תוצאת חיפוש

Left Ventricular Outflow Tract Obstruction without Left Ventric-Ular Hypertrophy Treated with Ace Inhibitors

Jacob Feldman, Irit Laxer, Abraham Yaretzky

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

We describe a very unusual case of sudden, severe worsening of congestive heart failure which was caused by ACE inhibitors. Diagnosis was made by echocardiogram showing a typical picture of dynamic, left ventricular outflow tract obstruction without left ventricular hypertrophy, which disappeared on discontinuing ACE inhibitors. This phenomenon has already been described as a complication of other drugs such as nitrates, commonly used as provocative tests for latent obstructive cardiomyopathy. To our knowledge ACE inhibihave not been described as a causative factor.

Treatment of Velopharyngeal Insufficiency

Abraham Amir, Ram Silfen, Daniel J. Hauben

Dept. of Plastic and Reconstructive Surgery, Rabin Medical Center, Beilinson Campus, Petah Tikvah

Weak and hypernasal speech, along with nasal escape of air, are the main characteristics of velo-pharyngeal incompetence (VPI). We describe 10 years of experience (1989-1998) with surgical treatment of VPI.

51 patients underwent pharyngeal flap elevation. 37 had cleft palate (8 of them submucous), 7 had neuromuscular disorders and another 7 were idiopathic. All underwent evaluation by a speech therapist before and after operation. 25 had further nasal endoscopy and/or videofluroscopy.

There was significant speech improvement in volume and clarity in 35 (73%), mild improvement in 13 (27%) and none in 3. The complication rate was 15% and included sleep apnea, wound infection and dehiscence, stridor and bleeding. Complications were correlated with advanced age.

VPI should be diagnosed as early as possible to achieve good results and to prevent social problems.

Severe Pneumonia Caused by Bordetella Bronchiseptica

Taufik Zuabi, Adir Faivisevitz, Michael L. Alkan

Yoseftal Hospital, Eilat; Soroka Medical Center, Tel Hashomer; and Ben Gurion University Center for Health Sciences, Beer Sheba

Bordetella bronchiseptica rarely causes disease in man, and is an unusual pathogen in animals. It causes a pertussis-like syndrome, but pneumonia and sepsis have been described in the immunocompromised as well as in the immunocompetent. A 53-year-old man with adult-onset diabetes and healed pulmonary tuberculosis presented with lobar pneumonia and rapidly developed septic shock with adult respiratory distress syndrome. He responded well to the combination of piperacillin-tazobactam.

Severe Heat Stroke in an Intensive Care Unit

Amir Halkin, Dina Lev, Oded Szold, Philip Bidermann, Sarah Bulocnic, Pinchas Halpern, Patrick Sorkine

Depts. of Medicine and Surgery, and Intensive Care Unit, Tel Aviv Medical Center

During the August 1998 heat wave in Tel Aviv we admitted many patients for acute heat-related illness; 6 had severe heat stroke and were admitted in critical condition. We describe their clinical courses during the first 5 days of hospitalization, including response to treatment and implications for future management of this disorder.

The mean APACHE II score of the 6 was 30±3.5 and mean Glasgow Coma Scale rating 3.5±0.5; they were in hypovolemic shock and respiratory failure, necessitating mechanical ventilation. Despite early effective therapy (core temperature in all was reduced to less than 398C in less than 1 hour), there was 1 death (mortality 15%) and 4 required further intensive care for life-threatening multiple organ failure.

During severe heat waves a significant number of referrals for acute heat-related illness must be anticipated, possibly overwhelming admission capacity of regional intensive-care units. Severe heat stroke complicated by multi-organ failure is not necessarily related to prior physical activity. Although important in determining prognosis, early treatment does not prevent severe complications. Mechanisms regulating body heat may remain disturbed for days following early treatment and apparent stabilization, mandating continued hospitalization.

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.

Effect of Specific Inspiratory Muscle Training on Dyspnea and Exercise Tolerance in Congestive Heart Failure

Paltiel Weiner, Joseph Waizman, Rasmi Magadle, Noa Berar-Yanay, Benny Pelled

Depts. of Medicine A and Cardiology, Hillel Yaffe Medical Center, Hadera

It has been shown that the inspiratory muscles of patients with congestive heart failure (CHF) are weaker than normal. This weakness may contribute to dyspnea and limit exercise capacity. But respiratory muscles can be trained for increase in both strength and endurance. This study was designed to evaluate the effect of specific inspiratory muscle training (SIMT) on muscular performance, lung function, dyspnea and exercise capacity in moderate heart failure.

10 patients with CHF (NYHA functional class II-III) received 1/2 hour of SIMT daily, 6 times/week, for 3 months. They started breathing at a resistance 15% of their Pimax for 1 week and the resistance was then increased incrementally to 60%. Spirometry, inspiratory muscle strength and endurance, and the 12-minute walk test were performed before and after the training period. All showed an increase in inspiratory muscle strength and endurance. This was associated with a small but significant increase in FVC, a significant increase in the distance walked (458±29 to 562±32 m, p<0.01), and improvement in the dyspnea index score.

SIMT resulted in increased inspiratory muscle strength and endurance. This increase was associated with decreased dyspnea and an increase in submaximal exercise capacity. SIMT may prove to be useful complementary therapy in CHF.

Balloon Angioplasty of Native Coarctation of the Aorta

Benjamin Zeevi, Galit Bar-Mor, Michael Berant

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

The use of balloon dilatation to treat native coarctation of the aorta is gaining acceptance among interventional pediatric cardiologists, but is still controversial. We describe our experience with this procedure in 21 children, mean age 5.6 years and mean weight 21.1 kg. Most had an additional congenital heart defect, most commonly a bicuspid aortic valve. 17 were asymptomatic, 3 had tachypnea and 1 infant had severe congestive heart failure and was ventilated. The mean systolic blood pressure was 129.7 mm Hg.

Balloon dilatation was successful in 90% (19), decreasing the mean maximal systolic gradient from 35.3 to 9 mm Hg (p<0.001), and increasing the narrowest area from 3.9 to 8.2 mm (p<0.001), with a mean balloon-to-coarctation width-ratio of 2.8. There were no complications. Of 15 who underwent repeat cardiac catheterization at a mean interval of 10.6 months, 2 had a maximal systolic gradient of more than 20 mm Hg. 1 of these underwent successful repeat angioplasty and the other, who also had a small aneurysm, underwent surgical repair successfully. 2 others had small aneurysms and they are being followed clinically.

All patients were seen again after a mean interval of 31 months. The mean systolic blood pressure was 104 mm Hg, significantly lower than before intervention (p<0.002). 1 had an increased pressure gradient between right arm and leg of 35 mm Hg at later follow-up, and repeat cardiac catheterization demonstrated a good result 13 months after the initial procedure. She is awaiting a third catheterization. Overall, 90% had good mid-term results.

Based on our experience and recent reports, balloon angioplasty is safe and effective in most children older than 7 months and should be considered a viable alternative to operation for discrete aortic coarctation. Further long-term evaluation is needed.

Lymphoma of the Knee Joint Simulating Patellar Fracture

E. Lebel, M. Itzchaki

Orthopedics Dept., Shaare Zedek Medical Center, Jerusalem

Fracture of the patella is not uncommon after direct anterior knee trauma. However, there are other medical situations that resemble it radiologicaly. We present a patient mistakenly diagnosed as having a patellar fracture who had primary, solitary, malignant B-cell lymphoma of the knee space eroding the lower pole of the patella. We have found no reports of such a lesion in the literature. Another commbenign condition that might erode adjacent bone is chronic synovitis. Our patient was treated withchemo- and radiotherapy and the lesion fully regressed with no evidence of local or systemic recurrence 1.5 years after diagnosis.
 

Diagnosis and Treatment of Heart Failure within the Communuity

Haim Ben-Ami, Yehuda Edoute

Dept. of Medicine C, Rambam Medical Center and Technion Faculty of Medicine, Haifa

Congestive heart failure causes substantial morbidity and mortality. Symptoms and physical findings can help in diagnosis, but have limited sensitivity and specificity. Objective measurement of ventricular function is essential in virtually all patients in whom heart failure is suspected; reversible causes of heart failure must be sought.

Out-patient management includes education and counseling, emphasis on and assessment of compliance with diet, and pharmacological treatment. Angiotensin-converting enzyme inhibitors are the mainstay of treatment but are underused, and maximal doses are not given, apparently because of concern about side-effects. Diuretics should be administered only as needed to manage fluid overload. Calcium channel blockers are relatively contraindicated in patients with impaired ventricular function. Patient follow-up should be guided by results of the medical history and physical examination. Routine serial testing of ventricular function and exercise performance is discouraged.

Second Degree A-V Block in Graves© Disease

Yoram Singer, Pesach Shvartzman

Dept. of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Cardiac tachyarrhythmias are common in thyrotoxicosis. We report an uncommon case of a 53-year-old woman with Grave's disease who developed second degree A-V block while euthyroid on propylthiouracil. The most likely mechanism is an autoimmune response causing infiltration of the cardiac conduction pathways.

Use of Restraints in a General Hospital

Bella Bar-Cohen, Orly Rotem-Picker, Zvi Stern

Nursing Services and Administration, Hadassah University Medical Center, Jerusalem

28 in-patient units were surveyed during a 5-day period to determine the extent of the use of physical restraints in hospitalized patients. Information was gathered on the characteristics of restrained patients and indications for use and removal of restraints, patterns and means of restraints, monitoring, and written notations. 31 different patients (6% of those surveyed) were restrained in 13 units during the 5 days of the survey, an average of 15 (3%) daily.

Characteristics of restrained patients were: age 70 and over requiring emergency hospitalization, reduced level of consciousness, limitation of mobility, incontinence, history of 2 or more chronic diseases, requiring multiple drugs, and use of multiple medical devices. Bilateral, soft hand restraints were most often used to prevent patients from removing tubes. Nurses initiated the decision to apply or remove restraints, which were usually removed as the patients' condition improved. Written policies were lacking regarding monitoring and follow-up of restrained patients. Clearly written policies and increased staff awareness of potential hazards may reduce the use of restraints and the length of time they are employed.

Pheochromocytoma Multi-Organ Crisis: Nonseptic Hyperthermia and Shock

Michael Y. Shapira, Elena Zuckerman, Taufic Zuebi, Oded Jurim

Divisions of Medicine and Surgery, Hadassah-University Hospital; Geriatrics Dept.; Herzog Hospital, Jerusalem; and Dept. of Medicine, Yoseftal Hospital, Eilat

Pheochromocytoma usually presents with nonspecific symptoms such as headache, palpitation, chest pain and hypertension. We present a 48-year-old woman hospitalized due to a pheochromocytoma multi-organ crisis (PMC). It consists of a tetrad of symptoms: multi-organ failure, hyperthermia, encephalopathy and unstable blood pressure. Distinguishing PMC from septic shock may be difficult, and requires needs a high clinical index of suspicion.

Cardiac Failure following Sting of Yellow Scorpion in an Adult

C. Kristal, I.Y. Shemesh, Y. Mishal, A. Bourvin

Intensive Care Unit, Dept. of Anesthesia and Medical Dept., Barzilai Medical Center, Ashkelon

3 men, aged 18, 29, and 47 had severe cardiovascular disturbances following the sting of the yellow scorpion (Leiurus quinquestriatus hebraeus), which is considered the most dangerous scorpion in Israel. Cardiovascular complications are common in children after scorpion sting, but are rare in adults. Pulmonary edema developed in 1 of those being reported and hypertension and arrhythmias in the other 2. Severe deterioration in left ventricle function was confirmed by echocardiographic measurement of diminished ejection fraction. All patients recovered completely. This is the first report of severe cardiac involvement in adults following scorpion sting. We therefor recommend that even adults who develop cardiac symptoms after scorpion sting, particularly those with chronic cardiac disease, be monitored and treated in an intensive care unit.

Intradermal Hepatitis B Vaccination in Those Not Responsive to Intra-Muscular Vaccination

Hanna Bauer, Israel Potasman, Neora Pick

Infectious Disease Unit, Bnai Zion Medical Center and Faculty of Medicine, The Technion, Haifa

Health care workers are at continuous risk of hepatitis B infection. Currently recommended intramuscular vaccination confers immunity in only 85-90%. We examined the immunogenicity and safety of intradermal vaccination of hepatitis B vaccine in nonresponders. 400 hospital employees who had been immunized as recommended were screened for anti-HBs antibodies and 50 were found seronegative. Each received an intramuscular booster injection and antibody level was measured a month later. Excluded were 33 employees, including 24 late responders, 2 HbsAg carriers and 7 uncooperative employees. 17 employees (mean age 47.1 yrs) then received a series of 3 intradermal injections of Energix B, 0.25 ml in the forearm, 2-3 weeks apart. The mean number of previous intramuscular injections was 4.6±1.4 month later there was a mean titer of 315.4±347.0 miu/ml of antibody in 16/17 workers. Side effects were minimal. Intradermal injection of hepatitis B vaccine for nonresponders seems effective for inducing seroconversion. Its cost-effectiveness for the health care system warrants assessment.

Orthostatic Hypotension as a Manifestation of Malignant Lymphoproliferative Disease

H. Semo, A. Adunsky, E. Grossman

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

An 85-year-old man was admitted with 6-month history of incapacitating orthostatic hypotension. Investigation led to the discovery of sympathetic dysautonomia, sensorimotneuropathy and malignant lymphoproliferative disease. Several attempts to treat the orhypotension or the neoplastic disease failed to improve his condition. Orthostatic hypotension precipitated by sympathetic dysautonomia may be an infrequent effect of early malignant lymphoproliferative disease.