תוצאת חיפוש

Compulsory, Ambulatory Psychiatric Treatment

R. Durst, A. Teitelbaum, Y. Bar-El, M. Shlafman, Y. Ginath

Arie Jaros Jerusalem Mental Health Center and Talbieh Mental Health Center (Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem) and Israel Ministry of Health, Jerusalem District

The Treatment of Mentally Sick Persons Law of 1955, was repealed and replaced by the Law of 1991. Under the latter, the Order for Compulsory Ambulatory Treatment (OCAT) was addressed for the first time (Section 11, a-d). According to this law, the district psychiatrist instead of issuing a hospitalization order, may issue an OCAT, under which the required treatment is given within the scope of a clinic which he designates, for up to 6 months and under conditions which he specifies. This is done on the basis of psychiatric examination, or an application in writing from the director of a hospital or clinic, when continued ambulatory treatment is needed after discharge from hospital or instead of compulsory hospitalization. The district psychiatrist may extend the period of treatment for further periods, none of which is to exceed 6 months. Compulsory ambulatory treatment is to enable patients to benefit from the positive aspects of living freely in the community, while receiving prompt treatment under compulsory conditions. The concept offers a partial solution, achieving a balance between civil liberties and clinical needs, between over-confinement and under-treatment which might be dangerous or neglectful. The clinical impression has been that the OCAT has not fulfilled expectations. The purpose of this study was to examine the topic in a systematic way in Jerusalem and the soutern districts for the 4 years since inception of the law. In 44.4% of cases OCAT was proven to be effective, while in 33.1% it was found to be ineffective and did not prevent compulsory hospitalization, one of its main goals. It was partially effective in the rest of the cases. It is recommended that suitable means for the enforcement of the law be allocated and that the subject of forceful hospitalization and OCAT be made a mandatory subject in the residency program of psychiatrists.

Traumatic Hyphema*

Tamar Talmon, Itzchak Beiran, Benjamin Miller

Dept. of Ophthalmology, Rambam Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Traumatic hyphema usually occurs in young men at the rate of 17-20/1000,000. Major complications include secondary hemorrhage, glaucoma, corneal staining and disturbances in visual acuity. Final visual acuity is predominantly the outcome of all the ocular injuries occurring during the trauma, mainly to the posterior segment of the eye. We describe all cases of traumatic hyphema treated in our department over a period of 3.5 years. Antifibrinolytic treatment is recommended in the literature in traumatic hyphema to prevent secondary hemorrhage. Our findings differ from those in the literature in that they show a lower prevalence of more severe hemorrhages and of secondary hemorrhage. In light of these differences, and with regard to possible side effects of such treatment, we suggest that antifibrinolytic treatment not be used in our population. We recommend that treatment for traumatic hyphema should include restricted activity, local corticosteroidal preparations, frequent follow-up visits and vigorous diagnostic work-up in order to find any additional eye damage. We strongly recommend the use of preventive measures (eye-shields) in high risk activities such as sports, house-hold work and military training.

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* Based on work submitted to the Faculty of Medicine, Technion-Israel Institute of Technology, by Tamar Talmon in partial fulfillment of the requirements for the MD degree.

Penetrating Ocular Injuries: a Retrospective Study

M. Schneck, S. Weitzman, T. Lifshitz, B. Biedner

Dept. of Ophthalmology, and Epidemiology and Health Services Evaluation Unit, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Penetrating injuries of the eye are an important cause of unilateral visual loss. We studied a series of 82 cases of penetrating injuries treated here from 1987 through 1993. The injuries were caused by sharp objects in 66% and blunt trauma in 6%. The prognosis after a penetrating injury is greatly influenced by the nature of the injury and the extent of the initial drainage. Among factors associated with an unfavorable visual outcome were diminished preoperative visual acuity and scleral wounds with dense vitreous hemorrhage.

Epidemiological Characteristics of Outbreaks of Diarrhea and Food Poisoning in the Israel Defense Forces

I. Grotto, Y. Mandel, I. Ashkenazi, J. Shemer

Army Health Branch, IDF Medical Corps and Sackler Faculty of Medicine, Tel Aviv University

Acute infectious diseases of the gastrointestinal tract and food poisoning are problems of great importance in the Israel Defense Force (IDF). They involve individual and epidemic morbidity, with impairment of health of individual soldiers and in the activities of units. Outbreaks of gastrointestinal infectious diseases must be reported to the IDF army health branch, which conducts epidemiological investigation. This study is based on data from yearly epidemiological reports for 1978-1989, and from a computerized database for the years 1990-1995. The incidence of outbreaks is characterized by an unstable trend, It was highest at the end of the 80's (68.3 per 100,000 soldiers on active duty) and lowest for the last 2 years (1994-1995, 36.3 per 100,000). The incidence of soldiers involved in food-borne outbreaks has been more stable, constantly declining during the course of the years. There was marked seasonality with a peak in the summer months. Sporadic morbidity was constant in 1990-1995, with a yearly attack rate of 60% in soldiers on active duty. Shigella strains were the leading cause of outbreaks until 1993, while in 1994-1995 their proportion decreased, with an increase in the proportion of Salmonella strains. As to Staphylococcus aureus, its role in causing food poisoning has been characterized by marked changes. Shigella sonnei replaced Shigella flexneri as the leading strain. 73.3% of outbreaks were small, with fewer than 40 soldiers involved, while 5.4% of outbreaks affected more than 100 soldiers. Outbreaks in which a bacterial agent was identified or which occurred in new-recruit bases were larger than those in which a bacterial agent was not identified, or which occurred in active field unit bases. In conclusion, the rates of infectious disease of the gastrointestinal tract are still high, although there has been a marked decrease since 1994. The incidence of outbreaks has also decreased, as well as the role of Shigella as a leading causative agent.

Therapeutic and Toxic Theophylline Levels in Asthma Attacks

Aliza Zeidman, Joseph Gardyn, Zinaida Fradin, Gershon Fink, Moshe Mittelman

Dept. of Medicine B, Rabin Medical Center, Golda (Hasharon) Campus and Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva; and Sackler Faculty of Medicine, Tel Aviv University

Although first-line therapy for bronchial asthma has changed over the past decade to anti-inflammatory medication such as inhaled corticosteroids and cromolyn with possible addition of beta-agonists, theophylline is still useful and therefor widely used. However, several studies have raised serious questions regarding its efficacy in acute asthmatic exacerbations. These studies, the narrow therapeutic range of the drug, the frequency of side effects and interactions with common drugs, and individual variation in clearance and metabolism, have prompted its reevaluation in the management of asthma. Therapeutic serum levels of theophylline are between 10 to 20 mcg/ml. Most adults achieve these concentrations with daily slow-release oral theophylline preparations, 200-400 mg (approximately 10 mg/Kg) twice a day. However, when such a patient presents to the emergency room (ER) in an asthmatic attack, immediate intravenous theophylline is often given, regardless of maintenance treatment. Since the rationale for this common therapeutic approach has been challenged, the current study was undertaken. Serum theophylline levels were measured in 23 consecutive asthmatics presenting to the ER in an acute attack. 15 (68%) had therapeutic levels (above 10 mcg/ml) and 2 had toxic levels (above 20 mcg/ml), prior to receiving the standard intravenous theophylline dose given for an attack. These data indicate that most patients with bronchial asthma on oral maintenance theophylline do not require additional intravenous theophylline when in an attack. It probably will not benefit them and may even induce serious theophylline toxicity.

Traumatic Common Carotid-Internal Jugular Fistula: Positive Aspect

R. Avrahami, M. Liverson, M. Haddad, A. Zelikovsky

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

A 42-year-old man presented with a penetrating neck injury from a pellet gun. Physical examination showed an open 1 cm wound on the right side of the neck, hematoma of the right sternocleidomastoid muscle, and carotid artery injury. He was hemodynamically stable and there was no neurological deficit. Arteriogram of the neck disclosed a pseudoaneurysm with an arteriovenous fistula between the common carotid artery and internal jugular vein. At surgery, the tears in the carotid artery and jugular vein were sutured and a vacuum drain was introduced. The postoperative course was uneventful, and the patient was discharged 5 days later. Instead of the expected results of a penetrating carotid artery injury, such as blood loss, airway obstruction or neurological deficit, the arteriovenous fistula caused by the pellet actually saved the patient's life. Blood flow from the artery via the pseudoaneurysm to the jugular vein kept the patient in stable condition.

Hyponatremia due to Prolonged Excessive Ingestion of Water

I. Shavit, J. Diment, S. Ravid, N. Shehadeh

Dept. of Pediatrics A, Rambam Medical Center and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

We report a 1.5-year-old boy admitted for restlessness and constipation. He was found to have hyponatremia caused by voluntary drinking of excessive amounts of water. Although unusual in children, intoxication by oral water is a recognized clinical syndrome in infants, 3-6 months old, fed with dilute formula. Water intoxication in older children is rare. The diagnosis was established by the water deprivation test.

Angioedema Caused by Splenectomy with Malignant Lymphoma Foll-Owed by Multiple Myeloma 7 Years Later

A. Shahar, R. Sharon, M. Lorber, S. Pollack

Institute of Allergy, Clinical Immunology and AIDS and Institute of Hematology, Rambam Medical Center and B. Rappaport Technion- Faculty of Medicine, Haifa

Acquired C1-inhibitor (C1-INH) deficiency has been reported in patients with immunoglobulin abnormalities and lymphoproliferative disorders, and angioedema has appeared simultaneously with the lymphoproliferative disease. We present a 50-year-old woman with acquired C1-INH deficiency and angioedema which preceded by 7 years the diagnosis of malignant mantle cell lymphoma. During the interval she was treated with Danazole and there were no attacks of angioedema. When routine follow-up bone marrow aspiration revealed infiltration of nonspecified lymphoma cells, exploratory laparotomy and splenectomy were performed. A month later Danazol was stopped, C1-INH levels returned to normal and there were no attacks of angioedema. Mantle cell lymphoma consisting of lymphocytes with cytoplasmic IgM-lambda was diagnosed in the excised spleen but chemotherapy was not initiated. 6 months later, a second lymphoproliferative disorder, multiple myeloma IgA kappa, was diagnosed.

Red Cell Na+/H+ Exchange and Role of Protein Kinase C in its Stimu-Lation in Diabetes Mellitus, Essential Hypertension and Nephropathy

Wladimir Koren, Robert Koldanov, Edna Peleg, Eva Izsak, Meir Berezin, Talma Rosenthal

Dept. of Medicine C, Hypertension Unit and Endocrinology Institute, Chaim Sheba Medical Center, Tel Hashomer

Na+/H+ exchange (NHE) was measured as maximal initial velocity of pH-dependent H+ efflux from red cells into an alkaline medium containing Na+ in patients with insulin-dependent or noninsulin-dependent diabetes, with and without hypertension and in normoglycemic, essential hypertensives and normal controls (50 subjects in each subgroup). Maximal velocities of NHE were found in microalbuminuric patients in all subgroups, and NHE correlated with the rate of microalbuminuria (r=0.61, p=0.02). Daily insulin requirements were greater in those with elevated NHE (84±8 vs 42±4 U/day). There was no correlation between NHE and levels of plasma glucose, HbA1 and plasma aldosterone and lipid profile and PRA. NHE was correlated with plasma prolactin (r=0.51, p=0.02) and PTH r=0.24, p=0.05). In uremic patients, NHE was inversively correlated with creatinine clearance (r=-0.48, p=0.03). Since calphostin C, a selective inhibitor of protein kinase C, lowered increased NHE in vitro, the protein kinase C-dependent pathway of the exchanger regulation was concluded to be responsible for NHE activation in diabetes mellitus and essential hypertension.

Epidemiologic Characteristics of Pediatric Emergency Room Referral and Hospitalization for Diarrhea in the Negev

Moni Benifla, Drora Fraser, Zvi Weizman, Amalia Levy, Ron Dagan

Dept. of Epidemiology and Health Services Evaluation and S. Daniel International Center for Health and Nutrition, Ben-Gurion University of the Negev, and Pediatric Dept. and Pediatric Infectious Disease Unit, Soroka Medical Center and Ben-Gurion University of the Negev

Diarrheal diseases weigh heavily on the health of children, especially in developing countries, but also impose burdens on health care services worldwide. This study was performed to determine whether patterns of referrals in the Negev to the pediatric emergency room (PER) for diarrhea differ between the Jewish and Bedouin populations of the Negev, and the extent of the burden imposed on the PER and in-hospital services in the Negev. Characteristics of referrals and hospitalizations were examined from March 1994 to February 1995. Of the 27,834 referrals to the PER for children under 16, 2518 (9%) had diarrhea and there were 5,169 hospital admissions, 701 (13.6%). The annual rates of referral were 146 per 10,000 in Jews and 225 in Bedouin, giving an odds ratio (OR) of 1.5 (p<0.001). for Bedouin. The rates of hospitalization were 23 per 10,000 in Jews and 99 in Bedouin (OR 4.4, p<0.001). 1380 (54.8%) of the PER referrals were of infants under a year of age. For hospitalization, the annual rates were 164 per 10,000 in Jews and 756 in Bedouins (OR 4.9, p<0.001). During June to August referrals and hospitalizations for diarrhea were significantly higher, and from December to February significantly lower than during the remaining months. These differences arise from the marked seasonal pattern in the Bedouin population, whereas in the Jewish population there was no seasonal variation. Even in the 90's the burden on health services in the Negev as a result of diarrheal illness is considerable and the Bedouin population still contributes to that burden disproportionately. There is need both to reduce the gap in referrals and hospitalization between the populations, as well as to reduce the rates, using currently available means such as education, while developing new technologies, such as vaccines.

Solid Organ Retransplantation

Yaron Ilan, Dan Admon, Michael Friedlander

Division of Medicine, Dept. of Cardiology and Nephrology Unit, Hadassah Medical Center, Jerusalem

The need for solid organ retransplantation is a major factor in the shortage of available organs. Between 1972 and 1992, 56 out of 309 kidney transplants and 2 out of 20 liver transplants performed in our hospital were retransplantations. The present study evaluates local and world experience with organ retransplantations in terms of the medical and ethical issues.

Ischemic Hepatitis in Congestive Heart Failure after an Episode of Hypotension

Ora Shovman, Jacob George, Yehuda Shoenfeld

Dept. of Medicine B and Autoimmune Disease Clinic Research Unit, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Ischemic hepatitis can occur as an acute episode in advanced congestive heart failure (CHF). The mechanism is massive necrosis of the central lobules resulting from acute hypoxia when low cardiac output further reduces oxygen supply, aggravating underlying congestion due to poor venous outflow. We describe a 70-year-old woman with congestive heart failure for 7 years who was admitted with jaundice, vomiting, abdominal pain and oliguria after an episode of hypotension. The diagnosis of ischemic hepatitis was established by a documented episode of severe hypotension, followed by elevation of serum transaminases, a rise in serum bilirubin and LDH levels, prolonged prothrombin time and acute renal failure. Other causes of acute hepatitis, such as a virus or drugs were excluded, and improved liver and renal function followed hemodynamic stabilization. We conclude that ischemic hepatitis should be considered whenever acute hepatitis follows a recent episode of systemic hypotension, especially in the context of concomitant CHF.

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.

Angioplasty and Stenting of the Carotid Artery

Eli Atar, Alexander Garniek, Issam Rabi, Benymina Morag, Zallman Rubinstein

Dept. of Diagnostic Imaging, Interventional Radiology Unit, and Dept. of Vascular Surgery; Chaim Sheba Medical Center, Tel Hashomer (Affiliated with the Sackler Faculty of Medicine, Tel Aviv University)

Percutaneous endovascular techniques are well established procedures in the management of peripheral vascular disease and visceral arterial stenosis. They are now being adapted for use in the carotid artery as well. 8 patients with 9 extracranial carotid artery stenoses were successfully treated by percutaneous angioplasty, following which in 4 of them 5 stents were inserted. The stenotic lesions were situated in the proximal internal carotid artery and in its bifurcation and also in the common carotid artery. The indications for angioplasty in these patients were the same as for surgery. There were no major complications. 1 patient had transient hemiparesis lasting a few hours, and another had bradycardia following balloon dilatation in the region of the carotid body. Percutaneous endovascular treatment of carotid artery stenosis is becoming a safe, feasible alternative to surgery.

Cutaneous Leishmaniasis: Incidental Outbreak in a New Endemic Area?

A. Biton, S. Namir, B. Mosovich, D. Vardi

Regional Dermatology Clinic, Kupat Holim Klalit, Beer Sheba, and Ben-Gurion University of the Negev

In the autumn of '94 we saw 32 patients with cutaneous leishmaniasis from a newly populated area south of Yerucham. Yerucham had never previously been reported as a focus of leishmaniasis. Ongoing construction in the town and the health hazards that resulted may play a part in this new situation. There are a number of ways of controlling and preventing outbreaks of leishmaniasis. They include elimination of the vector, Phlebotomus and its host, the gerbils as well as their food supply, "maloach" bushes, other health hazards and vaccination of the population. Patients were treated according to the severity of disease. It is still too early to determine whether our efforts to limit the spread of the outbreak have been successful.