תוצאת חיפוש

אהוד ברגר, רוני שילה, אברהם ויצמן, חנן מוניץ

המח' לבריאות הנפש א' ויחידת המחקר, המרכז לבריאות הנפש גהה

סכיזופרניה היא מחלה הטרוגנית עם מיגוון תסמינים רחב, ללא אטיולוגיה ברורה או אחידה. במהלך השנים, הועלו תיאוריות שונות בניסיון להסביר את ההסתמנות בסכיזופרניה באמצעות דגמים שונים, ומרביתם מבוססים על הפרעה בפעילות מרכזית של נירוטרנסמיטרים שונים, במיוחד דופאמין, סרוטונין וגלוטמאט.

בתחילה שלטה התיאוריה הדופאמינרגית שהניחה, כי קיימת פעילות-יתר דופאמינרגית במוח בחולים בסיזופרניה, במיוחד גירוי עודף של קולטנים מסוג D₂, בעיקר במסלולים מזולימביים ומזוקורטיקליים.

מיכל בר-נתן, יחזקאל סידי, חנן גור

המח' לרפואה פנימית ג', מרכז רפואי שיבא, תל-השומר

תסחיף ריאתי (ת"ר) הוא מצב שכיח בתחומי רפואה שונים והסתמנותו הקלינית מגוונת. הביטויים השכיחים כוללים קוצר נשימה פתאומי, כאב צידרי (pleural pain), שיעול, גניחת-דם ועילפון. טאכיפנאה, טאכיקרדיה, גודש ורידי צוואר והיפוקסמיה. שיעור התמותה מת"ר הוא 6%-8%, למרות טיפול, אך בחולים עם ת"ר המלווה בירידת לחץ-דם, עלול שיעור התמותה להגיע עד 30%.

מצב קליני קשה יותר הוא תסחיף ריאתי מסיבי (תר"מ). זהו מצב מסכן חיים, הכרוך בשיעור תמותה גבוה ביותר ומחייב טיפול מיידי. מרבית החולים (60%-70%) עלולים למות תוך 1-6 שעות מתחילת התסמינים, אם לא יוחל טיפול. הטיפול בחולה עם תר"מ מחייב שיתוף פעולה של צוות רפואי הכולל את הרופאים המטפלים, אנשי דימות פולשני, יחידה לטיפול נמרץ ומנתחי לב. ההחלטות חייבות להתקבל במהירות על סמך הוריות המעוגנות בתוצאות מחקרים, אך מביאות בחשבון את הידע והניסיון המקומי של הצוות הרפואי.

המטרה בסקירה הנוכחית היא לדון בהיבטים השונים של הטיפול בחולה עם תר"מ, על סמך המידע בספרות ועל סמך הניסיון שרכשנו בטיפול במספר חולים עם תר"מ בשנים האחרונות, תוך ניסיון לשתף את קהל הקוראים בתרשימי הזרימה לטיפול, שגובשו במחלקתנו.

(1) אלנה יצחקוב, (2) ארדון רובינשטיין

(1) המח' לרפואה פנימית ה', (2) המכון למטאבוליזם ביה"ח איכילוב, תל-אביב

השכיחות של מחלת לב איסכמית בחולי סוכרת מסוג 2 גדולה פי 2-4 מכלל האוכלוסייה, והתמותה בחולי סוכרת עם טרשת עורקים עקב מחלת לב איסכמית גדולה פי 3-6 מכלל האוכלוסייה. כ-80%-75% מהחולים בסוכרת מסוג 2 נפטרים מטרשת עורקים ומסיבוכיה.

סוכרת מהווה גורם סיכון עיקרי לטרשת עורקים והפרעות במשק השומנים (lipids) והליפופרוטאינים הם מהגורמים העיקריים לסוכרת. בסוכרתיים, כמו בלא סוכרתיים, יכולות רמות שומנים גבוהות להיות קשורות למצבים שאינם קשורים להיפרגליקמיה ולתינגודת לאינסולין, כמו לדוגמה, מחלת כליות, תת תריסיות, מחלת כבד או הפרעות גנטיות במשק הליפופרוטאינים.

Nephrogenic Adenoma - Benign Lesion of Urinary Tract System

Zohar A. Dotan, Yoram Mor, Sarit Aviel-Ronen, Jacob Ramon

Department of Urology and Pathology, Sheba Medical Center, Tel Hashomer, Israel

Nephrogenic adenoma is a rare metaplastic benign lesion of the urinary tract caused by chronic irritation to the urinary epithelium. The appearance of this lesion is usually characterized by hematuria and irritative symptoms. Nephrogenic adenoma may be found most commonly in the bladder and the urethra and less frequently in the renal pelvis and ureters. We present 5 patients who underwent surgery due to bladder or urethral nephrogenic adenoma. Despite the fact that nephrogenic adenoma is a benign lesion, long term follow-up is needed due to the high recurrence rate and the potential, though rare, malignant transformation.

ערן תמיר, דרור רובינסון, גבריאל אגר, נחום הלפרין

המח' לאורתופדיה, מרכז רפואי אסף הרופא, צריפין

חומצה היאלורונית היא מולקולת ענק במשקל מולקולתי של 3.5-5 מיליון דלטון, המורכבת משרשרת פוליסאכארידית של D-glucuronate ו-N-acetylglucosamine המופיעים לסירוגין. חומצה היאלורונית מיוצרת על ידי תאים מסוג A בריקמה הסינובית של המיפרק ומהווה מרכיב חשוב התורם לתכונות המגנות של הנוזל הסינובי, הכוללות בלימת זעזועים ושימון המישטחים הסחוסיים. בנוסף לכך המישטח הפנימי של הממברנה הסינובית מצופה בשיכבת חומצה היאלורונית, המונעת נדידת תאים ומולקולות גדולות לתוך המיפרק.

Following 90 Patients with Antiphospholipid Syndrome: Manifestations of the Disease, Follow-Up of Antibodies Titers and Correlations with Clinical Manifestations in the Israeli Population - Patients in the Sheba Medical Center, Tel Hashomer

Ibrahim Marai, Yair Levi, Gezal Godard, Yehuda Shoenfeld

Department of Medicine B and Research Unit of Autoimmune Diseases, Chaim Sheba Medical Center (affiliated to Tel-Aviv University), Israel.

The antiphospholipid syndrome (APS) is defined by the presence of antiphospholipid antibodies (aPLs) with venous or arterial thrombosis, recurrent pregnancy loss or thrombocytopenia. The syndrome can be either primary or secondary to an underlying condition, most commonly systemic lupus erythematosus (SLE).

The purpose of the study was to review the manifestations of the APS in Israeli patients and to investigate the difference between patients with primary or secondary syndrome. Analysis of the correlation between the manifestations of the disease and the antibody titers [LA (lupus anticoagulant), IgG aCL (anticardiolipin), IgM aCL] was also performed.

In the study there were 90 patients with APS in the Sheba Medical Center. The clinical findings for all patients were recorded according to established protocol.

Results: Arterial thrombotic events were present in 51.1% of the patients; cereberal ischemic attacks were the most frequent arterial events. Venous thrombotic events were present in 45.6% patients; deep venous thrombosis was the most frequent venous event. Obstetric complications were found in 37.3% of patients; the most frequent complication was abortions. The clinical findings of patients with primary or secondary syndrome were similar. Patients with APS associated with lupus had a high prevalence of hemolytic anemia (28.6% v 3.3%; P=0.001), and ANA (antinuclear antibody) (75% v 12.9%; P=0.0001). There was no correlation between the antibody titers (LA, IgG aCL, IgM aCL) and clinical manifestations. The patients received anticoagulant treatment and antiaggregant drugs to prevent recurrence of symptoms. Clinical manifestations in Israeli patients did not differ from those in non-Israeli patients.

Conclusions: Venous or arterial thrombosis and obstetric complications are the most frequent clinical findings in APS. There was no different in clinical manifestations between primary and secondary syndrome. The findings of autoimmune hemolytic anemia and ANA were more frequent in patients with secondary APS. There was no correlation between antiphospholipid antibody titers and manifestations of disease. Overall, the patients require therapy with anticoagulant treatment and antiaggregant drugs. The clinical manifestations were similar in Israeli and non-Israeli patients.

The Lack of Awareness of the Israeli Population Regarding Gastrointestinal Complications from Non-Steroidal Anti-Inflammatory Drugs

Gisels Zandman-Goddard, Pnina Langevitz

Medicine Dept. B and F. The SlE Clinic and The Rheumatology Unit, Sheba Medical Center, Tel Hashomer, Israel

Non-steroidal anti-inflammatory drugs (NSAID) are potent analgesic agents. They are indicated for rheumatoid arthritis, osteoarthritis, severe acute and prolonged chronic pain. A wide range of analgesic agents are available. The objective of this study was to assess the patient's knowledge of his illness, his knowledge familiarity with NSAID medications and their side effects and thereupon, to evaluate the awareness, utilization, satisfaction and expectations associated with current available treatment.

During the year 2000, a randomized telephone screening questionnaire, was completed over a 2 month period for a sample group of the general Israeli population over 50 years of age.

Of the 3179 persons contacted, 2028 responded and 292 persons were treated with NSAIDs and further investigated. Fifty percent suffered from chronic musculoskeletal pain, 22% had osteoarthritis, 10% had rheumatoid arthritis, and 18% had undefined chronic pain. The average age of the respondent was 65 years old. The average duration of treatment was 11 years. The most common drugs used by the 292 respondents that were taking NSAIDs were diclofenac (Voltaren) - 51% and naproxen (Naxyn) - 21%. Only 4% were treated with COX-2 specific inhibitors. Twenty percent of the respondents utilized more than one NSAID simultaneously. Forty seven percent of the patients had peptic ulcer disease but only 39% of them were simultaneously treated with an NSAID and a gastroprotective agent. Sixty eight percent of patients expected amelioration of symptoms while taking NSAIDs. Seventy seven percent of respondents were dissatisfied with treatment. The patients expressed that they did not have a reliable easily accessible source of information on their disorder or on available treatment options.

Many respondents were not aware of their medical diagnosis. In general, patients were not aware of all the available NSAIDs or the side effects of gastrointestinal complications. Enhancement of information available to the patient is warranted to improve the provision of efficient therapy, reduce side effects and increase patient satisfaction from therapy.

Traumatic Brain Injury: The National Trauma Registry*

Einat Peles, Vita Barell, Valentina Boyko, Arnona Ziv, Giora Kaplan

Health Services Research Unit, Ministry of Health, Sheba Medical Center Tel-Hashomer

Background: Traumatic Brain Injury (TBI) has been established as a category in reporting systems. Uniform data systems case definition has been suggested for hospital discharge data surveillance systems cases based on ICD-9-CM diagnostic codes. These include fractures and specific mention of intracranial injuries such as contusion, laceration, hemorrhage, and concussion. Inspection of data from the Israel National Trauma Registry suggested that two diagnostic groups of very different severity and outcome were being unjustifiably combined.

Aim: To evaluate the validity of categorizing TBI into two discrete groups, using the presence of specific mention of intracranial injury and/or loss of consciousness for more than one hour as the definition of definite TBI. Possible TBI includes skull fractures with no mention of intracranial injury and/or concussion with no loss of consciousness.

Methods: The study population includes all traumatic injuries admitted to hospital, dying in the ER or transferred to other hospitals and recorded in the 1998 Trauma Registry in all 6 level I trauma centers in Israel and two level II centers.

Results: The significant difference in severity between groups supports the validity of sub-dividing the TBI classification into definite and possible subcategories. As a result, we obtain two different severity groups without measuring specific severity scores which are limited in the reporting system.

Conclusion: The groups were significantly different in severity, hospital resource use, immediate outcome, demographic and injury circumstances.

*           Level I: Rambam, Beilinson-Schneider, Sheba, Ichilov (Tel Aviv Sourasky Medical Center), Hadassah Ein Karem and Soroka.

            Level II: Hillel Yaffe and Kaplan

Primary Gastrointestinal Stromal Tumors

Y. Wiener¹, R. Gold¹, S. Zehavy², J. Sandbank², A. Halevy¹

¹Dept. of General Surgery and Dept. of Pathology, ²Assaf Harofeh Medical Center, Israel

Stromal tumors of the GI tract are rare. In the retrospective and prospective study we investigated the relationship between tumor symptomatology, tumor grade and prognostic factors. During the period May 1993 - September 1999, 11 female and 13 male patients with a mean age of 62 (range-29-81) years were operated for primary gastrointestinal stomal tumors (GIST) in our department. Observed signs and symptoms were: GI bleeding (65%), abdominal pain (45%), abdominal mass (15%) and weakness (5%). In 4 patients tumor was an incidental finding during investigation or operation for another tumor. Tumor location (in decreasing order) was: stomach (15), small bowel (SB, 6), esophagus (1), duodenum (1) and colon (1). Preoperative biopsy or FNA were diagnostic in less than 50% of the cases. Operative procedures included wedge resection (8 patients), resection of segment of bowel (10) and extended resection (6), of diaphragm, SB, colon, bladder, kidney and liver. The mean tumor size was 7.8 (range-0.9-22) cm. Four tumors were graded as benign, 8 of indeterminate malignant potential and 12 malignant.

Conclusion: The main presentation of GIST is acute GI bleeding. Endoscopy is most effective for studying proximal tumors, and CT should be used to identify distal GI tract tumors. Tumor size or malignancy were not necessarily predictive of GI bleeding. When invasive to adjacent organs is present, wide excision should be contemplated as long-term survival can be achieved.

יעקב ברקון ומאיר שליט

היח' לאלרגיה ואימונולוגיה קלינית, האגף לרפואה פנימית, ביה"ח הדסה, ירושלים

בשנים האחרונות, הצטבר מידע רב על מעורבות ליקוטריאנים בגנחת הסימפונות ובמחלות דלקתיות למיניהן. במטרה למנוע את פעולתם בתהליך האלרגי-דלקתי, פותחו תרופות נוגדות ליקוטריאנים (נלק"ט), ולאחר שהוכחה יעילותן, הן הוכנסו לשימוש נרחב בטיפול בחולי גנחת. לאחרונה התברר, שתרופות אלו פעילות גם בנזלת אלרגית וכעת נערכים מחקרים רב-מרכזיים במטרה לבדוק את יעילותן כנגד מחלה זו. כן דווח בשנתיים האחרונות על הצלחות טיפוליות של נלק"ט בחולים הלוקים בחרלת כרונית (ח"כ). המטרה בסקירה זו היא לעמוד על תפקיד הליקוטריאנים בחרלת כרונית ולסכם את הידוע לגבי יעילות תרופות נלק"ט בטיפול בלוקים במחלה זו.

Characteristics of Nasopharyngeal Carriage of Streptococcus Pneumoniae in Children During Acute Respiratory Disease

A. Aran¹, D. Fraser², R. Dagan¹

Pediatric Infectious Disease Unit¹, Epidemiology Department², Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva

Streptococcus pneumoniae is an important cause of pediatric morbidity and its main reservoir is the nasopharynx, from which it can disseminate and cause invasive disease. From November 1997 through March 1998, nasopharyngeal carriage of S. pneumoniae was evaluated in 250 children under the age of 36 months: 123 Jews and 127 Bedouins with acute respiratory disease and in 980 healthy control children (852 Jews and 128 Bedouins).

Carriage rate was higher among sick children. Among Jewish children it was 57% and 35% of sick and healthy children respectively (p<0.01), and among Bedouin children it figured as 80% and 67% respectively (p=0.01). The difference in carriage rate was most prominent in infants under the age of 5 months: among Jewish children it was 60% and 27% of sick and healthy children respectively (p<0.001) and among Bedouins it was 82% and 65% respectively (p=0.05).

Higher carriage rate of penicillin resistant pneumococci (PRP) was also detected in sick children, with no relation to antibiotic treatment in the month prior to sampling. In Jewish children PRP was detected in 12%, 28% (p<0.001) and 36% (p<0.001) of healthy children, sick children with previous antibiotic treatment and sick children with no treatment, respectively.

The seroypes included in the newly developed 7-valent conjugate vaccine: 4, 6B, 9V, 14, 18C, 19F, 23F, that are highly pathogenic and often antibiotic resistant contributed 74% of isolates in sick Jewish children who had previous antibiotic treatment and 39% of isolates in healthy children (p<0.001). In Bedouin children vaccine types carriers rate among the sick children was not higher than in healthy children.

Acute respiratory disease increases the risk of pneumococcal carriage in general and carriage of resistant pneumococci in particular. Previous antibiotic treatment increases the risk of carring one of the pathogenic serotypes included in the 7-valent vaccine. The impact of disease is most prominent in infants under 5 months, since they are usually less exposed to S. pneumoniae carriers than older children.

Since the increase in carriage rate during illness is mostly due to the serotypes included in the newly developed conjugate vaccine, future immunization programme may decrease not only morbidity rate but also nasopharyngeal carriage rate of pneumococci in general and of antibiotic-resistant pneumococci in particular.

Laparoscopic Approach in Treating Hepatic Cysts 

P. Schachter, V. Sorin, M. Shimonov, A. Rosen, A. Czerniak

Dept. of Surgery A, Wolfson Medical Center, Holon

Solitary and multiple hepatic cysts are now more commonly found because of advances in imaging techniques. Most hepatic cysts are asymptomatic, but when they do cause symptoms they require surgical intervention. The advent of laparoscopy and of laparoscopic ultrasonography allow comprehensive evaluation and treatment of the cysts.

12 patients with hepatic cysts were treated laparoscopically. 8 with single cysts underwent successful subtotal cyst resection without signs of recurrence (up to 20 years of follow-up). 4 with polycystic liver disease underwent sub-total resection of superficial cysts. Deep cysts were unroofed and drained under laparoscopic ultrasound guidance. In this group, 1 experienced recurrence of symptoms and required partial hepatectomy of the involved segment. In another, a connection between a deep cyst and bile ducts was demonstrated and cystojejunostomy was performed.

The laparoscopic approach in the management of patients with liver cysts is effective and safe, and we recommend it as the procedure of choice for single hepatic cysts. In polycystic liver disease the procedure is much less successful.

Cortical Blindness Following Coronary Angiography 

Addie Ron, Simcha Meisel, Myra Shapiro-Feinberg,Herman O. Klein

Depts. of Medicine, Cardiology and Diagnostic Imaging,Meir Medical Center, Kfar Saba

Cortical blindness has been occasionally reported as a complication after cerebral angiography, but is rare after coronary angiography. The contrast agent is believed to be responsible for the sudden development of blindness. Although the exact mechanism is unknown, it appears that the contrast agent disrupts the blood brain barrier, mostly in the occipital areas.

We report a 77-year-old man who suddenly developed transient, bilateral cortical blindness 4 hours after coronary angiography. Using contrast enhancement, the CT scan showed typical, symmetrical involvement of both occipital lobes. There were no other neurological deficits. Vision and CT findings returned to normal within 48 hours.

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.

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.