תוצאת חיפוש

Spontaneous Internal Jugular Vein Thrombosis Complicating Chronic Pulmonary Disease

Nir Hilzenrat, Edit Liberty, Luna Avnon

Depts. of Medicine B and E, and Pulmonary Disease Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba

Spontaneous internal jugular thrombosis is a rare vascular disorder. It usually occurs as a result of external pressure due to a tumor, infection or as a result of damage to the vessel wall after trauma or central venous catheterization. We report a 35-year-old woman who suffered from severe pulmonary hypertension due to chronic cystic lung disease. She was admitted due to sudden, severe, right-sided neck pain. Internal jugular occlusion by a thrombus was demonstrated by ultrasound and CT-scans but no apparent cause was found. We postulated that the important factors in the development of her thrombosis were stasis due to pulmonary hypertension and high blood viscosity.

Folic Acid Deficiency in Chronically Hospitalized Mental Patients

Ivan Fuchs, Leonid Omansky, Yaakov Lerner

Eitanim Mental Health Center, Jerusalem (Affiliated with the Hebrew University-Hadassah Medical School)

Studies over the past 30 years have shown a relationship between folic acid deficiency and psychopathology. FA deficiency was observed more often in depressed and in psychotic patients, in alcoholics, in those suffering from organic mental disorders and in the psycho-geriatric population. In a chronic inpatient population of 120 patients, of the 106 in whom FA serum levels were examined, only 1 had a definitely subnormal level. An additional 16 had close to the lower limit of normal (2 ng/ml) and were considered borderline cases. FA-deficient and borderline patients were then compared to matched patients with normal FA levels on the MMSE and PANSS scales by blinded raters. Small differences were found between the 2 groups. The FA-deficient and borderline patients had more organic and psychotic symptoms, but the differences were not statistically significant.

Characteristics of Israeli Primary Health Care Physicians who Treat Depression

Jonathan Rabinowitz, Dina Feldman, Revital Gross, Wienka Boerma

Bar Ilan University, Ramat Gan; Israel Ministry of Health; JDC-Brookdale Institute, Jerusalem; and Netherlands Institute of Primary Health Care (NIVEL)

Primary health care physicians have a pivotal role in treating mental health problems. We determined the proportion of primary care physicians in Israel who treat depression and their characteristics. The study was based on a stratified national random sample of primary care physicians (n677, response rate 78%). From these physicians' reports 22% always treat depression, 36.6% usually, 28.6% sometimes, and 12.6% never. Based on a logistic regression model the physicians who always or usually treated depression were distinguished from the other physicians by their treating more medical conditions on their own, seeing themselves as having more first contact for psychosocial problems, having frequent contact with social workers and specializing in family medicine. Primary health care physicians play a major role in treating depression on their own. This raises new questions about how they treat depression themselves, and under what circumstances they treat or refer to a specialist.

The Electroencephalogram in Psychiatric Patients

Mark Weiser, Raya Lapidus, Yehuda Abramowitch, Michael Davidson

Psychiatric Division, Sheba Medical Center and Beer Yaakov Mental Health Center

270 consecutive electroencephalograms (EEGs) performed in a psychiatric hospital were reviewed. 194 (75%) were within normal limits but 66 (25%) showed diffuse generalized slowing. The contribution of the abnormal EEGs to diagnosis and treatment was evaluated by retrospective file review. In none of the cases with abnormal EEGs was there a relationship to diagnosis or treatment.

Massive Pulmonary Embolism

Ron Ben Abraham, Eran Segal, Dov Freimark, Elinor Goshen, Hanoch Hod, Jacob Lavee, Zvi Ziskind, Azriel Perel

Depts. of Anesthesiology and Intensive Care, Cardiology, Nuclear Medicine and Cardiac Surgery, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Pulmonary embolism is a common event in hospitalized patients. In some cases it presents with hemodynamic collapse, indicating massive obliteration of the pulmonary vasculature and has a very grim prognosis; 2/3 of such patients die within 2 hours of onset of symptoms. We describe our experience in 13 patients with massive pulmonary embolism. An aggressive diagnostic and therapeutic approach, utilizing sophisticated imaging techniques, thrombolytic therapy and surgery, led to the survival of 8 of the patients. Our experience supports an aggressive approach in these seriously ill patients.

Community-Acquired Pneumonia in the Elderly: Guidelines for Hospitalization

Jacob Feldman, Abraham Yarezky, Carola Vigder

Geriatric. Dept., Meir Hospital, Kfar Saba and Sakler Faculty of Medicine, Tel Aviv University

A prospective study was carried out among elderly patients with community-acquired pneumonia to determine if there are any specific features that could help in deciding whether to hospitalize, or to treat in the community. We concluded that there is no correlation between clinical presentation of pneumonia and outcome, except for impairment of consciousness. Laboratory data showed a correlation between oxygen saturation in arterial blood, levels of hemoglobin and albumin, and outcome. Sputum culture was not helpful in deciding about diagnosis and treatment, which remain empiric. These patients should be treated at home if conditions permit. Recommendations are made for improving such conditions.

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.

Suicidal Calls to a Telephone Emergency Service

Itzchak Gilat, Zvi E. Gil

ERAN (Israel Association for Emotional First Aid)

Suicidal threats and suicidal ideation among callers to the Israeli hot-line (ERAN) were investigated, using 2 methods of analysis. The first, an epidemiological survey based on 8,272 calls received by all 8 ERAN posts during 2 years, reported on their standard form for recording interactions with suicidal callers. The second is content analysis of 42 detailed reports of interactions with such callers. Epidemiological analysis revealed a higher rate of suicidal ideation among callers with a psychiatric history, compared with those without a history. However, the 2 groups did not differ in rate of suicidal threats. In addition, suicidal threats of adolescents were related mainly to problems of identity and self-image, while mental disorders were the main problems among adults. Content analysis identified 2 patterns of terminating the interaction, which represent 2 strategies of intervention to prevent suicide. The first is establishing a contact between the caller and an appropriate individual in the caller's environment who undertakes responsibility to help the caller. The second strategy is reducing the caller's tension, leading to a withdrawal of the suicidal threat. The first pattern is more characteristic of interactions with psychiatric callers, while the second is more frequent among non-psychiatric callers to ERAN. The hot-line makes a unique contribution in helping those threatening suicide, which constitutes a real emergency.

Nursing Home-Acquired Pneumonia: Guidelines for Hospitalization

A. Yaretzky, C. Vigder, I. Feldman

Geriatric Dept., Meir Hospital, Kfar Saba, and Sackler Faculty of Medicine, Tel Aviv University

To determine if there are any specific features of nursing-home acquired pneumonia we carried out a retrospective study in a nursing home between 1995-1996, based on clinical and laboratory data. We found no correlation between these findings and the severity of pneumonia, so it would be hazardous to determine rigid guidelines. These patients should be treated in the nursing home as long as conditions allow, in order to avoid hospitalization.

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.

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.

Patients' Opinions of the Role of Primary Care Physicians and the Organization of Health Care Services

Revital Gross, Hava Tabenkin, Shuli Bramli, Pesach Schvartzman

JDC-Brookdale Institute, Jerusalem; Dept. of Family Medicine, HaEmek Hospital, Afula; Kupat Holim Clalit, Northern District; Institute for Specialization, Ben-Gurion University, Northern Branch; and Dept. of Family Medicine, Ben-Gurion University of the Negev and Kupat Holim Clalit, Beer Sheba

Patients' opinions of the role of the primary care physician were studied. The study population consisted of Hebrew-speaking members of the Clalit Sick Fund, aged 18+, who visited primary care and specialty clinics. Interviews took place during January-March 1995 in the Emek and Jerusalem, and during August-October 1995 in Beer Sheba. A total of 2,734 interviews were conducted, and the response rate was 88%. 64% of the respondents preferred the primary care physician as the first address for most problems occurring during the day. Multivariate analysis revealed that the variables predicting this preference were: being over age 45, having completed less than 12 years of schooling, being satisfied with the physician, and when a child's illness was involved. Whether the physician was a specialist had only a marginal effect. The findings also show that among those who did go directly to a specialist for the current visit, 49% would still prefer the primary care physician to be the first address for most problems. However, half of the respondents initiated the current visit to the specialty clinic themselves. The findings also showed that a preference for the primary care physician to be the first address had an independent and statistically significant effect on the following aspects of service consumption: taking the initiative to go to a specialist, the intention to return to the primary care physician or to the specialist for continuing care, and the patient's belief that referral to a specialist was needed. The findings of the study may be of assistance to policy-makers on the national level and to sick funds in planning the role of the primary care physician, so that it corresponds, on the one hand, to the needs of the sick funds and the economic constraints in the health system, and on the other, to the preferences of the patient.

Kleptomania: Phenomenological, Clinical and Legal Aspects

R. Durst, G. Katz, K. Jabotinsky-Rubin, H.Y. Knobler

Kfar Shaul Mental Health Center, Jerusalem

Kleptomania is currently classified in psychiatric nomenclature as one of the impulse control disorders (DSM-IV, 1994). It is characterized by repeated failure to resist impulses to steal objects, not for personal use or monetary gain. The objects are therefore discarded, given away, or hoarded (ICD-10, 1992). This disorder is known since the early 18th century from the phenomenological and clinical viewpoints, yet is still debated with regard to therapeutic strategies and criminal liability. Although there are usually complications associated with the legal consequences of being caught and arrested, subjects continue to violate the law despite repeated arrests and convictions. In a 28-year old man suffering from kleptomania, years of psychodynamic psychotherapy were ineffective. Only when he was treated as suffering from an impulse control disorder or a variant of obsessive-compulsive disorder, was there significant improvement. The positive response to buspirone (5-HT1A) augmentation of fluvoxamine (SSRI) suggested that disturbed central serotonergic neurotransmission might play an important role in the pathogenesis of kleptomania. This concept is strengthened by the comorbidity of the syndrome with depression and by its compulsive traits. We stress that although kleptomaniacs cannot differentiate between right and wrong, testing shows that their sense of reality is intact, but they act under the influence of drives they cannot resist.

Thoracoscopic Biopsy of Pulmonary Lesions in Nonpulmonary Malignancy following Chemotherapy

Oded Zamir, Myriam Weyl Ben-Arush, Dan Seror, Herbert R. Freund

Surgical Dept., Hadassah-University Hospital, Mount Scopus, Jerusalem and Miri Shitrit Pediatric Hematology and Oncology Unit, Rambam Medical Center, Haifa

The appearance of focal pulmonary lesions in a patient with a nonpulmonary malignancy is worrisome. Apart from metastasis, the differential diagnosis includes benign conditions such as infectious and granulomatous diseases, enlarged lymph nodes, atelectasis, radiation pneumonitis, and bronchiolitis obliterans with organizing pneumonia (BOOP). CT-guided needle biopsy is not always diagnostic and may not be feasible in very small lesions. Since open lung biopsy is associated with considerable morbidity, many physicians tend to postpone tissue diagnosis for a few weeks and perform a biopsy only if repeat chest CT scans show increase in size or number of the lesions. This approach may lead to undesirable delay of appropriate treatment. We report video-assisted thoracoscopic lung biopsy in 7 patients with nonpulmonary malignancy who developed lung lesions following chemotherapy and/or radiation therapy. Histological examination proved metastatic lesions in only 2. There were no operative complications and recovery was rapid and smooth in all patients. Thoracoscopic lung biopsy is an effective, minimally invasive diagnostic tool that obviates the need for thoracotomy in these patients.

Inhaled Budesonide for Chronic Obstructive Pulmonary Disease

Paltiel Weiner, Doron Zamir, Marinella Beckerman

Medical Dept A, Hillel Yaffe Medical Center, Hadera

A significant, large minority of patients with chronic obstructive pulmonary disease (COPD) respond favorably to corticosteroid treatment; but the benefit may be outweighed by its side effects. Long-term administration of inhaled steroids is a safe means of treatment. We hypothesized that treatment with inhaled budesonide would improve clinical symptoms and pulmonary function in subjects with COPD, and that the response to an inhaled B2-agonist would individualize steroid responders. In 44 patients with stable COPD in a double- blind crossover trial, we compared a 6-week course of inhalations of 800 mg/d budesonide with a placebo, separated by a 4-week interval when no medication was taken. In 33 out of 42 responders to the B2-agonist who remained in the study, there was a significant improvement in FEV1 of greater than 20% following budesonide inhalation, as compared to placebo. There was also a significant difference between the 2 periods of treatment as to the mean number of B2-agonist inhalations. We conclude that about 1/4 of patients with stable COPD respond to bronchodilators, and treatment with inhaled steroids improves spirometry data and inhaled B2-agonist consumption in about 3/4.