This is a serious problem as it seems to represent a final manifestation of congestive heart failure.

In an 85-year-old woman diuretic resistance was recognized as the cause of failure of conventional diuretic therapy. When the dose of furosemide was rapidly increased from 120 mg per os to 1000 mg IV within 4 days, diuresis began and there was dramatic improvement in her condition. The dose was then gradually decreased until a conventional maintenance dose of 200 mg/day per os was reached. This dose was sufficient to keep her heart failure under control.

Type 2 Diabetes among Adolescents in Israel 

Orit Pinhas-Hamiel, Ilana Koren, Pnina Vardi

Maccabi Juvenile Diabetes Center, Ramat Hasharon and Lin Diabetes Center, Haifa

Type 2 diabetes has been considered rare in children and adolescents. Recently, increase in the incidence of type 2 diabetes has been reported among adolescents in various parts of the world. We report the occurrence of type 2 diabetes among adolescents in Israel.

A boy of 14 and girls of 16.5 and 17 were pubertal and extremely obese, with a body mass index (BMI) between 39-47 kg/m². Acanthosis nigricans, elevated diastolic blood pressure, and hirsutism with menstrual disorders, were associated with insulin resistance, and should raise suspicion of type 2 diabetes. Significant obesity and strong family histories of type 2 diabetes appeared to be important risk factors. Since type 2 leads to long-term morbidity and mortality, its early identification and appropriate treatment are crucial.

Early Detection of Glaucoma by a Mobile Unit

S. Kurtz, M. Goldenfeld, S. Melamed

Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer

Glaucoma, the third leading cause of blindness in the western world, is characterized by painless, gradual loss of visual fields which may lead to severe visual impairment or even blindness. In 4 years of operation of a mobile glaucoma unit for screening and early diagnosis of glaucoma, 10,037 subjects aged 18-95 years were screened (4504 women, 45%); 55% were under 50 years (Graph 1).

Ocular hypertension was diagnosed in 8.0%; primary open angle glaucoma (POAG) in 0.8%, with 2/3 already under treatment, the rest newly diagnosed. Pseudo-exfoliative glaucoma was diagnosed in 0.2%; only 2 cases had closed angle glaucoma; 91% of those screened were normal (Fig. 4; age stratification, Graph 3).

POAG increased with age, from 0.2% in those under 40 years to 10% in those over 80; POAG was more common in men, but OHT was similar in both sexes (6.0% vs. 5.3%). There was no correlation between incidence of POAG and place of work except in the Sorek Nuclear Center (1.9% vs. 0.8%, p=0.11). Other conditions significantly more frequent in POAG than normals were diabetes mellitus (x 2.5), systemic hypertension (x 4), myopia (x 2) and history of intraocular surgery (x 6).

Causes of Blindness in Israel 

Y. Hod, Y. Corcia, Y. Yassur, O. Geyer

Depts. of Ophthalmology, Carmel Medical Center, Haifa and Rabin Medical Center, Petah Tikva; Israel Ministry of Labor and Social Affairs, Jerusalem; and Rehabilitation Services Administration, Services for the Blind

Of the world population, 38 million are blind and another 110 million are visually impaired. Even in the developed countries there are 3.5 million who are blind.

This study of blindness in Israel is based on the National Blind Registry. At the end of 1998, 15,937 were registered as blind, 0.3% of the total population; 776 (5%) of them were 18 years old or younger; 6,426 (40%) 18-65 years old; and 8,735 (55%) 65 years or older.

The leading causes of blindness in Israel are glaucoma (2,074, 13%), macular degeneration (1,954, 12%) and diabetes mellitus (1,680, 11%). Since glaucoma and diabetes, and to a lesser extent glaucoma, respond to treatment, blindness could have been avoided in most cases. National screening programs for early diagnosis and treatment of these diseases would reduce prevalence of the newly blind.

Cortical Blindness Following Coronary Angiography 

Addie Ron, Simcha Meisel, Myra Shapiro-Feinberg,Herman O. Klein

Depts. of Medicine, Cardiology and Diagnostic Imaging,Meir Medical Center, Kfar Saba

Cortical blindness has been occasionally reported as a complication after cerebral angiography, but is rare after coronary angiography. The contrast agent is believed to be responsible for the sudden development of blindness. Although the exact mechanism is unknown, it appears that the contrast agent disrupts the blood brain barrier, mostly in the occipital areas.

We report a 77-year-old man who suddenly developed transient, bilateral cortical blindness 4 hours after coronary angiography. Using contrast enhancement, the CT scan showed typical, symmetrical involvement of both occipital lobes. There were no other neurological deficits. Vision and CT findings returned to normal within 48 hours.

Endoscopic Parathyroidectomy - Preliminary Experience 

Joseph Kuriansky, Laureano Fernandez-Cruz

Dept. of General Surgery and Transplantation, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University; and Dept. of Surgery, Hospital Clinic, University of Barcelona

Since the advent of extraperitoneal approaches for laparoscopic surgery, the creation of extraperitoneal virtual spaces has spread rapidly. We describe our preliminary experience with selective neck exploration and endoscopic parathyroidectomy in 4 women, aged 57-74, with primary hyperparathyroidism.

Preoperative localization of parathyroid adenoma was assessed by technetium-sestamibi scanning and cervical ultrasonography. A cervical work space was created by the introduction of a trocar with an inflatable balloon-tip and maintained with low-pressure CO² insufflation. All procedures were completed endoscopically. There were no intraoperative complications. Mean operative time was 40 minutes and cosmetic results were very satisfactory.

We found endoscopic parathyroidectomy a feasible and safe option and particularly appropriate for the surgical treatment of primary hyperparathyroidism. Further refinements in technique will enhance its practicability in exploring the mediastinum for ectopic parathyroid glands and in those with secondary hyperparathyroidism.

Thoracoscopic Splanchnicectomy for Intractable Pancreatic Pain

Joseph Kuriansky, Alejandro Saenz, Laureano Fernandez-Cruz

Dept. of Surgery, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University; and Dept. of Surgery, Clinic Hospital, Barcelona

Intractable pain is the most distressing symptom in nonresectable pancreatic carcinoma and in chronic pancreatitis. Recently, thoracoscopic splanchnicectomy has been advocated as a minimally invasive method of pain control in these patients. Between May 1995 and April 1998, 24 patients with nonresectable pancreatic cancer and 4 with chronic pancreatitis, underwent 43 thoracoscopic splanchnicectomies. All suffered from intractable pain, were opiate-dependent and unable to perform normal daily activities. Unilateral left splanchnicectomy was done in 13 and bilateral in 15.

All procedures were completed thoracoscopically. Operative time ranged from 25 to 60 min and mean hospital stay was 3 days. Median pain intensity was reduced by 50% in 24 and no further narcotics or analgesics were required. We found thoracoscopic splanchnicectomy a safe and effective procedure for intractable pancreatic pain.

Extraperitoneal Laparoscopic Adrenalectomy

J. Kuriansky, A. Saenz, D. Rosin, E. Astudillo, L. Fernandez-Cruz

Dept. of General Surgery and Transplantation, Sheba Medical Center, Tel Hashomer, and Dept. of Surgery, Hospital Clinic, Barcelona

Laparoscopic adrenalectomy has recently been shown to be safe and effective for a variety of benign adrenal tumors, such as aldosterone adenoma, pheochromocytoma, nonfunctioning adenoma, Cushing's adenoma and Cushing's syndrome. Recently, laparoscopic surgeons adopted an extraperitoneal approach in which a space is created by the introduction of a trocar with an inflatable balloon tip. This technique with a minimal access procedure provides direct access to the adrenal glands without interfering with intraperitoneal organs.

Laparoscopic adrenalectomy using the extraperitoneal approach was completed in 18/20 consecutive patients. Mean operative time was 95 min (range 80-120) and median hospital stay 3 days. Blood transfusion was not required, and there were no postoperative complications.

Screening for Down's Syndrome by Measuring Fetal Nuchal Translucency Thickness

Ron Maymon, Eli Dreazen, Zwi Weinraub, Ian Bukovsky, Arie Herman

Ultrasound Unit, Dept. of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin, and Sackler Faculty of Medicine, Tel Aviv University

Increased fetal muchal translucency (NT) thickness at 10-14 weeks of gestation may indicate underlying fetal chromosomal abnormalities, anatomical anomalies and genetic syndromes. Between January 1997 and May 1998, 1400 women 10-14 weeks pregnant underwent sonographic screening for detection of Down's syndrome (DS). Follow-up was complete in 1208 (86%).

Maternal age ranged from 17-44 years (mean 18.0). 87% were found by screening to have a higher risk (1:380) for DS diagnosed at birth. All these fetuses were karyotyped and 8 had chromosomal abnormalities. 2 fetuses with normal NT were diagnosed later as having DS, 1 by the mid-gestation triple test and 1 by amniocentesis because of advanced maternal age.

Thus sonographic screening identified 8 out of 10 fetuses found to have chromosomal abnormalities at birth. Neonates not karyotyped before birth had no traits at birth that justified chromosomal analysis. Results of this study suggest that NT measurement, combined with maternal age, is an effective 1st trimester screening method for DS in an unselected obstetric population.