תוצאת חיפוש

Propafenone Dose for Emergency Room Conversion of Paroxysmal Atrial Fibrillation

D. Antonelli, A. Darawsha, S. Rimbrot, N.A. Freedberg, T. Rosenfeld

Dept. of Cardiology and Emergency Room, Central Emek Hospital, Afula

Paroxysmal atrial fibrillation (AF), a frequent cause of repeated hospitalization, is effectively treated with propafenone. The time to conversion to sinus rhythm is a consideration when managing AF in the emergency room. We investigated the conversion rates of paroxysmal AF by 3 different oral propafenone (P) regimens, in terms of time to conversion.

188 patients with onset of AF within 48 hours were treated with propafenone (P): 48 received 600 mg as a first oral dose followed after 8 hrs by 150 mg (Group A); 82 received 300 mg as a first dose, followed by the same dose 3 and again 8 hrs later (B); 58 received 150 mg every 3 hrs, up to a total dose of 600 mg (C). P was stopped when sinus rhythm was achieved.

Rates of conversion to sinus rhythm after 3 hrs in the 3 groups were: 46%, 41% and 26% respectively; after 8 hrs: 77%, 78% and 70%; and after 12 hrs: 81%, 84% and 76%. Treatment was discontinued in 8. There was excessive QRS widening (>25% of the basal value) in 1 in group A, 1 in group B and 2 in group C; wide-QRS tachycardia occurred in 4 in group B. In Group A there was a higher rate of early successful conversion, with a lower incidence of side-effects than with the other regimens.

Sacral Insufficiency Fractures - A Frequent Cause of Low Back Pain in Elderly Women

H. Semo, Z. Zwas, A. Goshen, S. Levenkrohn, A. Adunsky

Depts. of Geriatric Medicine and Nuclear Medicine, Sheba Medical Center, Tel Hashomer

Sudden low back pain is common in elderly women. It causes physical and mental stress, and results in deterioration of functional movement and in activities of daily living. Awareness of possible sacral insufficiency fracture is important; they may be demonstrated by imaging modalities, mainly radionuclide bone scan. Prognosis is good and accurate diagnosis serves to exclude malignancy and relieve fear of chronic pain and disability. We describe 4 women, aged 84, 82, 71 and 77 who illustrating the clinical and imaging findings of this disorder.

Impact of Clinical Pharmacist on Drug Therapy in Medical Departments

Ariel Hamerman, Rimona Rotem, Naftali Meidan, Avi Porath

Pharmacy Services, Hospital Management and Medical Dept. F, Soroka University Medical Center, Beer Sheba

Several studies have documented the impact of clinical pharmacy services on patient care and drug costs in hospital wards. However most hospitals in Israel do not provide such services and until recently their benefits in local health care have not been demonstrated. We therefor determined whether the activity of a pharmacist in the medical department of a medical center leads to improved quality of drug utilization and reduced costs.

During the first 3 months of the clinical pharmacist's work all interventions and consultation were documented. The effect of these interventions on drug costs was calculated by the change in drug acquisition costs during the study period compared with those of preceding months, as well as in the other 5 medical departments of the hospital without clinical pharmacy services.

During the study period the pharmacist joined 44 clinical rounds in which he documented 40 consultations in response to physicians' requests for drug information and 42 interventions on his own initiative. The pharmacist's recommendations were accepted in 38 of the 42 cases (90%). In 10 cases the pharmacist's initiative in improving the quality of drug therapy led to an increase in drug acquisition costs. However, the overall drug costs during the study period decreased 12.6%. During the same period drug costs in the other medical departments decreased only 2.2%.

The results of this study conform with those of many other studies that show a beneficial impact of the clinical pharmacist on the quality of drug therapy and on drug costs. They indicate that the clinical pharmacist can play a crucial role in the medical department.

Laparoscopic Donor Nephrectomy: Initial Experience

Amir Szold, Joseph M. Klausner, Richard Nakache

Advanced Endoscopic Surgery Unit, Transplantation Unit and Depts. of Surgery B-C, Tel Aviv-Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University

We present our initial experience in laparoscopic nephrectomy. 6 patients were operated for a kidney donation and 2 for treatment of a benign disease. All procedures were completed successfully, with no conversion to laparotomy or intra-operative complications. Mean operating time was 210 minutes, and in the donor kidneys the mean warm-ischemic time was 165 seconds. There were 3 postoperative complications, and mean hospitalization was 3.5 days. The transplanted kidneys are all functioning.

From our initial experience, laparoscopic nephrectomy appears to be both feasible and safe. Its implementation requires a combined team with experience in donor surgery and advanced laparoscopic skills. The procedure may increase the availability of living donor kidneys, due to the smaller impact on the donor compared to conventional donor nephrectomy.

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.
 

Adjuvant Therapy of Large Bowel Carcinoma

G. Ezekiel, S. Walfisch, Y. Cohen*

Dept. of Oncology and Colorectal Unit, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

The National Institutes of Health (NIH) held a consensus conference which recommended 5-FU and levamisole as adjuvant chemotherapy for colon cancer MAC (Modified Astler Coller) stage C.

From 1991-1994, 37 such patients diagnosed here were treated with 5-FU (intravenous dose of 450/mg/m²/d for 5 days and from day 29, once a week for 48 weeks) and oral levamisole (50 mg 3 times/d. for 3 days, every 2 weeks for a year), as suggested by NIH guidelines.

16 patients were males and 21 were females, mean age was 62 years and median 64. Cancer locations were: right colon (in 16, 43%), left colon (19, 51%), multiple colon primaries (2, 1%). 25 (68%) had 1-3 positive lymph nodes and 12 (32%) had 4 or more positive lymph nodes.

Only 20 (54%) finished treatment as prescribed. In the others, 1 or both drugs caused side-effects for which the drugs had to be stopped. 6 patients relapsed while on treatment.

The most common side-effects were diarrhea, stomatitis and bone marrow suppression. 3 were hospitalized due to neutropenic fever. 5-year actuarial survival of all patients was 61%; 5-year relapse-free survival was 61%; 5-year relapse-free survival of right versus left colon was 41% and 82%, respectively (p<0.01). There was no significant difference in 5-year survival of those with 1-3 positive lymph nodes as compared to those with 4 or more (62% and 56%, respectively). 5-year survival in those who finished or did not finish treatment (excluding those who stopped treatment because of progressive disease) was 83% and 70%, respectively (NS).

The 5-year survival of our series was similar to that of patients treated similarly elsewhere. The 5-FU and levamisole treatment was not tolerated well by our study population. It has recently been replaced in our service by a 5-FU and leucovorin regimen given for 6 months.

* Jules E. Harris Chair in Oncology.

Pediatric Research in an Office-Setting Network

Zahi Grossman, Ernesto Kahan, Samuel Gross, Shai Ashkenazi, Itamar Shalit

Kupat Holim Maccabi, Tel Aviv; Israel Ambulatory Pediatric Association; Dept. of Family Medicine, Tel Aviv University; and Schneider Children's Medical Center, Petah Tikva

Pediatric care in the community is gradually replacing traditional care in hospitals. Despite that, research activity in the community setting is minimal due to objective difficulties. These are mainly constraints of time, office work and lack of research-supporting logistics. In the past decade, throughout the world, primary physicians interested in research have grouped together and formed research networks. The aim of such networks is to support and promote research in the community.

An Israel Pediatric Research in Office-Setting network (IPROS) was established 2 years ago by the Israel Ambulatory Pediatric Association (IAPA). Today, there are over 140 pediatricians listed in IPROS, representing the heterogeneous composition of pediatricians in Israel. The network's policy is defined by a joint steering committee. The committee is composed of IAPA representatives, senior network members and Schneider Hospital senior investigators. The research subjects are diverse, and represent common practical issues.

Effective intra-net communication is vital to the existence of the network, and is accomplished by 3 modalities: 1) semiannual updates by mail, 2) e-mail, using an electronic mailing list to facilitate connection between members, 3) semi-annual meetings. Research budgets are derived from public sources like the Ministry of Health and IAPA, and private sources such as pharmaceutical companies. The administration of the network is supported by Schneider Children's Medical Center, and financed by IAPA.

Rehospitalization of Children

U. Brook, Y. Buyanover

Pediatrics Dept., Wolfson Medical Center, Holon, and Sackler Medical School, Tel Aviv University

The aims of the study were to determine the rate of rehospitalization in 1997 a month after the end of initial hospitalization. 72 of 1174 children (6.1%) were rehospitalized. The mean age was 4.6±3.6 years (range 1 month-16 years). The average duration of the initial hospitalization of the 72 children was 8.3±6.0 (range 1-50) days, but only 3.6 days for all hospitalized children. The duration of the rehospitalization was 4.1±2.1 days (range 1-10 days). the interval between the 2 hospitalizations was 11.1±9.6 days (range 1-30 days). Among the diseases of the rehospitalized children in decreasing order were: respiratory diseases (including ORL) (40.9%), gastrointestinal diseases (27.7%), nervous system diseases, and bacteremia and septicemia (5.6%). Second hospitalizations in connection with these conditions were: gastrointestinal disease (34.7%); respiratory disease (29%); and bacteremia and septicemia (11.1%). Our recommendations are for attending physicians to follow-up regularly and periodically children who suffer from chronic diseases and are prone to develop exacerbations. This should be done in cooperation with hospital specialists so that the cooperation may reduce the rehospitalization of these children.

Clinical, Social and Economic Aspects of Comprehensive Geriatric Assessment

Jacob Feldman, Liora Peleg, Abraham Yaretzky

Geriatric Dept., Sapir Medical Center, Kfar Saba, and Sackler Faculty of Medicine, Tel Aviv University

It is well known that maelderly patients are referred to nursing homes because of "functional decline" without being thoroughly in. We studied 9 elderly patients, all referred to hospital due to functional decline and diagnosed as follows: spinal stenosis - 2 cases, depression - 3, thyrotoxicosis -1, Parkinson -1, polypharmacy and congestive heart failure -1 patient each. Proper diagnosis and appropriate treatment prevent unnecessary hospitalization in nursing homes. Our study is meant to draw attention to this crucial aspect of geriatric medicine.

1000 Cardiac Catheterizations in Congenital Heart Disease

Benjamin Zeevi, Galit Bar-Mor, Michael Berant

Cardiac Catheterization Unit, Schneider Children's Medical Center, and Sackler School of Medicine, Tel Aviv University

Over the past 15 years, percutaneous therapeutic cardiac catheterization has become increasingly important in the treatment of congenital heart disease. We describe our experience in 1000 such catheterizations between 1993-1997. 55% were in 1-12-year-olds; only 20% were in patients younger than 1 year old and 11.3% were in adults with congenital heart defects. In about 50% it was at least a second cardiac catheterization. Overall, there were 425 therapeutic cardiac catheterizations, increasing from 33% in the first 200 procedures, to 63% in the last 200.

We performed 30 different types of therapeutic catheterizations: 23.3% were valvular dilations, 21.4% vessel angioplasties, 36.9% closure procedures, 9.2% electrophysiological procedures, and 9.2% miscellaneous. In 31.3% of therapeutic catheterizations we used 12 new procedures. Minor complications occurred in 8.5% and major in 0.6%; most complications were successfully treated or were self-limited and there was no residual damage.

In this report the current role of each type of major catheterization is discussed on the basis of our experience. Further development of technology for lesions not amenable to currently available transcatheter methods, and longer follow-up for current techniques will consolidate the role of therapeutic cardiac catheterization in congenital heart disease.

Monocytic Ehrlichiosis - An Emerging Pathogen

Irena Zikonov, Israel Potasman

Dept. of Internal Medicine A and Infectious Disease Unit, B'nai Zion Medical Center and Technion Faculty of Medicine, Haifa

Ehrlichiosis is an emerging zoonotic disease transmitted to man by ticks. Its clinical features include fever, headache, myalgia, nausea and rash. The diagnosis requires a high index of suspicion; the disease has a specific serology, and has never been reported in Israel.

We describe a 52-year-old man hospitalized with fever, a diffuse rash, arthralgia and epididymitis. Skin biopsy disclosed necrotizing small vessel disease consistent with periarteritis nodosa. Acute phase serum titer for E. chaffeensis was 1:256. Fever promptly subsided following ciprofloxacin.

Information Provided for Informed Consent in Clinical Trials

Avishay Sella

Genitourinary Medical Oncology Unit, Dept. of Oncology, Rabin Medical Center (Beilinson Campus), Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University

The Helsinki Declaration contains recommendations guiding physicians who conduct clinical trials. One is that the requirement for informed consent is essential for approval of a trial. An important component of the informed consent doctrine is that all data required for the participant's decision must be provided. We analyze data of a therapeutic trial, and define 12 data components outlined in, or directly derived from the Helsinki Declaration.

61 instances of informed consent for therapeutic clinical trials from various fields of medicine, from 1994 to 1997, were analyzed. In each the presence of the 12 components was evaluated.

The data demonstrated that there were only 5 components cited in most cases of informed consent: trial objectives, methods, treatment plan, risks, and the option of withdrawing. Benefit to the participant was mentioned in half the cases, while only limited information was provided about other components such as life-threatening and unpredictable risks, and alternative treatment.

Examples of informed consent from 1997 showed statistical improvement since 1994 in the data concerning trial objectives, methods, risks and alternative therapy. Informed consent documents of international multicenter trials compared with local trials showed statistical improvement in the data components of the trial objectives, methods, and risks, including those of potentially life-threatening and unpredictable risks, and alternative therapy. Analysis of informed consent showed that not all components required for a comprehensive decision regarding participation in a clinical trial are included. These data emphasize the need to design a structured informed consent protocol in which all the required data components are specifically outlined for potential participants.

Prognostic Implications in Pediatric Head Injuries

Gideon Paret, Ron Ben Abraham, Susana Berman, Amir Vardi, Rami Harel, Yossi Manisterski, Zohar Barzilay

Depts. of Pediatric Intensive Care and of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

An unselected series of 200 consecutive cases of major head trauma in children aged 6 months to 16 years, seen during 4 years, was studied. Injuries were due to road accidents (40%), falls (30.5%) and other causes (29.5%), and were assessed clinically and by cranial CT.

On admission the Glasgow Coma Score ranged from 4.72-11.65 and in addition to pupillary responses and brain stem reflexes, was a significant predictor of outcome. Brain edema, midline shift, intracranial hemorrhage and also hyperglycemia, hypokalemia and coagulopathy, were associated with poor outcome. While 17% died, 53% were discharged in good functional condition.

Early identification of clinical features related to prognosis can help the caring team provide maximal support for patient and family.

Laparoscopic Treatment of Small Bowel Obstruction Caused by Adhesions

S. Kyzer, Y. Aloni, I. Charuzi

Surgery Unit B, Wolfson Medical Center, Holon

We describe our experience in 14 patients operated on for small bowel obstruction, who underwent laparoscopic adhesiolysis. In 13 (93%) the obstruction was relieved and only 1 case required conversion to open operation. Bowel activity usually resumed within 24-48 hours, and there were no remarkable intraoperative and postoperative complications. During follow-up none developed recurrent obstruction.

Our experience demonstrates that laparoscopic adhesiolysis is a valid therapeutic option. Additional experience is needed to determine which types of cases are suitable for the procedure.

Malignant Nodular Hidradenoma (Sweat Gland Tumor)

Anat Engel, Yaron Bar-Dayan, Santiago Engelberg, Yair Levi

Depts. of Medicine B, Pathology, and Disease Research Unit, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Malignanhidradenoma is a very rare tumor that originates from sweat glands. We present a 61-year-old man with an ulcerated tumor in his right flank, 4 cm in diameter, that was excised with a wide free margin. Histopathologic study showed an ill-defined, epithelial neoformation, formed by lobules of clear polygonal cells in the deep dermis and subcutaneous tissue, diagnosed as malignant nodular hidradenoma.

1.5 years after excision there was enlargement of the right axillary and inguinal lymph nodes, which showed metastatic, adnexal neoplastic cells. Axillary resection and superficial dissection of the right inguinal nodes were performed. After 3 months the tumor had spread to other lymph nodes and acute obstructive renal failure required insertion of a pig-tail catheter into the right ureter. Radiotherapy was followed by chemo-therapy, but he died from end-stage metastatic disease in multi-organ failure.