תוצאת חיפוש

The Fate of Gallstones "Dropped" during Laparoscopy

Menashe Barzilai, Arie Bitterman, Dorit Schlag-Eisenberg, Nathan Peled

Depts. of Radiology and Surgery B, Carmel Medical Center, Haifa

Laparoscopic cholecystectomy is considered the procedure of choice for removing symptomatic, stone-containing gallbladders. It is estimated that in 30-40% of these operations stone(s) spill into the peritoneal cavity. It was assumed that these "dropped stones" are harmless and are dissolved and absorbed spontaneously. We present a 70-year-old woman in whom such a stone, dropped during laparoscopy, led to formation of an intraperitoneal abscess.

The Current Compulsory Hospitalization Order and Patients' Rights

Y. Bar-el, R. Durst, J Mazar, J. Rabinowitz, Y. Lerner, H.Y. Knobler

Office of Jerusalem District Psychiatrist; Jerusalem Mental Health Center, Kfar Shaul Hospital; Mental Health Services, Israel Ministry of Health; School of Social Work, Bar-Ilan University; and Falk Institute for Mental Health and Behavioral Sciences, Kfar Shaul (Affiliated with the Hebrew University - Hadassah Medical School)

Israel's "Treatment of Mentally Sick Persons Law" of 1955 was repealed and replaced by the "Treatment of Mental Patients Law" of 1991. Under the latter, the "Compulsory Hospitalization Order" (CHO) defines the new order based on accumulated experience with the old legislation, and on the philosophy that considers the CHO one of the most severely oppressive forms of deprivation of human liberty and rights. The new order sets limits and boundaries for CHO, guarding the rights of those unavoidably committed by force. According to the new law, the district psychiatrist decides upon and issues the order, while the tribunal (District Psychiatric Committee) considers appeals. The order is limited to 1 week, with an option for the district psychiatrist to prolong it on written request for up to 14 days. The tribunal can later prolong the order further.

The objective of this study was to review changes that have occurred following enforcement of the new law in the Jerusalem district. A comparison was made between CHO's issued the year before the new legislation took effect and the year after. The comparison included review of all CHO's and medical files of all patients hospitalized by coercion during 1990 and 1992. It was assumed that there would be a decline in rate and length of hospitalization of patients forced to be committed by the new law.

The main findings refuted this hypothesis. In 1992 there was an increase of 38% in the number of compulsory hospitalizations. This increase derived mainly from increased demands for CHO's from psychiatric emergency rooms. There was also an increase in patients hospitalized by order of the District Psychiatric Committee using its authority under section 10(C) of the law.

Conversely, length of compulsory hospitalization was shorter under the new law.

In light of these findings, it would seem that the new law has only partially fulfilled expectations of reform in individual rights. There is need for further evaluation and follow-up of the CHO in order to determine whether the "Treatment of Mental Patients Law" of 1991 has in fact fulfilled its objectives. Furthermore, it is necessary to determine means, medical or legal, that may possibly advance further the prospective of human rights while maintaining a suitable balance between civil liberties and clinical needs, of over-confinement versus under-treatment, which may lead to neglect or danger.

The Mitrofanoff Pouch in Lower Urinary Tract Reconstruction

J.H. Pinthus, Y. Mor, J. Ramon

Urology Dept., Chaim Sheba Medical Center, Tel Hashomer

The Mitrofanoff principle, first described in 1980, consists of implanting a tubular organ such as the appendix, ureter, or fallopian tube into the wall of the bladder (or urinary reservoir) to create a non-refluxing, catherizable urinary conduit. Between 1993-1996, 7 men and 1 woman (aged 48-64, average 59) underwent radical cystectomy and urethrectomy combined with the creation of a MAINZ I urinary reservoir (based on the Mitrofanoff principle). In men the indication for the procedure was the diagnosis of invasive transitional cell carcinoma of the bladder with involvement of the prostatic urethra. All patients had refused urinary diversion to an ileal conduit because of its deleterious effect on the quality of life.

In all patients the postoperative course was uneventful, apart from intraperitoneal urinary leakage from the reservoir in 1, successfully managed conservatively. The patients have gained full control of urinary drainage, performing intermittent self-catheterizations every 4-5 hours. In 3 patients there were difficulties with catheterization due to stenosis of the conduit, usually at the skin level. None have suffered leakage from the reservoir, during the day, even when it was full.

Our experience shows that creation of a continent urinary reservoir according to the MAINZ I technique is an excellent surgical solution for patients in whom the creation of an orthotopic reservoir is impractical. The use of the umbilicus as a stomal site preserves normal body image and thus does not interfere with quality of life as in those undergoing radical cystectomy.

Purpura - an Unusual Presentation of Takayasu Arteritis

N. Reichman, N. Kaufman, R. Mader, E. Flatau

Dept. of Medicine B and Rheumatic Disease Unit, HaEmek Hospital, Afula and Rappaport Faculty of Medicine, The Technion, Haifa

Takayasu arteritis is an uncommon vasculitis, often referred to as aortic arch syndrome. It is most prevalent in young women. Physical findings such as the combination of pulseless arms and carotid bruits suggest the diagnosis. Associated skin manifestations such as pyoderma gangrenosum and erythema nodosum have been described. We present a 27-year-old woman with diffuse purpuric eruption and Takayasu arteritis. This appears to be the first description of such an association.

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.

Trichobezoars

M. Barzilai, N. Peled, M. Soudack, L. Siplovich

Carmel and Rambam Medical Centers, Haifa and Afula Medical Center 

Trichobezoars are accumulations of hair casts in the stomach associated with trichophagia. The typical patient is an adolescent female who presents with alopecia and an upper abdominal mass which on moving can cause intermittent gastric outlet obstruction. Only a minority of patients have severe psychiatric disorders. When hair strands extend from the main mass in the stomach, all along the small bowel and reaching the cecum, the condition is termed the Rapunzel syndrome. In about 5% of patients there are separate hair masses in the stomach. The clinical presentation includes abdominal pain, loss of appetite, weight-loss, vomiting, loose stools, pancreatitis, jaundice, anemia and hypoalbuminemia. These signs and symptoms raise the suspicion of malignancy. Complications of bezoars include ulcers, perforation of the bowel, obstruction and intussusception. Diagnosis can be established either by barium swallow or by CT scan. Ultrasound might suggest the diagnosis, but sonographic features are definitely not pathognomonic. Treatment is surgical, as endoscopic removal is usually unsuccessful. We present 2 children in whom trichobezoars were found.

Living-Related Liver Transplantation

N. Bar-Nathan, Z. Shapira, E. Shaharabani, A. Yussim, Y. Ben-Ari, T. Sheinfeld, I. Zehavi, R. Shapira, G. Dinari, Z. Ben-Ari, R. Tur-Kaspa, E. Mor

Dept. of Transplantation and Liver Institute, Rabin Medical Center (Beilinson Campus), and Pediatric Intensive Care and Pediatric Gastroenterology Units, Schneider Children's Medical Center, Petah Tikva

Our experience with living-related liver transplantation is described. In 2 boys and 1 girl, aged 4-4.5 years with acute, fulminating hepatitis A, the presence of very severe jaundice (bilirubin levels > 18 mg%) associated with severe coagulopathy (INR>10) and encephalopathy indicated the need for urgent liver transplantation. In all 3 cases the left lateral hepatic segment of a matched blood type parent was transplanted. None of the donors suffered a serious complication postoperatively and all returned to full activity in 6-16 weeks. The post-transplantation course was uneventful in 1 child, but in the other 2 there was hepatic arterial thrombosis in 1 at 1 day and in the other at 8 days post-transplantation. Early detection of arterial thrombosis by Doppler sonography permitted salvage of the 2 hepatic grafts after thrombectomy and re-anastomosis. In 1 of these 2 children an anastomotic biliary stricture was found 2 months after transplantation. It was corrected at surgery and a percutaneous stent was inserted. All 3 children are alive with normal graft function at 2, 7 and 8 months post-transplantation, respectively. This initial experience indicates that living-related liver transplantation is feasible in Israel. The technique might help to solve our severe organ shortage for children awaiting liver transplantation.

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.

Liver Allografts from Donors older than 60: Benefits and Risks

Eytan Mor, Dan Shmueli, Ziv Ben-Ari, Nathan Bar-Nathan, Ezra Sharabani, Alexander Yussim, Boris Dorfman, Ran Tur-Kaspa, Zaki Shapira

Transplantation Dept. and Institute of Liver Diseases, Rabin Medical Center, Beilinson Campus; and Sackler School of Medicine, Tel Aviv University

With limited organ resources and an increasing number of candidates for liver transplantation, the world-wide trend is towards using liver allografts from donors older than 60 years. This strategy, however, may be hazardous because of the known correlation between advanced donor age and graft dysfunction. Since January 1996, each of 5 patients received a liver allograft from a donor older than 60 years. Preservation time in these cases was shortened as much as possible and liver allografts were used only if there were no other potential risk factors for primary nonfunction. Mean cold ischemic time was significantly shorter in this donor group (7.8 hrs) than for livers from 28 younger donors (10.2 hour; p<0.01). 3 of the 5 grafts from older donors had normal function immediately. The other 2 initially had biochemical features of preservation injury, but graft function returned to normal within the first week after transplantation. All 5 patients currently have normal graft function, with follow-up ranging from 3-8 months. There was no difference between the 5 recipients of grafts from older donors and 28 adult recipients of grafts from younger donors in extent of preservation injury and in immediate graft function. We conclude that in countries with limited organ resources, such as Israel, liver allografts from older donors can be used within defined limits and minimal preservation time.

Biological Test for Menopausal Osteoporosis

Benjamin Klein, Nathan Rojansky

Depts. of Experimental Surgery and of Obstetrics and Gynecology, Hadassah- Hebrew University Medical Center, Ein Kerem, Jerusalem

Osteoporosis has become a major public health problem in many western countries in which about 25% of women by the age of 65 will have had osteopenic fractures. The most important contributing factor to this condition is loss of gonadal function. This progressive disease, characterized by reduction in bone mass, may be prevented by estrogen replacement therapy. While there are several methods of diagnosing the disease when already established, there is no method that can identify women at high risk of developing osteoporosis. We have developed a biological test in which the serum of postmenopausal women is added to rat osteoprogenitor cell culture and its influence on proliferation, differentiation and mineralization of bone cells is determined. The serum of 20 menopausal women was examined by the biological test and the results compared to the findings of dual photon absorptiometry. This showed that rapid bone-losers had a significantly lower mineralization index as compared to nonosteopenic women (p<0.0001). The proliferation index (cell count) and alkaline phosphatase activity did not show significant differences between osteopenic and nonosteopenic groups. This preliminary study showed that a test based on serum reacting with a culture of bone cells to induce mineralization may be of value in the diagnosis of osteoporosis.

Quinidine-Induced Rheumatic Toxicity

D. Almoznino-Sarafian, N. Cohen, R. Zaidenstein, V. Dishi, E. Zeckler

Depts. of Medicine C, A and F, Assaf Harofeh Medical Center, Zerifin (Affiliated with the Sackler Faculty of Medicine, Tel Aviv University)

2 women with quinidine-induced lupus are presented. This condition is rare; only about 30 cases have been reported in the English literature. Both our patients had arthritis of the wrist, antinuclear antibodies with homogenous pattern and elevated ESR. Anti-double stranded DNA antibodies were present in 1 patient, and a petechial rash in the other. Complete resolution of arthritis occurred within a few days after quinidine withdrawal, but antinuclear antibodies persisted for several months.

Acute Effusive Constrictive Pericarditis in Influenza A

N. Reichman, N. Kaufman, E. Flatau

Dept. of Medicine B, Central Emek Hospital, Afula and Technion Faculty of Medicine, Haifa

Constrictive pericarditis may complicate the course of several viral infections, mainly Coxsackie virus group B, as well as in rheumatoid disease, radiation and neoplasm. Perimyocardial involvement during influenzal infections is usually mild and does not progress to constriction or tamponade. A single case of cardiac tamponade caused by influenza A was reported in 1986. We report a case of acute effusive-constrictive pericarditis due to influenza A infection. Corticosteroids resulted in some benefit, but did not relieve constriction, which required extensive pericardiectomy.