תוצאת חיפוש

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.

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.

Determining Power Factors of Clinical Departments in a Medical Center

Netta Notzer

Medical Education Unit, Sackler Faculty of Medicine, Tel Aviv University

The intradepartmental power factors in a medical center were studied. 3 strategic contingency factors were examined, based on the model of Hickson et al. (1971): centrality, substitutability, and coping-with uncertainty. Only coping-with-uncertainty contributed directly to departmental power, and not the summation of the 3.

Power derives from department resources, connections and influence outside the medical center. Aspects related to in- patient treatment or teaching of residents did not contribute directly to departmental power status. Power is gained in stages: in the first the department contributes to the factor of centrality (mainly patient treatment, teaching and research). In the middle stage, power is gained due to the factor of substitutability- the unique services and research which the department has developed. The third stage contributes directly to power-coping with uncertainty. This implies the ability of a department to solve crucial problems of the medical center. Surprisingly, the clinical field (i.e. surgery) did not contribute significantly to power. The current trend is toward empowering ambulatory units in the medical center.

Plagiocephaly in Children: Etiology, Differential Diagnosis and Helmet Treatment

A. Margulis, V. Hatuel, A. Weinberg, A. Neuman, Z. Israel, M.R. Wexler

Depts. of Plastic Surgery, Occupational Therapy, and Neurosurgery, Hadassah University Hospital, Jerusalem

Plagiocephaly in a head-and-neck irradiated rat model or rhomboid-shaped head, occurs in at least 1 in 300 live births. In most cases such asymmetry is not caused by synostosis of the unilateral coronal or lambdoid sutures, but is rather a deformity produced by intrauterine and/or postnatal deformational forces. Categorization and diagnosis of plagiocephaly as synostotic or deformational is reliably made by physical examination and computerized tomography. Its differential diagnosis is extremely important because prompt surgical correction is usually indicated for the synostotic type. In contrast, infants with deformational frontal or occipital plagiocephaly generally respond to helmet treatment.

10 infants with significant deformational plagiocephaly were treated with individual plastic helmets during the past 2 years and 4 other infants with plagiocephaly are currently being treated. In each instance, cranial asymmetry dramatically improved as the brain grew and the head filled out the helmet. There were no significant complications. Awareness of deformational plagiocephaly allows more accurate diagnosis and appropriate treatment, avoiding unnecessary surgical intervention in patients with positional molding.

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.

Malignant Lymphoma of the Bladder

Y. Mor, Z. Dotan, J.H. Pinthus, I.S. Engelberg, J. Golomb, J. Ramon

Depts. of Urology and Pathology, Chaim Sheba Medical Center, Tel Hashomer

Urinary tract lymphoma is usually reported when the secondarily stem is affected by widespread non-Hodgkin lymphoma. We describe an 83-year-old woman who presented with secondary lymphoma of the bladder 3 years after diagnosis when it initially infiltrated her breast. Treatment included local transurethral excision followed by chemotherapy, during which she died of disseminated disease.

Acute Malaria in an Israeli Tourist to Kenya

Doron Zamir, Chen Zamir, Shimon Storch, Moni Litmanovich, Paltiel Weiner

Dept. of Internal Medicine A, Hadera Sub-District Health Office and Nephrology Dept. and Intensive Care and Infectious Disease Units, Hillel Yaffe Medical Center, Hadera

Malaria is 1 of the main causes of death in third world countries. It has become extinct in Israel and imported cases are rare, since most visitors to endemic countries take anti-malarial prophylaxis. We report an Israeli tourist to Kenya infected with falciparum malaria complicated by severe metabolic acidosis, renal failure and adult respiratory distress syndrome. After intensive care treatment this preventable condition improved.

Treatment of Retroperitoneal Sarcoma

Dina Lev-Chelouche, Subhi Abu-Abeid, Mordechai Gutman, Yoram Kluger, Moshe Michovitch, Isaac Meller, Moshe Inbar, Joseph M. Klausner

Depts. of Surgery B, Orthopedic Oncology and Oncology, Tel Aviv - Sourasky Medical Center (Affiliated with Sackler Faculty of Medicine, Tel Aviv University)

Soft tissue sarcomas are exceedingly rare, making up less than 1% of all solid malignancies. In the retroperitoneum, they tend to be large when diagnosed and are a therapeutic challenge to the surgical oncologist. Our experience with 51 patients with retroperitoneal sarcomas operated on during the past 4 years is presented. 37 were primary and 26 presented as recurrent tumors. The group included many different histological sub-types, the majority being high grade tumors.

Complete resection was achieved in 84%, necessitating extensive surgery, but was not possible in 8 patients (16%) who underwent partial resection or biopsy only. There was 1 perioperative fatality (2%). 18 (35%) suffered complications, all of which were reversible. The estimated 5-year survival in the complete resection group is 40%, while none of those who underwent partial resection survived more than 2 years. There was significantly better survival in patients with primary, low grade sarcomas which were smaller than 8 cm, compared to those with high-grade, recurrent sarcomas larger than 8 cm. Local recurrence developed in 8 patients of the complete resection group (18%), 2 months to 3 years after surgery.

These data show that despite the concept of retroperitoneal sarcomas as being aggressive, invasive tumors with a poor prognosis, the prognosis is not unusually bad. With proper surgical technique, resectability may be high, with improved overall survival.

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.

Preliminary Report of Experience with Laparoscopic Splenectomy

Joseph Kuriansky, Ron Bilik, Moshe Shabtai, Itamar Avigad, Amram Ayalon

Depts. of General Surgery and Transplantation and Pediatric Surgery, Sheba Medical Center, Tel Hashomer; and Sackler School of Medicine, Tel Aviv University

Laparoscopic splenectomy is effective and technically feasible for treating various hematological diseases such as idiopathic thrombocytopenic purpura (ITP), congenital sphero„cytosis, hemolytic anemia, and Hodgkin's lymphoma. An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is frequently difficult. The laparoscopic posterolateral approach involves dissection of the posterolateral attachments to the diaphragm, followed by the disection and ligation of all splenic branches near the splenic parenchyma. We used it in 9 adults and 4 children: 11 patients had ITP, 1 spherocytosis and 1 Hodgkin's lymphoma.

This procedure was completed in 13 patients, but in 2 it had to be converted to open surgery. Mean operating time was 3 hours and mean postoperative stay 3 days. Blood transfusion was not required and there were no postoperative complications.

Laparoscopic splenectomy is safe in both adults and children, and the posterolateral approach provides excellent visualization and allows control of the branches of the splenic vein and artery in the splenic hilum.

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.

Is Official Data on Reported Morbidity Valid? Hepatitis A in Israel as an Example

Yehuda Lerman, Gabriel Chodik, Hava Aloni, Shai Ashkenazi

Occupational Health and Rehabilitation Institute, Ra'anana, Schneider Children's Hospital, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University

Hepatitis A is one of the most frequently reported notifiable infectious diseases in Israel. The annual incidence as reported is around 70/100,000. The physician or the diagnostic laboratory notifies the district health office of the Ministry of Health.

The purpose of this research was to evaluate the sensitivity of passive surveillance of hepatitis A morbidity among adults, 18 years and over. Methods included study of notifications to the Ministry of Health or hospitalizations of cases of hepatitis A and of positive laboratory tests results (IgM) for hepatitis A. We estimated the extent of under-reporting by 2 different methods of extrapolation.

Data based on passive surveillance among the adult population, between 1.1.1993-31.12.1994, comprised less than 1/5 of the actual number of cases. Physicians notified about 6.2% of their hepatitis A patients. 5.1% of the notifications to the district health office were sent twice or more, usually both by the physicians and labs.

The official data on hepatitis A morbidity, based on passive surveillance, are considerably underestimated. Physicians and public health officials should be aware that such data may not accurately reflect the magnitude of the risk or the amount of disease that can be prevented. Efforts should be made to improve this situation.

Multisystem Disease Caused by BCG Imitating Miliary Tuberculosis

I. Tsikonov, D. Yeshurun, J.E. Naschitz

Dept. of Medicine A, Bnai Zion Medical Center and B. Rappaport Faculty of Medicine, The Technion, Haifa

As the prevalence of tuberculosis is on the rise in western countries, we present a 79-year-old man who developed a pulmonary tuberculosis-like syndrome following immunotherapy with BCG for carcinoma of the urinary bladder. The symptoms subsided following 3-drug antitubercular treatment, and the addition of steroids following negative cultures for Mycobacterium tuberculosis. The course of this disease, named BCG-osis, is much more favorable than miliary tuberculosis, even with milder treatment. It is important to keep in mind this phenomenon now that there is increasing treatment of cancers with BCG.

Ramsay Hunt Syndrome

Doron Aframian, R. Ben-Oliel, Yair Sharav

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

Ramsay Hunt syndrome is caused by infection of the geniculate ganglion of the seventh cranial nerve by varicella- zoster virus. A case in an 82-year-old woman is described. She presented with oral lesions, right facial palsy and an eruption and pain in her right ear. Oral examination revealed small circumscribed erosions on the right anterior two-thirds of the tongue, with loss of taste. There were also lesions on her right palate. Early diagnosis and treatment are important as immediate treatment is more likely to prevent irreversible complications affecting the facial and other cranial nerves involved.

The Current Compulsory Hospitalization Order and Patients' Rights

Y. Bar-el, R. Durst, J Mazar, J. Rabinowitz, Y. Lerner, H.Y. Knobler

Office of Jerusalem District Psychiatrist; Jerusalem Mental Health Center, Kfar Shaul Hospital; Mental Health Services, Israel Ministry of Health; School of Social Work, Bar-Ilan University; and Falk Institute for Mental Health and Behavioral Sciences, Kfar Shaul (Affiliated with the Hebrew University - Hadassah Medical School)

Israel's "Treatment of Mentally Sick Persons Law" of 1955 was repealed and replaced by the "Treatment of Mental Patients Law" of 1991. Under the latter, the "Compulsory Hospitalization Order" (CHO) defines the new order based on accumulated experience with the old legislation, and on the philosophy that considers the CHO one of the most severely oppressive forms of deprivation of human liberty and rights. The new order sets limits and boundaries for CHO, guarding the rights of those unavoidably committed by force. According to the new law, the district psychiatrist decides upon and issues the order, while the tribunal (District Psychiatric Committee) considers appeals. The order is limited to 1 week, with an option for the district psychiatrist to prolong it on written request for up to 14 days. The tribunal can later prolong the order further.

The objective of this study was to review changes that have occurred following enforcement of the new law in the Jerusalem district. A comparison was made between CHO's issued the year before the new legislation took effect and the year after. The comparison included review of all CHO's and medical files of all patients hospitalized by coercion during 1990 and 1992. It was assumed that there would be a decline in rate and length of hospitalization of patients forced to be committed by the new law.

The main findings refuted this hypothesis. In 1992 there was an increase of 38% in the number of compulsory hospitalizations. This increase derived mainly from increased demands for CHO's from psychiatric emergency rooms. There was also an increase in patients hospitalized by order of the District Psychiatric Committee using its authority under section 10(C) of the law.

Conversely, length of compulsory hospitalization was shorter under the new law.

In light of these findings, it would seem that the new law has only partially fulfilled expectations of reform in individual rights. There is need for further evaluation and follow-up of the CHO in order to determine whether the "Treatment of Mental Patients Law" of 1991 has in fact fulfilled its objectives. Furthermore, it is necessary to determine means, medical or legal, that may possibly advance further the prospective of human rights while maintaining a suitable balance between civil liberties and clinical needs, of over-confinement versus under-treatment, which may lead to neglect or danger.