Anaphylactic Shock after Diclofenac Sodium 

Amnon Hadar, Gershon Holcberg, Moshe Mazor

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

Anaphylaxis due to diclofenac sodium (Voltaren) is rare. We describe a 39-year-old woman who received a suppository of diclofenac for analgesia 6-hours after cesarean section. She developed severe angioedema and profound hemodynamic shock 10 minutes after the diclofenac, to which she had been exposed in the past without any side-effects. There are few reports of such an acute, life-threatening, multisystem reaction to this drug in the English literature.

Identifying the Elderly at Risk for Falling 

D. Galinsky, V. Fried, A. Biderman, J. Cwikel, Y. Ben Moshe

Geriatric Dept., Soroka University Hospital and Depts. of Family Medicine and of Social Work, Faculty of Health Sciences, Ben-Gurion University of the Negev; and ESHEL, Beer Sheba

Falling is one of the main problems affecting the health of the elderly. A community project was carried out to detect elderly people at high risk for falls. One of its aims was also to develop tools allowing primary care professionals to detect the elderly at risk for falling. Such a screening test in the community-dwelling elderly (EFST) and a protocol for diagnosis and treatment of the elderly at risk for falls is presented.

Introduction of Routine Hepatitis Immunization in Israel 

Emilia Anis, Alex Leventhal, Malvina Roitman, Paul E. Slater 

Notification of hepatitis A, which is endemic in Israel, has been compulsory since the establishment of the State. From 1992-98 an average of 2,600 cases were reported annually. Many infections are asymptomatic and mild, especially in children. In general, severity increases with age; in Western countries the case fatality rate is 1.5/1,000 among children less than 5 years old and 27/1,000 among those over 50. Until 1987 incidence in Israel was higher in Jews than in non-Jews, but since 1988 incidence has been about 50% higher in non-Jews.

Among Jews highest age specific rates shifted from children 1-4 years old to children 5-9 years old in 1970, and in non-Jews in 1989. Improved sanitary conditions and personal hygiene have reduced very early childhood exposure and hence increased the proportion of susceptible older children and adults, in whom symptomatic disease is more prevalent.

Israel is the first country in the world to include hepatitis A vaccine in its routine immunization schedule. The vaccine is given in 2 doses: at 18 months and 24-30 months of age, and there will be epidemiologic and serologic follow-up. A significant decrease in hepatitis A morbidity is expected in small children within 5 years. The percentage of reported cases in older children and in adults is expected to increase, although the absolute incidence among these groups will decrease.
 

Dept. of Epidemiology and Public Health Services, Israel Ministry of Health, Jerusalem

Diabetic Ketoacidosis during the Ramadan Fast 

I. Friedrich, Y. Levy

Dept. of Medicine A, HaEmek Medical Center, Afula, and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

We report a 15-year-old Muslim boy with insulin-dependent diabetes mellitus (IDDM) who presented with diabetic ketoacidosis (DKA) during the Muslim Ramadan month of day-time fasting. DKA apparently occurred due to omitting pre-lunch insulin combined with dehydration and overeating during the permitted sunset-to-sunrise meals.

It is well-known that fasting accelerates development of lipolysis and ketosis and increases glucagon levels. Thus, these pathophysiological aberrations related to fasting in ketosis-prone patients, in conjunction with fasting, endanger metabolic control in IDDM.

Sacrospinous Ligament Fixation for Vaginal Vault Prolapse

M. Neuman, B. Zuckerman, O. Lavie, U. Beller

Division of Gynecological Surgery and Oncology, Shaare Zedek Medical Center, Jerusalem

Sacrospinous ligament fixation is a well-known method for correction of vaginal vault prolapse. The procedure is primarily indicated after hysterectomy and as a prophylactic measure for total uterine prolapse.

8 women with post-hysterectomy vaginal vault prolapse aged 48-72 years, were referred 1-25 years following primary surgery. Sacrospinous ligament fixation was elected to enable simultaneous correction of cystocele and rectocele, and to preserve sexual function. All operations were completed without significant complications.

In 6 of the 8 patients located for long-term interview, 1 reported mild bulging of the introitus, another mild urinary stress incontinence, urgency and frequency and 1 reported frequency only. Sexual function in 4 was without complaints. Defecation in all patients was normal.
We conclude that this operation is safe and effective. We encourage gynecologic surgeons to consult an experienced tutor prior to performing this procedure, as this type of surgery is quite dangerous and many gynecologists are not familiar enough with it.  

Corneal Infection - Causes and Effects on Vision

Y. Domniz, R. Avisar, H. Savir

Ophthalmology Depts., Assaf Harofeh Medical Center, Zerifin, and Hasharon Hospital, Petah Tikva

We conducted a retrospective 5-year survey of corneal infections treated in the ophthalmology ward of Hasharon Hospital. The most frequent type of corneal infection was corneal abscess; the most frequent cause was Staphylococcus albus, although this bacterium is not reported as a frequent cause of corneal infections.

There was improvement in visual acuity in 69.2% and no change in 15.4%. Corneal infection by Pseudomonas aeruginosa was the most frequent cause of worsening of corneal acuity (23.08%). The greatest improvement of visual acuity was in those with corneal ulcers. The worst visual acuity was in those with corneal abscesses. Pseudomonas aeruginosa was the main cause of infection in contact-lens wearers.

In the world medical literature, Staphylococcus albus is considered of very low virulence. This bacterium was the most frequent cause of corneal infections in our study so it may have greater virulence in Israel.

Hemorrhoidectomy Using A Circular Stapler 

Asaf Levanon, Arie Biterman, A. Behar, Oded Cohen

Dept. of Surgery A, Carmel Medical Center, Haifa

We compared traditional local excision of hemorrhoids in 40 patients (group A) with excision using the CDH-33 surgical stapler designed for bowel anastomosis, in 41 (group B). In this technique a purse-string suture is prepared 3 cm above the dentate line, and the stapler is inserted and used to form a mucosa-mucosal anastomosis. This technique is less time-consuming than the traditional technique.

Data were collected from patients' medical files and from detailed questionnaires in which symptoms prior to and after operation were reported. Mean ages were 53.0 and 51.5 years and male/female ratios were 1.0:1.2 and 1.0:1.1 respectively, neither significant. The most common complaints in both groups were pain and rectal bleeding. All patients had a lower-GI investigation prior to operation to exclude other causes of rectal bleeding.

Recovery averaged 2 months in both groups. Patient satisfaction was assessed by decrease or absence of symptoms on return to normal daily activities. Satisfaction tended to be greater in group B. More patients in group A complained of tightness and discomfort at the operative site, but this was not significant.

We are extending our study to a larger number of patients to determine if there are statistically significant differences between the results of the 2 methods.

Psychogenic Polydipsia Leading to Water Intoxication

L. Umansky, A. Sella

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

Psychogenic polydipsia and its frequent complication, water intoxication, are well-known to psychologists. There are biochemical and psychiatric theories of psychogenic polydipsia which often correlate with each other.

A 48-year-old man with chronic paranoid schizophrenia developed symptoms of psychogenic polydipsia. This provoked disturbances in electrolyte balance, resulting in a rapid decrease in serum sodium concentration and eventual death. There is a paucity of information and little awareness of this problem in the professional literature.

Does Incidence of Hepatitis AIncrease During Shmitah (The Sabbatical Year)?

Zvi Ackerman, Ita Goldstein, Elizabeth Ackerman

Depts. of Medicine, Hadassah University Hospital, Mount Scopus; Bikur Holim Hospital; Hebrew University-Hadassah Medical School; and Pediatrics Dept., Kupat Holim, Jerusalem

In Israel the biblical injunction of the sabbatical year (shmitah) prevails, whereby all Jewish-owned land should lie fallow during every seventh year. Consequently, it is customary for members of the orthodox Jewish community to eat only produce grown by non-Jews (Arabs). Many Arab farmers use sewage water for irrigation and since such water could be infected with hepatitis A virus (HAV), there is concern about the possibility of HAV epidemics during the sabbatical year.

We therefore we examined the data of the Israeli Center for Disease Control (ICDC). We found no obvious increase in incidence of viral hepatitis during, nor in the year immediately after, all sabbatical years since 1951. However, the data was not comprehensive as it included only partial information on morbidity from HAV in our Jewish inhabitants. Also, there was no data specific for the orthodox Jewish community, which is especially at risk for HAV from sewage-irrigated vegetables. Irrespective of shmitah, there should be constant effort to prevent HAV infection in Israel.

Hemophagocytic Syndrome

I. Morag, M. Goldman, T. Bistrizer, C. Kaplinsky

Pediatric Division, Assaf Harofeh Medical Center, Zerifin and Pediatric Hematology-Oncology Dept., Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Hemophagocytic syndrome is a rare, fulminant disease characterized by generalized histiocytic proliferation associated with phagocytosis of erythrocytes, platelets, and to a lesser extent, of white blood cells. We report a 2-year-old boy admitted with high fever and irritability, with a rash, marked hepatomegaly and generalized lymphadenopathy. Liver function tests were abnormal and there was thrombocytopenia and hyperlipidemia. Bone marrow aspiration revealed hemophagocytosis. Despite intensive treatment with steroids, intravenous immunoglobulin and cytotoxic drugs, he died within 10 weeks.

Treatment of Hypertension with Losartan

R. Zimlichman

Dept. of Medicine and Hypertension, Wolfson Medical Center, Holon

The efficacy, safety and side-effects of treatment with losartan (Ocsaar) was studied for the first time in Israel in a large group of patients with mild to moderate hypertension in several community clinics. The 421 patients (51% men) aged 30-86 years (mean 58.6) received 50 mg of losartan daily, increased when necessary to 100 mg, and/or a second antihypertensive drug was given. After 4 weeks blood pressure was normalized in 344 and after 12 weeks in 363. Side-effects were minimal and treatment was effective in all age groups.

Control of Brucellosis in Taibe: Intersectoral Collaboration

Lutfi Jaber, Shmuel Dahan, Ilana Harari

Bridge-to-Peace Community Pediatric Center, Taibe; Community Pediatrics Unit, Schneider Children's Medical Center, Petah Tikva; Sackler Faculty of M, Tel Aviv University; and Israel Ministry of Health, Sharon District

Brucellosis is contracted from domestic animals. Poor hygiene, primitive animal breeding methods and traditional food preparation are the main contributory factors. We describe an intersectoral program for controlling brucellosis in Taibe, an Arab town in Israel, which had a particularly high incidence of the disease in 1992 and 1993.

At the beginning of 1994 the Israel Ministry of Health and the Community Pediatric Center of Taibe established a community-based program for controlling brucellosis in Taibe. It included an intensive public health education campaign and periodic examination and vaccination of animals. Physicians, veterinarians, nurses, school officials and health inspectors were recruited for this purpose. Residents' awareness of brucellosis was determined before and after the study.

After intervention, the incidence of the disease sharply declined from 176.6 and 175.0/100,000 in 1992 and 1993 respectively, to 5.7, 10.4 and 2.5/100,000 in 1994, 1995 and 1996, respectively, (odds-ratio 24.44; p<00000). Residents' awareness of brucellosis and preventive measures were significantly increased by the end of the study. We conclude that intersectoral collaboration is an important tool for controlling brucellosis.

Photodynamic Therapy for Dysphagia due to Esophageal Carcinoma

H. Kashtan, F. Konikoff, R. Haddad, M. Umansky, Y. Skornick, Z. Halpern

Dept. of Surgery A and Institute of Gastroenterology, Tel Aviv Medical Center and Sackler Faculty of Medicine, Tel Aviv University

Surgery is the mainstay in the treatment of esophageal carcinoma and is effective for palliation of dysphagia. Patients unfit for surgery are difficult therapeutic problems. We evaluated photodynamic therapy for palliation of dysphagia in this condition.

Patients were given 5-aminolevulinic acid, 60 mg/kg, orally and 24 hour later gastroscopy was performed during which red light illumination (100 j/cmŽ2 for 600 seconds) was administered. This was repeated 48 hours later. The degree of dysphagia was recorded before and 14 days after treatment.

8 patients with an advanced non-resectable tumor, or who were unfit for surgery, were thus treated. 4 had squamous cell carcinoma of the mid-esophagus and 4 had adenocarcinoma of the lower esophagus. There was mild, self- limited photosensitivity in all. Liver and renal function tests and blood count were not affected by the treatment. Dysphagia was improved in all except 1 patient. A patient with early stage disease continued to eat a normal diet.

We believe that photodynamic therapy with systemic aminolevulinic acid as a photosensitizer and a non-laser light source is feasible and safe in advanced esophageal cancer. It is an effective modality for relief of dysphagia in that condition.

Listeria Monocytogenes Infections - Ten Years' Experience

Tova Rainis, Israel Potasman

Infectious Disease Unit, Bnai Zion Medical Center, and Faculty of Medicine, Technion, Haifa

7 cases of listeriosis were diagnosed here between 1988-1997 (6 in last 3 years), or 2.94/100,000 admissions. 2 elderly patients suffered from meningitis and 2 pregnant women presented with premature contractions, 1 of whom delivered a premature, infected baby. 2 other patients had fever and gastroenteritis.

Listeria monocytogenes was isolated from blood in 4, CSF in 2 and the placenta in 1. It was isolated from those with bacterial meningitis. All patients recovered. Both increased awareness for prevention and better diagnosis are essential to reduce morbidity from this unusual pathogen.

Premature Birth and Cognitive Functioning in Adolescence

Ofra Lubetzky, Avi Weitzman, Izhak Gilat, Samuel Tyano

Levinsky College of Education and Geha Hospital, Tel Aviv and Sackler Faculty of Medicine, Tel Aviv University

Premature infants are considered a high-risk population for developing cognitive dysfunction. Studies have indicated lower cognitive performance among elementary school children born prematurely. We focused on cognitive functioning of such adolescents. This age was chosen because of its critical importance in the development of the individual.

50 adolescents aged 14-16 years born prematurely were compared with 50 born at full-term and matched for gender, age and socioeconomic status. All subjects attended regular schools and did not suffer severe neurological disorders. Cognitive functioning was measured by the Bender-Visual Motor Gestalt Test and by 3 subtests from the Wechsler Intelligence Scale for Children (revised WISC-R test).

Results revealed that prematurely born adolescents scored lower than those born at term on all measures of cognitive performance. The results are discussed in terms of their developmental meaning and of therapy for the prematurely born.