תוצאת חיפוש

Laser Treatment of Airway Obstruction in Infants and Children

Y. Efrati, S.M. Sarfaty, S. Kromholz, G. Eshel, M. Weinberg, I. Vinograd

Depts. of Pediatric Surgery, Otolaryngology, Anesthesia and Pediatric Intensive Care, Assaf Harofeh Medical Center, Zerifin (Affiliated with Sackler Faculty of Medicine, Tel Aviv University)

Airway obstruction during infancy and childhood requiring surgical ablation is rare, and surgical intervention poses a significant challenge. During recent decades, appropriate endoscopic instrumentation, together with advanced laser beam technology have provided new operative modalities for such patients.

From 1993 to 1995 we treated 40 infants and children, 26 males and 14 females, 13 days to 11 years old (mean 3.3 years) with Nd-YAG or CO² laser. Obstructing lesions included granulation tissue or polyps (16 cases), septa or webs (27), or benign tumors (4). 7 had more than a single lesion.

All were treated endoscopically under general anesthesia without any operative or postoperative deaths. Surgical intervention removed the obstruction and related symptoms in 34. In 6, laser treatment failed, necessitating additional surgical procedures. 3 had circumferential subglottic web. Operative complications included bleeding during removal of a hemangioma in 1 and recrudescence in another. Postoperative complications were transient respiratory failure and pneumonia in 6, all of which resolved with appropriate treatment.

This series proves that laser technology is feasible in the treatment of airway obstruction during infancy and childhood, and is safe and effective.

Congenital Syphilis: Need for Adequate Antenatal Care

Mark Friedberg

Pediatrics B Dept., Soroka Medical Center, Beer Sheba

Congenital syphilis is well-known and treatable with penicillin. Diagnosis in the neonate and young child may be difficult and consequently morbidity and mortality can be high. Prevention in children is of utmost importance and can be achieved by proper antenatal care and adequate follow-up of pregnant women. This includes identification of pregnant women at risk for contracting syphilis. The case presented demonstrates this need.

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.

One-Stage Surgery for Hirschsprung's Disease in Children

Mark Weinberg, Baruch Klin, Itzhak Vinograd

Dept. of Pediatric Surgery, Assaf Harofeh Medical Center, Zerifin, and Sackler School of Medicine, Tel Aviv University

Traditionally Hirschsprung's disease has been treated by 2-or 3-stage procedures. During the past 6 years a 1-stage Duhamel procedure without stoma has become our treatment of choice for Hirschsprung's disease in neonates and young infants. Over a 6-year period, 15 infants and children with colonic Hirschsprung's disease were treated with the 1-stage Duhamel retro-rectal pull-through procedure without a stoma, with the Lester-Martin modification. All patients had the usual short segment aganglionosis, but 1 had a long segment which included the splenic flexure.

Early complications included wound infection in 1 and minor rectal bleeding in 3. Late complications included constipation in 1 and enterocolitis in 4. Long-term functional results were very good in all those operated except for 1 with rectal achalasia.

We conclude that Hirschsprung's disease can be successfully treated with a 1-stage pull-through operation, the child usually benefitting from the shorter hospital stay and the avoidance of a colostomy.

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.

Polyneuropathy in Critical Illness

M. Mouallem, A. Adunsky, H. Semo, M. Dolgopiat

Depts. of Medicine E, Geriatrics, and Neurological Rehabilitation, Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University

Critical illness polyneuropathy developed in 8 patients aged 22-84 years in our intensive care units. This acute polyneuropathy, predominantly axonal and motor, develops in the setting of the systemic inflammatory response syndrome and multi-organ failure. It is found in about 50% of patients treated in intensive care units for more than 2 weeks. In those who survive, neurological and functional recovery is the rule.

Oral Manifestations of Bulimia Nervosa

Doron Aframian, Alice Markitziu

Dept. of Oral Diagnosis, Medicine and Radiology, Hebrew University- Hadassah School of Dental Medicine, Jerusalem

Bulimia nervosa (BN) is an eating disorder frquently accompanied by changes of the hard and soft tissues of the oral cavity and of the salivary glands. Routine dental examination in a 25-year-old woman disclosed oral signs and symptoms characteristic of BN and she was referred for psychiatric evaluation. Oral evaluation of patients suspected of BN is recommended to prevent irreversible damage to the oral and perioral structures.

Quality Assurance in the Mental Health Department of the Israel Defense Forces

Mordechai Mark, Moshe Z. Abramowitz, Orna Intrator, Ehud Bodner, Rami Shklar, Haim Y. Knobler

Mental Health Department, Medical Corps, Israel Defence Forces

A review of quality assurance in the mental health department of the Israel Defence Forces allowed the examination of certain unique elements of quality control which pertain to the military. These include the psychiatric medical board, the computerized documentation of appointments and sessions with soldiers, the psychiatric hospitalization database, control systems implemented in the draft boards, peer-review boards and supervision, and a special officer in charge of handling outside consultations and queries. There were other components of quality assurance and control as well. These instruments are vital in a dynamic system constantly striving to improve clinical performance.

Future plans include the continued use and expansion of quality control boards, the inclusion of quality assurance in the curriculum of mental health officers, and the use of clinical guidelines in working with soldiers. All of this is in keeping with the principle of continuous quality improvement, with the aim of viewing the soldier in need of help as a client.

The Electroencephalogram in Psychiatric Patients

Mark Weiser, Raya Lapidus, Yehuda Abramowitch, Michael Davidson

Psychiatric Division, Sheba Medical Center and Beer Yaakov Mental Health Center

270 consecutive electroencephalograms (EEGs) performed in a psychiatric hospital were reviewed. 194 (75%) were within normal limits but 66 (25%) showed diffuse generalized slowing. The contribution of the abnormal EEGs to diagnosis and treatment was evaluated by retrospective file review. In none of the cases with abnormal EEGs was there a relationship to diagnosis or treatment.

Geriatric Rehabilitation in Israel: Assessment of Needs and In-Patient Services

J. Gindin, M.A. Clarfield, Z. Haklai, P. Zedaka, J. Brodesky, M. Davis

Geriatric Division, Kaplan-Hartzfeld Hospitals, Rehovot; Geriatric Wing, and Health Information and Computer Service, Israel Ministry of Health; Central Bureau of Statistics, Prime Minister's Office; Brookdale Institute, Jerusalem; and Health of the Elderly, Israel Center for Disease Control

Geriatric rehabilitation (GR) in Israel, which has not been thoroughly investigated, was examined by a subcommittee of the Committee on Health of the Elderly, in the Israel Center for Disease Control.

The needs of the elderly population for rehabilitational services were assessed and the existing services reviewed. A survey of GR beds, their geographic distribution, and the number of patients over 65 after CVA and hip fracture (the 2 main causes for GR need) was carried out. Data were gathered from records of the Ministry of Health and the Central Bureau of Statistics.

In 1994 there were 1,503 beds for active, long-term geriatric care in general and geriatric hospitals: 751 beds were assigned to rehabilitative geriatrics, and the rest to skilled-nursing geriatrics. A high concentration of beds was found in the geographical center of the country, in contrast to a small number in the periphery. Approximately 10,100 patients were hospitalized that year in rehabilitative geriatric and skilled-nursing wards.

There was considerable variation between services, as expressed in the wide range in average duration of hospitalization (from 12-269 days). Most of the beds for GR and skilled-nursing care beds were mixed in the geriatric wards together in the wards.

Limited services and public needs have led to the development of services outside the licensed and regulated settings, a process which has not yet been investigated. About 6,700 older patients were hospitalized during 1994 with a primary diagnosis of CVA. It has been estimated that 4,000 of them needed GR. 2,624 older patients died that year of CVA.

The increase in CVA prevalence between 1987 and 1994 was far greater than the increase in morbidity, in both the general and older populations. Nearly 4,000 elderly patients with a primary diagnosis of hip fracture, most of whom needed rehabilitation, were hospitalized in 1994. The total number of older patients who needed GR following CVA or hip fracture that year was set at 8,000. However, this figure is up to 30% lower than the actual rates, since the those 2 diagnoses include only 70% of total GR needs.

It is impossible to obtain a comprehensive picture of GR in Israel based only on currently available data. The subcommittee outlined areas to be thoroughly examined in-depth, including services and needs, as well as GR tools and processes and how to maintain the achievements of rehabilitation after discharge.

Massive Pulmonary Embolism

Ron Ben Abraham, Eran Segal, Dov Freimark, Elinor Goshen, Hanoch Hod, Jacob Lavee, Zvi Ziskind, Azriel Perel

Depts. of Anesthesiology and Intensive Care, Cardiology, Nuclear Medicine and Cardiac Surgery, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Pulmonary embolism is a common event in hospitalized patients. In some cases it presents with hemodynamic collapse, indicating massive obliteration of the pulmonary vasculature and has a very grim prognosis; 2/3 of such patients die within 2 hours of onset of symptoms. We describe our experience in 13 patients with massive pulmonary embolism. An aggressive diagnostic and therapeutic approach, utilizing sophisticated imaging techniques, thrombolytic therapy and surgery, led to the survival of 8 of the patients. Our experience supports an aggressive approach in these seriously ill patients.

Chemical Synovectomy in Arthritis by Intra-Articular Injection of Osmic Acid

D. Markovits, M. Rozenbaum, I. Rosner, E. Rottenstriech

Dept. of Medicine A, Carmel Hospital; Rheumatology Unit, Bnai Zion Hospital; and Zevulun Medical Clinic, Haifa

18 patients suffering from persistent synovitis despite medical therapy were treated with an intra-articular injection of osmic acid. After 1 year of follow-up, 68% had good results and there were no complications nor detectable radiographic evidence of disease progression. Because osmic acid is almost as effective as surgical synovectomy and is cheap and easy to administer, it can be recommended as the first choice for treatment of corticosteroid-resistant arthritis in the early stages of the disease.