תוצאת חיפוש

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.

Early Results with Threaded Spinal Cage Fusion Systems

Ely Ashkenazi, Stephen T. Onesti

Neurosurgery Depts. of Hadassah-University Hospital, Jerusalem and Montefiore Medical Center, New York

Lumbar interbody fusion is a surgical technique used to treat symptomatic lumbar disc disease. Low back disorders are the most common of the musculoskeletal disorders causing a tremendous burden of disability. One of the causes of low back pain and radiculopathy is spinal instability, which can be treated by spinal fusion. In the past year, threaded cage systems have become available for segmental lumbar fusion for degenerative disc disease. These systems offer several biomechanical advantages over traditional lumbar fusion and instrumentation techniques, and are better tolerated.

From December 1996 until June 1997 we operated and fused spines of 17 patients, using 2 different fusion systems (anterior and posterior approaches). We present our early results.

Laparoscopic Approach to Perforated Duodenal Ulcer

D. Rosin, Y. Kurianski, M. Shabtai, A. Ayalon

Dept. of General Surgery and Transplantation, Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University

As laparoscopy becomes more prevalent, it is being used for a growing variety of abdominal operations, both electively and as emergency treatment. We describe our preliminary experience in laparoscopic repair of perforated duodenal ulcer. 2 women and 2 men, aged 40-78 were operated over a period of 4 months and in all laparoscopic suture and omentopexy were performed with meticulous abdominal lavage. Despite somewhat longer operative time but a similar period of hospitalization, the easier post-operative course and fewer wound complications justify this technique. The effectiveness of medical treatment of peptic disease, and especially the anti-Helicobacter pylori regimen, supports the view that closure of the perforation is usually enough, and vagotomy is not needed.

Necrotizing Soft Tissue Infection

E. Rath, I. Shelef, E. Avinoah, Y. Lichtman, O. Levy, D. Atar

Depts. of Orthopedics, Diagnostic Radiology and General Surgery C, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

The dramatic course of necrotizing soft tissue infection represents a medical emergency, since it is limb - and life-threatening. Most necrotizing soft tissue infections are caused by mixed aerobic and anaerobic Gram-negative and Gram-positive organisms. Most case have been reported in immunocompromised hosts after penetrating trauma or surgery. We describe a unique series of cases of necrotizing soft tissue infection. The mainstay of treatment is early and daily debridement of devitalized tissue and broad-spectrum antibiotics. Hyperbaric oxygen therapy should be considered.

Islet Autoantibody Assays in Type I Diabetes can Replace ICA Test

Daniel Lazar, Naomi Weintrob, Natalia Abramov, Sara Assa, Konstantin Bloch, Regina Ofan, Hadassa Ben-Zaken, Pnina Vardi

Institute for Pediatric Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva and Felsenstein Medical Research Center, Tel Aviv University

Islet cell antibodies (ICA) continue to serve as the basis of the principal serological test for definition of active autoimmunity of beta-cells. Its disadvantages are the need for human pancreatic tissue and difficulty in obtaining quantitative results. In the past decade biochemically-defined beta-cell antigens were described, leading to the development of sensitive and specific autoantibody assays, to predict insulin-dependent diabetes mellitus (IDDM). We examined the value of combined biochemically-based serological assays, such as autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA) and ICA512 (ICA512A) to replace the traditional ICA assay.

Blood samples of 114 newly diagnosed IDDM patients, aged 12‏5 yrs (range 2 months - 29 years) were tested for ICA (indirect immunofluorescence), IAA, GADA and ICA512A (radiobinding assay). The latter 2 assays were performed using recombinant human [35S]-labeled antigen produced by in vitro transcription/translation. We found that fewer sera scored positive for ICA and/or IAA (80.7%, 92/114) than for 1 or more of IAA, GAD, or ICA512 (88.6%, 101/114). We conclude that combined testing for IAA, GAD and ICA512 can replace the traditional ICA/IAA test to predict IDDM and is helpful in the differential diagnosis of insulin-dependent and noninsulin-dependent diabetes.

Delirium Tremens in Israel

G.-Z. Ezrielev

Mental Health Center, Beer Sheba

We discuss pathogenetic aspects (biochemical, pharmacological) of delirium tremens (DT) in accordance with the acute clinical processes, the development of psychosis, and preventive treatment used in the various stages. A typical patient, a 33-year-old man, and the difficulties in diagnosis and treatment are presented and conclusions from the dangerous behavior of the patient are drawn.

Percutaneous Revascularization of the Left Main Coronary Artery as Coronary Artery Bypass in High Surgical Risks

Yoseph Rozenman, Chaim Lotan, Hisham Nassar, Mervyn S. Gotsman

Cardiology Dept., Hadassah-University Hospital (Ein Kerem) and Hebrew University-Hadassah Medical School, Jerusalem

Coronary artery bypass grafting is the treatment of choice for obstructive disease of the left main coronary artery. Its proximal location and easy accessibility make the left main artery an inviting target for percutaneous intervention, an approach contraindicated by the high associated risk. We describe 2 patients at high operative risk in whom the obstructed main coronary artery was successfully revascularized percutaneously. Coronary stenting and rotational ablation of calcified arteries are essential for successful outcome and minimize complications.

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.

Enhancing Cultural Sensitivity of Psychiatrists from Russia

Haim Y. Knobler, Shlomit Katz, Inessa Poliakova, Rimona Durst

Jerusalem Mental Health Center, Kfar Shaul Hospital, Jerusalem

The importance of understanding the local culture and enhancing cultural sensitivity became evident during supervision of immigrant psychiatrists from the former Soviet Union. The aim of the present study was to describe enhancement of this cultural sensitivity in the supervision of 2 immigrant psychiatrists. In the first, understanding the patient's cultural world helped the immigrant psychiatrist form the therapeutic alliance. In the second, the immigrant psychiatrist's understanding of the patient's cultural background led him to change both diagnosis and treatment. In both cases, development of cultural sensitivity through supervision enabled successful treatment. Enhancement of cultural sensitivity may accelerate absorption of the immigrant psychiatrists themselves. Discussing cultural issues during work may accelerate the absorption of all immigrant physicians.

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.

Accessibility of Information and Informed Consent: Experiences of Breast Cancer Patients

Ephraim Tabory, Susan Sered

Dept. of Sociology and Anthropology, Bar-Ilan University, Ramat Gan

We studied the social and cultural frameworks that impact on breast cancer patients in the medical system. The subjects were 98 Jewish women who had undergone mastectomy or lumpectomy for cancer 6 months to 3 years prior to the interview. They emanated from a variety of socioeconomic and ethnic backgrounds, and reflected the age range of women with breast cancer in the general Jewish population of Israel. Patients were asked about each stage of the medical process they had experienced: diagnosis, surgery, oncological care, and follow-up care. The interview revealed a general perception of having received insufficient information regarding their medical condition and treatment. The problem tended to be most severe during the diagnostic stage, when women had not yet been officially included as patients within the system. The problem was relatively severe during follow-up care, when they often did not have an address for their questions. Few women received a schedule of follow-up care that allowed them to carry on with the many necessary tests in an orderly and comprehensive manner. Most important, systematic absence of informed consent also characterized the decision-making process regarding surgery and oncological treatment. Few women felt they had been informed about treatment options, side-effects, or long-term implications of the treatment offered. We found no indication of inequitable medical treatment that would suggest a manifest pattern of discrimination, but we did find some social variables related to a feeling of insufficient personal care and information. In particular, older women said they received less attention, support, and information from the medical staff relative to the younger women.

Progression of Diabetic Retinopathy after Cataract Extraction

Y. Raniel, Y. Teichner, Z. Friedman

Annette and Aron Rozin Dept. of Ophthalmology, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

A prospective study of the effect of cataract extraction with intraocular lens implantation on the course of diabetic retinopathy (DR) in 44 patients (59 eyes) was carried out. It showed that in the 1-3 years following surgery, there was progression of DR (including development of newly formed retinopathy) in 35% of the patients (28.8% of eyes). Progression was more marked in patients with pre-operative bilateral DR compared to those without bilateral DR (77% and 16% respectively). Insulin dependence did not play a role in progression. Final visual acuity was better in patients without pre-operative DR, as well as in eyes without progressive retinopathy.

Central Cord Syndrome in the Elderly Who Fall: a Diagnostic Trap

A. Adunsky, H. Semo, S. Levenkrohn

Geriatric Rehabilitation Dept., Chaim Sheba Medical Center, Tel Hashomer

Acute post-traumatic spinal injury is common and usually poses no diagnostic difficulties. Following a low-energy fall, the onset of acute central cord syndrome in the elderly is not common and is frequently misdiagnosed. Men aged 60 and 81, and a woman aged 75 are described, in whom central cord syndrome was overlooked. Awareness of this condition is important to avoid incorrect diagnosis and hazardous management.

Technetium 99-M Sestamibi Bone Scan in Musculo-Skeletal Neoplasms

Dror Robinson, Lena Pinkas, Lilia Mindlin, Nahum Halperin, Tifha Horn

Dept. of Orthopedics and Nuclear Medicine, Assaf Harofeh Medical Center, Zerifin

It is often difficult to assess accurately the nature of a skeletal lesion. Problems include differentiating a malignant from a benign bone tumor, as well as determining the cause of a pathologic fracture. Such fractures may occur through osteoporotic bone as well as through neoplasm-affected bone. Thus, development of an imaging modality capable of distinguishing between such lesions is of importance. During 1996, we ran a prospective study in which results of Tc-99m-methyl-diphosphate (MDP) bone scans were compared with those of sestamibi (MIBI) bone scans and with subsequent biopsy and clinical course. The results of the bone scans were assessed by 2 independent "blinded" observers, and the ratios of counts in lesions to those in normal tissue (L/N ratios) were calculated. In cases of malignant (7) and benign (8) tumors, intensity of uptake in MDP scans were not predictive of degree of aggressiveness. On the other hand, MIBI bone scans demonstrated significant difference in intensity of uptake between benign and malignant bone tumors (L/N ratios 2.05 vs 2.75). In 5 of 8 benign lesions the L/N ratio was 1. In the others, increased uptake was minimal. In 2 patients changes in uptake in MIBI bone scan following chemotherapy appeared to be related to the degree of tumor necrosis achieved. While the MIBI bone scan cannot replace tissue biopsy as a definitive diagnostic modality in bone neoplasms, it does appear to allow better preoperative assessment and prognosis.

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.