תוצאת חיפוש

Apomorphine for "Off-Periods" in Parkinson's Disease

J. Zoldan, D. Merims, A. Kuritzky, I. Ziv, E. Melamed

Dept. of Neurology, Rabin Medical Center, Beilinson Campus, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University

After 3-5 years of continuous use of 1-dopa preparations for Parkinson's disease, 25%-50% of patients develop side-effects such as the "on-off" phenomenon and involuntary movements that markedly impair function. One cause of these manifestations is evidently a disturbance in the absorption of 1-dopa.

We attempted to avoid this problem by using subcutaneous injections. Apomorphine is a rapid-acting dopamine agonist which causes a return from "off" to "on" within minutes.

We present the results of a trial of subcutaneous injections of apomorphine in 22 Parkinsonian patients (12 males, 10 females) with severe motor fluctuations. During 5 days prior to the apomorphine all received Motilium (domperidone, 60 mg/d) to prevent nausea and vomiting. All were hospitalized initially to determine optimal dosage and to teach them the technique of self-injection.

2 to 4 mg of apomorphine were injected 1 to 3 times daily for 2 to 12 months. In 17 patients (80%) "off" periods were reduced without significant side-effects. Apomorphine seems to be effective, tolerable treatment for shortening 1-dopa induced "off" periods.

Alpha-Amino Adipic Aciduria: a Rare Psycho-Motor Syndrome

Ben-Ami Sela, Tamar Massos, Dov Fogel, Joseph Zlotnik

Pathological Chemistry and Child Development Institutes, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

A 3.5-year-old boy with developmental motor retardation, hypotonicity, and severe speech disturbance had alpha-amino adipic acid in his blood and very high levels in his urine. In only 20 cases has this catabolite of lysine and hydroxylysine been found in high concentrations in urine, due to enzymatic block.

The clinical features associated with alpha-amino adipic aciduria may include mental retardation, developmental and motor delay, learning difficulties, convulsions, speech problems and ataxia. 3 siblings had milder symptoms of psychomotor delay and intermediate degrees of alpha amino-adipic aciduria, suggesting that the described developmental deficits could be related to this metabolite or its derivatives.

Clozapine in the Treatment of Schizophrenia

M. Mark, R. Magnezi, O. Luxenburg, M. Siebzehner, J. Shemer

Israel Center for Technology Assessment in Health Care, Sackler Faculty of Medicine, Tel Aviv University

Schizophrenia is associated with brain abnormalities and is typically evidenced by disorganized speech and behavior, delusions, and hallucinations; it usually requires extended hospitalization. Its incidence in the western world is estimated at 4-7 cases/10,000/year.

A method of shortening hospitalization and improving level of functioning is the use of unique medication, including clozapine, which has been in use in Israel for the past 6 years.

We report 327 patients who participated in a community rehabilitation program and were treated with clozapine. They were compared with 417 patients who corresponded to the guidelines of the Director of Mental Health Services for treatment with clozapine, but were not treated with it for reasons not defined in the guidelines.

The study included those 25-44 and 45-64 years of age and according to the division of the population of patients hospitalized in both government and private hospitals. The project demonstrates the savings from use of clozapine as opposed to the alternative of hospitalizing these patients. It also shows the complexity and difficulty in assimilating new technologies, in relation to the influence of social considerations and supplier/insurer accounting on the patterns of technological assimilation.

Severe Hypercalcemia Due to Renal Transitional Cell Carcinoma

D. Zamir, J. Weizman, N. Erlich, M. Amar, P. Weiner

Depts. of Medicine A, Urology and Pathology, Hillel Yaffe Medical Center, Hadera

Hypercalcemia is a common metabolic disorder, especially in the elderly. The most common etioloare hyperparathy-roidism or malignancy, most often of the lung, breast, kidney or hematological system. Because hypercalcemia is an uncommon manifestation in urinary tract epithelial tumors, especially those of the renal pelvis, we present a man aged 62 years with hypercalcemia due to renal transitional cell carcinoma.

Prevalence of Medical Complaints in the Community-Dwelling Elderly

J. Gindin, M. Geitzn, M. Dushenat, H. Siboni, D. Goldstein, Z. Shapira, N. Konstantin, A. Wurm, A. Goldsmid, E. Hay-Am

Geriatric Institute of Education and Research, Kaplan Medical Center, Rehovot; Pharmacology Dept., Kupat Holim Klalit, Tel Aviv and Central District; and Kupat Holim Klalit, Rishon LeZion

We assessed the prevalence of self-reported medical complaints among the community-dwelling elderly receiving regular medication, and determined associations between health and sociodemographic variables, and the prevalence of complaints.

The study included 170 patients, 60-90 years of age, living at home. Participants were recruited from the 3 main primary care clinics in Rishon LeZion. All were receiving chronic medication and were followed-up utilizing a long-term medication card. Data were gathered in interviews held in patients' homes using a structured questionnaire which included sociodemographics, diseases and medication, mental state assessment by Katzman's score, and a list of 15 medical complaints common among the aged. Relations to age, gender, education, living arrangements, number of diseases and number of medications per patient were determined.

Mean age of participants was 73.2±6.0 years and they suffered an average of 4.07±2.16 diseases and took 5.10±2.83 types of drugs. The most prevalent complaints were: weakness and fatigue (65.0%), agitation and restlessness (56.4%), dry mouth (45.6%), constipation (43.6%) and dizziness (43.2%). The number of diseases, gender, education and age had the strongest associations with the prevalence of specific complaints, as well as their total number. The association between number of medications and mean number of complaints was of borderline significance.

Nephron-Sparing Surgery - Initial Experience with 50 Patients

Sarel Halachmi, Alexander Kastin, Boaz Moskovitz, Ofer Nativ

Urology Dept., Bnai Zion Medical Center, Haifa

During recent years the use of the new imaging techniques, ultrasonography and computerized tomography, has increased. The accessibility to these methods has changed the pattern of detection of renal lesions. Over 90% of renal masses are now discovered incidentally, while investigating nonurological symptoms. Therefor, most lesions are discovered in their early stages.

The gold-standard procedure for removing renal masses is radical nephrectomy, which ensures complete removal of an organ-confined lesion, but involves loss of functional tissue. This might be critical in patients with a single kidney, or reduced nephron function. There are several diseases characterized by multiple renal lesions, such as Von Hippel-Lindau and tuberous sclerosis in which radical treatment may lead to chronic dialysis in young patients.

Nephron-sparing surgery was developed in order to preserve as much functional tissue as possible while removing safely any suspicious renal lesion. This new technique, not involving radical surgery, should be evaluated in cases of renal tumors for its ability to achieve the same cancer cures rates. We present our experience with our first 50 patients who underwent nephron-sparing surgery for removal of renal lesions.
 

ACE Gene Polymorphism in a Diabetic Cohort and Diabetic Nephropathy

Orna Levinson, Shmuel Oren, Chana Yagil, Marina Sapojnikov, Alexander Wechsler, Rosanna Bloch, Yoram Yagil

Laboratory for Molecular Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba and Barzilai Medical Center, Ashkelon

The renin-angiotensin system is thought to play an important role in the pathophysiology of kidney disease in diabetes. Previous studies have shown a possible association between the D allele of the angiotensin converting enzyme (ACE) gene, known to be associated with higher circulating levels of ACE, and increased risk of developing nephropathy in NIDDM. The present study investigated the distribution of ACE gene genotypes in the general population and patients with NIDDM, the association between the D allele and diabetic nephropathy, and the association between the ACE genotype and involvement of other target organs in NIDDM. The ACE genotype (insertion/deletion I/D) was determined in all subjects, subsequently divided into 3 groups based on their polymorphism (DD, DI and II). The presence of nephropathy was defined by an albumin-creatinine ratio of 30 mg/g or greater (mean of 2 first morning urine samples).

In the general population most had the D allele (DD or ID) and a minority the II genotype. There was no association between genotype and hypertension, ischemic heart disease, hyperlipidemia, and cerebrovascular or peripheral vascular disease. In diabetics the genotype distribution was not different from that in the general population. Within the diabetic group, there was no association between genotype and hypertension, hyperlipidemia, duration of diabetes, or HbA1C levels. Nephropathy, found in 81 of the 156 with NIDDM, was not associated with genotype. Diabetic nephropathy was not associated with retinopathy, neuropathy, or ischemic heart, cerebrovascular or peripheral vascular disease. We conclude that in the population sampled, there was no association between the D allele of the ACE gene and the risk of developing nephropathy in NIDDM.

High Alkaline Phosphatase in Subacute Thyroiditis

Rami Kantor, Rachel Pauzner, Elena Pali, Zvi Farfel

Dept. of Internal Medicine E, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Subacute thyroiditis may be hard to diagnose, therefore patients are sometimes misdiagnosed and subjected to unnecessary work-up. We report a 37-year-old man with subacute thyroiditis and a high concentration of serum alkaline phosphatase. After aspirin treatment there was clinical improvement and decrease in rapid ESR, and in high serum thyroxin and alkaline phosphatase. The increased alkaline phosphatase, seen in as many as 50% of patients, is of hepatic origin, and is not caused by high serum thyroxin. Awareness of this relationship may help in diagnosis and may prevent unnecessary diagnostic procedures, which may be invasive.

Management of Pancreatic Trauma in Damage-Control Laparotomy

Gad Shaked, Mario Golocovsky

Dept. of Surgery and Trauma Service, Soroka University Hospital, Beer Sheba and Dept. of Surgery and Trauma Service, Washington Hospital Center, Washington DC

Major pancreatic trauma challenges the trauma surgeon with diagnostic problems and choices of treatment modalities. The most important determinant guiding management is the integrity of the main pancreatic duct. The preoperative and intraoperative assessment and treatment of pancreatic injury may be difficult, especially when concurrent severe injuries are present. There are alternative approaches in the management of the traumatized pancreas when ductal injury is not obvious during initial exploratory laparotomy.

Operative Laparoscopy in Pregnancy

Eylon Lachman, Abraham Schienfeld, R. Boldes, Samuel Levin, Michael Burstein, Michael Stark

Depts. of Obstetrics and Gynecology, Misgav Ladach Hospital, Jerusalem

The development of laparoscopic surgery in gynecology and general surgery has greatly advanced over the past decade, and recently has been successfully performed in pregnancy. In the English literature we found that of the 518 cases reported (mean age 32 years) the most common was for cholecystectomy (45%), followed by operations on the adnexae (34%), appendectomy (15%) and others (6%). To these we add 3 cases of cholecystectomy and 1 of an adnexal tumor. Of all the reported cases, 33% were performed in the 1st trimester, 56% in the 2nd and 11% in the 3rd.

This review demonstrates a definite trend to laparoscopy in pregnancy. It appears to be safe when performed by experienced surgeons, but further studies addressing safety of laparoscopic surgery during pregnancy are needed to reach definitive conclusions.

Nerve Palsies Following Prolonged Use of Limb Tourniquets

G. Volpin, R. Said, W. Simri, B. Grimberg, M. Daniel

Depts. of Orthopedic Surgery and Neurology, Western Galilee Hospital, Nahariya

Nerve paralysis following the use of tourniquets, regular or pneumatic, for limb surgery is rare. We describe a 19-year-old male soldier who had tourniquets applied for 3 1/4 hours to his arm and both legs due to penetrating injuries. As a result, he suffered palsy of the radial nerve and both common peroneal nerves. Nerve palsy in such cases has not been described in the literature. It is not clear whether the cause is direct mechanical pressure on the nerve, nerve ischemia, or a combination of both.

We recommend that tourniquets should not be used continuously for more than 2 hours. If evacuation of the injured is delayed, the medical team should consider loosening tourniquets for short intervals or changing for a pressure bandage. This is providing the patient's condition is stable and bleeding does not start again on release of the tourniquet.

Laparoscopic Repair of Inguinal Hernia Experience in 54 Consecutive Cases

S. Kyzer, I. Kristalni, M. Alis, I. Charuzi

Surgical Dept. B, Wolfson Medcial Center, Holon

We describe our experience in 54 consecutive patients who underwent laparoscopic repair of 86 inguinal hernias. Laparoscopic repair of inguinal hernia is technically feasible, does not prolong the length of the procedure nor of hospitalization and is not accompanied by increased morbidity. Although there is not yet general agreement, in our experience and that of others, it appears that laparoscopic repair will be the preferred approach to the treatment of inguinal hernia.

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.

Iatrogenic Gallstone Ileus: A New Complication of Bouveret's Syndrome

Miguel Iuchtman, Amos Sternberg, Ricardo Alfici, Ehud Sternberg, Tzvi Fireman

Depts. of Surgery and Gastroenterology, Hillel Yaffe Medical Center, Hadera, and Rappaport Medical School, Haifa

Bouveret's syndrome involves gastric outlet obstruction caused by a gallstone in the duodenum. This type of gallstone ileus can be diagnosed and treated endoscopically. Endoscopic stone removal is especially indicated in poor risk patients. A dislodged impacted stone can migrate distally and cause small bowel mechanical obstruction. We report a 51-year-old woman who underwent endoscopic duodenal stone manipulation which resulted in small bowel obstruction.

Radiologic Appearance of "Falling Gallstones" during Laparoscopic Cholecystectomy

E. Alkalay, D. Yaffe, Z. Spindel

Eyn Vered Clinic and Depts. of Radiology and Surgery, Sapir Medical Center, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University

Laparoscopic cholecystectomy is the "gold standard" in treating cholelithiasis. Stones are frequently lost in the peritoneal cavity during the procedure, but "missing stones" have been regarded as insignificant. However, there is accumulating evidence that untreated "lost" stones may cause complications even years after operation.

We present a 65-year-old woman who presented with vague complaints, anemia and an elevated ESR. CT scan showed an infiltrating process in extra-abdominal muscles compatible with sarcoma. At operation, 2.5 years after previous laparoscopic cholecystectomy, an abscess was found which contained biliary stones. Because of their small size they were not visible on CT scan. We discuss the possible ways of handling "falling stones."