תוצאת חיפוש

Parturient Compliance in Intra-Partum Epidural Analgesia

Eyal Sheiner, Ilana Shoham-Vardi, Moshe Mazor, Reli Hershkowitz, Miriam Katz

Obstetrics and Gynecology Depts., and Epidemiology and Health Services Evaluation Dept., Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba

The relationship between parturients' sociodemographic characteristics and the tendency of the medical staff to offer and of the parturients to accept intrapartum epidural analgesia, was investigated. 97 Jewish parturients were interviewed during January 1996. Multiple logistic regression analysis was used to evaluate the statistical significance of the results. 10 parturients (10.3%) asked for intrapartum epidural analgesia, and while 46 (47.4%) were offered it, only 22 (22.7%) accepted. Epidural analgesia was mostly offered to, and accepted by: low birth-order parturients (1st-3rd delivery), those belonging to the upper middle class, and to parturients with higher compliance with prenatal diagnostic tests. There was no significant association between the tendency of the medical staff to offer epidural analgesia to secular as compared to traditional parturients.

We conclude that the use of intrapartum epidural analgesia is related to various maternal sociodemographic characteristics. If the low compliance with epidural analgesia is related to prejudice and unfounded fears, we recommend that the benefits of this type of analgesia be explained before birth in the antenatal clinics.

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.

Acute Hyperparathyroidism Caused by Hemorrhage into a Parathyroid Adenoma

I.E. Priel, Rama Katz, E. Dolev

Depts. of Medicine E and Radiology, Wolfson Medical Center, Holon and Sackler School of Medicine, Tel Aviv University

Acute hyperparathyroidism is a rare and dangerous condition. It is supposed to result from transformation of a mild chronic form into an acute and stormy illness. The causes and the mechanism of such a transformation are usually unknown. A case of acute hyperparathyroidism is presented in which hemorrhage into a parathyroid adenoma was recognized and diagnosed as the immediate cause of the transformation from the mild long-standing form of the disease into the severe acute form.

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.

First Year's Experience of the Post, Operative Cardiac Care Unit, Schneider Children's Medical Center

O. Dagan, E. Birk, J. Katz, B. Vidne

Cardiothoracic Pediatric Service, Schneider Children's Medical Center, Petah Tikva

In the past 10 years there has been a growing preference for early, complete correction of congenital heart disease. The first year of operation of this cardiac unit is described. 216 operations were performed: 15% in the neonatal age group and 35% in the newborn to l-year-old groups; 2% were palliative procedures. Mortality was 4.9%. Average stay in the ICU was 3.2  days, with a median of 2.25. Average length of ventilation was 35 hours, with a median of 17.5. Complications were: diaphragm paralysis in 13 (6%), 2/3 of which were recurrent operations; in 2 patients (0.9%) we had to plicate the diaphragm. There was severe neurological damage in 2, which deteriorated to brain death in 1. There was peripheral, reversible neurological damage in 4 (1.8%), and acute renal failure in 3%, with half of them requiring dialysis. 75% of these children died and there was superficial infection in 4.1%, deep wound infection in 1.3%, bacteremia in 4.1%, superior vena cava syndrome in 3 (1.3%) and chylothorax in 2 of them (0.9%). 1 patient (0.45%) required a ventricle-peritoneal shunt after acute viral meningitis. We are encouraged by our results to offer early complete correction to all children with congenital heart disease.

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.

Analgesia in Breast Surgery with Interpleural Bupivacaine

Z. Crystal, Y. Katz

Dept. of Anesthesiology, HaEmek Medical Center, Afula and B. Rappaport Faculty of Medicine, Technion, Haifa

A control group of 15 patients undergoing breast surgery was given general anesthesia. In 15 other patients an interpleural block with 0.4 ml/kg bupivacaine, 0.5%, was performed 20 minutes before induction of general anesthesia for pre-emptive analgesia. This was extended further by continuous administration of bupivacaine 0.25%, 0.125 ml/kg/hr by automatic infusion pump, with supplements of opiates for postoperative pain management. The combined technique was associated with significantly reduced perioperative opiate requirement with better emergence from anesthesia, fewer side effects, a prolonged pain-free period, and overall better quality of postoperative recovery.

Radical Retropubic Prostatectomy

Ran Katz, Amos Shapiro, Shimon Meretyk, Ezekiel H. Landau, Dov Pode

Urology Dept., Hadassah,University Hospital and Hebrew University,Hadassah Medical School, Jerusalem

Radical prostatectomy may cure most patients in whom the malignant tumor has not invaded through the prostatic capsule. Advances in surgical technique and accumulation of experience have decreased the complication rate significantly. Long-term results of surgical treatment are now better than those of other forms of treatment; hence radical prostatectomy is now recommended for men with life expectancies longer than 10 years. Between 1988 and 1995, 164 men with clinical stages T1 or T2 adenocarcinoma were admitted for radical prostatectomy. Most were not offered a nerve-sparing procedure, so as to allow wider, more complete resection. Those who wanted preservation of sexual function underwent the nerve- preserving procedure. In 6 patients operation was discontinued when metastases to the iliac lymph nodes were detected and in 1 when invasion of the pelvic wall was found. 157 underwent radical prostatectomy. Preoperative biopsy revealed a low-grade lesion (Gleason 2-4) in 19.1%, intermediate grade (Gleason 5-6) in 61.8% and high-grade (Gleason 7-9) in 19.1%; however, pathologic grading revealed that only 7.0% had grade 2-4 tumor, 60.5% grade 5-6 and 32.5% grade 7-9. Pathologic staging revealed T2 tumor in 58%, T3 in 38.8% (including microscopic invasion of the capsule or seminal vesicles); microscopic lymph node metastases were found in 3.2%. Tumor invasion through the capsule was found in only 2 of 13 treated with neoadjuvant androgen blockade, compared with 40% in those who did not receive this treatment. There was no operative mortality and only 14.7% has complications. All had urinary incontinence immediately after operation, but regained continence after an average of 4-5 months. 24 were incontinent for more than 12 months, but most of them had only mild stress incontinence. Most patients were impotent after the procedure. There was tumor recurrence, diagnosed by rise in serum PSA, in 26 during an average follow-up of 26.4 months (range 3-93). Cure rate of prostatic cancer by radical prostatectomy may be increased by improved preoperative staging methods and better patient selection; long term follow up is required for determining cure rate.

Effect of the Yom Kippur Fast on Parturition

A. Wiser, E. Maymon, M. Mazor, I. Shoham-Vardi, T. Silberstein, A. Wiznitzer, M. Katz

Depts. of Obstetrics and Gynecology and of Epidemiology, Soroka Medical Center, and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Food-withdrawal has been proposed as a possible mechanism for initiating the onset of labor in animals and humans. The hypothesis was based upon the reported increase in deliveries of infants during the Yom Kippur fast. We studied the effect of the fast on full term deliveries of Jewish women, with non-fasting Bedouin women as controls (1988-1995, 1,313 Jewish and 1,091 Bedouin deliveries). To determine the effect of Yom Kippur itself, delivery rates on Sukkot and Yom Kippur were compared in both groups. The mean delivery rate in the Jewish population was significantly higher during Yom Kippur and the day after, than during the 7 days before Yom Kippur (15.1±5.1 and 14.6±4.7 vs 10.7±3.5, p<0.04 and p<0.01, respectively). There was an increase in delivery rate during the 6 hours before the end of the fast. In the Bedouin women there were no changes in delivery rate during any of these periods. There were no significant differences in the rates of deliveries during the Sukkot festival between Jewish and Bedouin women. We conclude that fasting is associated with a significant increase in the rate of deliveries at term.

Superficial Dorsal Penile Vein Thrombosis (Mondor's Disease)

Ran Katz, Arye Blachar

Depts. of Urology and Radiology, Hadassah Medical Center, Hebrew University of Jerusalem

Superficial venous thrombosis of the chest wall was first described by Mondor in 1939. Braun-Falco reported in 1955 superficial penile vein involvement in diffuse thrombophlebitis of the abdominal wall and in 1958 Helm and Hodge first described isolated superficial dorsal penile vein thrombosis. Since then, fewer than 50 cases have been reported. The clinical presentation is usually redness and swelling of the dorsum of the penis, accompanied by a palpable, tender thrombotic vein. This acute and painful disease frightens the patient, who is concerned about his fertility and sexual function. The main cause of this disease is frequent sexual intercourse. Diagnosis is based upon anamnesis, physical examination and penile sonography with color Doppler imaging. It is usually a benign disease which resolves quickly under appropriate medical therapy. We present a man who was admitted for this condition and was successfully treated.

Separation of Conjoined Twins: The Anesthesiologist's Perspective

Zvi Grunwald, Yacov Katz

Dept. of Anesthesiology, Rabin Medical Center, Beilinson Campus and Schneider Children's Hospital, Petah Tikva

Managing anesthesia care for separation of conjoined twins poses a special challenge for the anesthesia team. Early preparation, thorough understanding of the anatomical and the physiological consequences of this complex anomaly, as well as careful coordination with the teams of surgeons, nurses and operating room personnel are mandatory to assure successful separation of the conjoined twins. It is recommended that the mother be transferred to and the babies be delivered at a tertiary care medical center, like the Children's Hospital. Special attention is devoted during the surgical procedure to cardiovascular stability, drug disposition, fluid balance and temperature control. The multidisciplinary team approach makes this complex surgery a success. When postoperative survival cannot be guaranteed for both twins, close contact and consultation is mandated with the parents, medical personnel and religious and legal advisors.