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        תוצאת חיפוש

        דצמבר 1998

        ריבה בריק
        עמ'

        Methotrexate Treatment in Refractory Juvenile Rheumatoid Arthritis

         

        R. Brik

         

        Pediatrics B Dept., Rambam Medical Center, Haifa

         

        The mean time from initiation of methotrexate (MTX) treatment of juvenile rheumatoid arthritis (JRA) to partial remission of clinical symptoms and total clinical remission was assessed. 9 girls and 8 boys, from 3 to 18 years of age (mean 11.4±5.4) with active JRA by American College of Rheumatology (ACR) criteria (5 systemic, 8 polyarticular and 4 pauciarticular disease onset), who failed to respond to adequate courses of non-steroidal anti-inflammatory drugs (NSAID), steroids or disease-modidrugs were studied.

         

        Clinic visits were scheduled at monthly intervals for physical and laboratory assessment disease activity and drug safety. Partial response to MTX was defined a 25% reduction of the active joint count and/or articular severity score. Total clinical remission was defined as in adult rheumatoid arthritis. The duration of disease activity until enrollment ranged from 6 months to 14 years (4.5±3.7 yr); duration of therapy was 3 months to 3 years (14.6±9.3mo) and dosage ranged from 5 to 15 mg/m²/week. Prednisone in doses below 10 mg/day and NSAID were permitted.

        14 of 17 patients (82%) had a 25% reduction in joint activity after 6 weeks to 4 months (9.2±3.2 weeks); 10 (59%) went into full clinical remission after 5 to 26 months (14.3±9 months); 3 relapsed after an initial response to treatment, and 4 (23%) did not respond to MTX. The non-responders were males who required higher doses of prednisone (p<0.0001).

        MTX appears to be effective therapy for children with JRA. An initial response can be expected in most patients after 9 weeks of treatment, and full clinical remission occurs after a mean of 14 months.

        הקבוצה הישראלית לסקרים באוטם חד בשריר הלב
        עמ'

        Characteristics, Management and Prognosis of Acute Myocardial Infarction (Israel 1990-1996)

         

        Israeli Survey Group On Acute Myocardial Infarction

         

        From 1990 to 1996 we conducted consecutive 2-month surveys in all CCUs (n=26) in Israel. The aim was to compare the characteristics, management, and prognosis of patients with acute myocardial infarction (AMI) between the 4 surveys.

         

        Patient characteristics were similar in all surveys. About 75% of patients were males and had a first MI. Mechanical and arrhythmic complications decreased slightly between 1990 and 1996. In contrast, frequency of treatment with thrombolysis, aspirin, beta-blockers and ACE-I, as well as coronary interventional procedures, increased tremendously.

        In parallel, 30-day and 1-year mortality decreased significantly, from 16.5% and 22.5%, respectively, to 9.0% and 13.9%. After multiple adjustment for factors associated with mortality, the 30-day relative risk of death for patients hospitalized in 1992, 1994 and 1996 was 0.79 (95% CI 0.59-1.08), 0.75 (95% CI 0.56-1.01) and 0.54 (95% CI 0.39-9.74), respectively, as compared with 1990.

         

        Although there is no direct proof that changes in management of AMI are related to the reduction in mortality seen during the course of the surveys, the association seems likely.

        שמואל כץ, אילן ארז, איטה ליטמנוביץ, לודוויג לזר, אריה רז וציפורה דולפין
        עמ'

        Bowel-Lengthening in a Newborn with Short Bowel Syndrome

         

        Schmuel Katz, Ilan Erez, Ita Litmanovitz, Ludwig Lazar, Arie Raz, Zipora Dolfin

         

        Depts. of Pediatric Surgery, Neonatology and Pediatrics; Meir Hospital, Kfar Saba

         

        Advances in parenteral nutrition and supportive therapy have led to improvement in survival of babies with short-bowel syndrome. Those whose intestinal mass is very unlikely to be adequate should have surgical therapy as soon as possible, before they develop the complications of long-term parenteral nutrition or significant enteritis.

         

        We present a newborn with short-bowel syndrome due to prenatal midgut volvulus. At operation the remaining viable jejunum, 15 cm long, was anastomosed to the cecum. All feeding attempts failed, and the infant suffered from malabsorption. Calories and proteins had to be supplied by intravenous total parenteral nutrition.

         

        At 3 months of age there was significant widening of the remaining bowel and Bianchi's bowel-lengthening procedure was performed. The postoperative course was uneventful and there was gradual improvement in intestinal absorptive capacity. The patient was weaned from parenteral nutrition at 3 years of age. Now, 2 years later, she eats a normal diet.

        יהודה לימוני ופסח שוורצמן
        עמ'

        Influence of Warning Labels on Medicines and Physicians' Orders on Patient Behavior

         

        Yehuda Limony, Pesah Shwarzman

         

        Child Health Center of Kupat Holim Klalit, Kiryat Gat and Dept. of Family Medicine, Ben-Gurion University of the Negev, Beer Sheba

         

        Compliance of 40 mothers with a warning label, "for external use," on a medicine package was checked in a survey in a primary care clinic for children. We also checked parents' attitudes to giving a medicine to their child when instructions given by the physician or by a friend contradicted the printed warning on the label. All mothers who were told that the medicine was recommended by their physicians accepted the recommendation without hesitation. Another group included 20 mothers who were told that the medicine was recommended by a friend. 9 of 20 mothers in this group refused to use the medicine. Talking with the nurse about the potential risk of medicine in general, some mothers, after second thought, refused to give the medicine to their child. At the end, 65% of recommendations made by a friend were rejected by mothers as compared to only 15% of the physicians' recommendations.

         

        35 of 40 mothers (87%) understood the meaning of the warning label, but only 13 (32%) had noticed it at all. We conclude that patients may accept their physicians' recommendation to use a medicine despite a contradictory warning label much more readily than when it was recommended by a friend. Therefore, any intervention program intended to promote a more cautious use of medicines should include not only the explanations of the various warning labels but should also promote a change in the patient's behavior to a more active search for warning labels.

        אשר שיבר, חיים ראובני, אשר אלחיאני ויצחק (צחי) בן-ציון
        עמ'

        Comparison between Every-Day and Every-3-Days Fluoxetine in Young, Moderately Depressed Out-Patients

         

        A. Shiber, H. Reuveni, A. Elhayany, I.Z. Ben-Zion

         

        Psychiatric Dept., Psychiatric Division, Soroka Medical Center and Ben-Gurion University of the Negev, Beer Sheba; and Medical Division for Drug Utilization, Kupat Holim Klalit (Sick Fund)

         

        Fluoxetine is now a well-known and often-used specific serotonin reuptake inhibitor (SSRI) and antidepressant. It has a very long active half- life, from 2-16 days. Our hypothesis was that sufficient therapeutic effectiveness would be achieved by prescribing the drug less frequently than once a day.

         

        To establish whether there is a difference between fluoxetine given daily or every 3 days, we assigned 25 outpatients with mild to moderate, acute major depressions (DSM-IV) to receive fluoxetine (20 mg), either each day or every 3 days. The study was open-labelled, using for assessment the HAM-D, GHQ-28 side-effect checklist and clinical judgment questionnaires. Follow-up lasted 6 months.

         

        Results indicated no differences in the clinical outcomes, except for slightly fewer side-effects in the study group. Although the open label design limits drawing definitive conclusions, our preliminary results provide more information, and support our hypothesis that low-dosage fluoxetine is beneficial. However, more comprehensive, double-blind studies are necessary to confirm our preliminary results.

        נובמבר 1998

        יוסף משעל, חיים יוספי, אמיל חי, דליה כץ, אליסה אמבון ורוזה שניידר
        עמ'

        Risk of Transmission of Viral Disease by Needle Puncture in Health Care Workers

         

        Yosef Mishal, Chaim Yosefy, Emil Hay, Dalia Catz, Elisia Ambon, Roza Schneider

         

        Infectious Disease Unit, Emergency Dept. and Microbiology Lab, Barzilai Medical Center, Ashkelon (Affiliated with Ben-Gurion University of the Negev)

         

        The accidental exposure of the health care workers (HCW) to blood and blood products constitutes a danger for transmission of blood-borne pathogens and the development of severe diseases. Most attention is focused on exposure to the viruses of hepatitis B, C and human immunodeficiency. The objectives of this prospective study were to determine the rate of exposure of our HCW to blood and blood products; to define the high risk groups; and to establish recommendations to prevent transmission or reduce the risk of exposure to these viruses.

        During the year 1996, 103 injuries from needle-puncture or other sharp objects were reported to our infectious diseases control unit. Most of those injured were women. 58.4% of the events occurred in the vicinity of the patient. The source of exposure was known in 60% of the cases. 73.8% of those injured had already been immunized against hepatitis B. The departments in which most exposures occurred were the operating theater (12.5%), medical departments A (10.6%) and B (9.6%), and the emergency department (7.7%). Nurses were at highest risk, constituting 47% of those injured.

         

        Our recommendations are that a continuous teaching program be established for the high risk groups; that HCW be urged to report every event of exposure; and to encourage HCW to undergo active immunization against hepatitis B.

        פטר יעקובי, אורלי גולדשטיק, רנטו פינקלשטיין ויוסף איצקוביץ-אלדור
        עמ'

        Empirical Treatment of Urinary Tract Infections in the Delivery Room

         

        Peter Jakobi, Orly Goldstick, Renato Finkelstein, Joseph Itzkovitz-Eldor

         

        Obstetrics and Gynecology Dept. and Infectious Disease Unit, Rambam Medical Center, Haifa

         

        Urinary tract infection (UTI) is the most common bacterial infection during pregnancy. In prenatal and delivery wards treatment is usually started at once in pregnant women with symptoms suggesting UTI, but there is no uniformity as to treatment. We surveyed such treatment in the delivery rooms throughout Israel, and whether the treatment differed in simple cystitis as opposed to pyelonephritis. Results of positive urine cultures from symptomatic parturients admitted here during 1995-1996 were examined.


        There were 17 different empiric treatment protocols in 28 delivery rooms, whose daily cost ranged from 1-119 NIS. We present the antimicrobial sensitivity of 156 bacteria isolated from the urinary cultures from pregnant women in our prenatal ward. Based upon urinary flora, sensitivity and daily cost, we suggest a protocol for empiric treatment. We recommend first and second generation cephalosporins for treatment of simple lower (UTIs), while gentamicin is suggested for treatment of clinical pyelonephritis during pregnancy. There is no medical nor economic justification for the multiplicity of empiric treatment protocols currently used. Considering our results, our protocol is cost-effective for the empiric treatment of UTI in hospitalized parturients and in the community as well.

        אברהם ישי ורפאל לובושיצקי
        עמ'

        Diagnosis of Hyperprolactinemia: Determination at Rest Rules Out Stress-Induction

         

        Avraham Ishay, Rafael Luboshitzky

         

        Endocrine Institute, HaEmek Medical Center, Afula and Rappaport Faculty of Medicine, The Technion, Haifa

         

        We present 3 women who were referred for evaluation of stress-related mild-to-moderate hyperprolactinemia. This frequent finding may mistakenly be considered a clinical problem, and lead to inappropriate investigation and therapy. We emphasize the importance of serial blood sampling for prolactin determination. We collected blood samples repeatedly under resting conditions from an indwelling venous brachial catheter, every 30 minutes for a total of 6 samples. All 3 patients had normal prolactin levels 30-60 minutes after starting the test. Neither further investigation nor medical therapy were needed and these anxious patients were reassured that their hyperprolactinemia was factitious.

        ישראל דודקביץ, משה סלעי ואהרון צ'צ'יק
        עמ'

        Concept Management in Penetration of Unusually Shaped Foreign Bodies into Extremities

         

        I. Dudkiewicz, M. Salai, A. Chechik

         

        Orthopedic Dept., Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

         

        During routine emergency room work penetration by foreign objects is frequently encountered, some of which may be very irregular in shape. These may cause further damage if inappropriately removed. It is important to perform a proper X-ray survey.

        מאיר כהן, ערן תמיר, סובחי אבו-עאיד, יאיר גלילי, מיכאל גלעדי, שמואל אביטל, רפאל שפיר ויוסף קלאוזנר
        עמ'

        The Diagnosis and Treatment of Fournier's Gangrene

         

        M. Cohen, E. Tamir, S. Abu-Abid, Y. Galili, M. Giladi, S. Avital, R. Shafir, Y. Klausner

         

        Surgery and Infectious Disease Depts. and Division of Surgery, Tel Aviv-Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

         

        We treated 2 women and 8 men suffering from Fournier's gangrene during 1990-96. 2 had diabetes, 1 suffered from ulcerative colitis and 1 was an alcoholic. In 8 of them the infection was triggered by a mixture of aerobic and anaerobic bacteria. Treatment consisted of repeated wide debridement and early colostomy. This aggressive approach resulted in relief of the septic signs within 24 hours and permitted early skin grafting of the wounds. 2 patients died due to sepsis that caused multiple organ failure. The 8 who survived were hospitalized for an average of 35 days. On follow-up examination 1-5 years later all patients had undergone closure of the colostomy and were completely rehabilitated.

        Fournier's gangrene is not rare in the geriatric population. We believe that early diagnosis and aggressive wide debridement, combined with early colostomy, are the keys to successful treatment.

        מיכאל קראוס וסימון-דניאל דואק
        עמ'

        Is Ileostomy Necessary In Surgical Treatment of Ulcerative Colitis and Familial Polyposis?

         

        Michael M. Krausz, Simon Daniel Duek

         

        Dept. of Surgery A, Rambam Medical Center, Bruce Rappaport Faculty of Medicine, The Technion, Haifa

         

        Proctolectomy with ileal pouch anal anastomosis (IPAA) has become the procedure of choice for the surgical treatment of ulcerative colitis (UC) and familial polyposis (FP). Ithas traditionally been performed in 2 stages, but recently the necessity for an ileostomy hbeen challenged by several authors who recommend a 1-stage procedure.

         

        5 years ago we started to test this policy for treatment of UC and FP. In 48 patients (Group A), 45 with UC, the 2-step procedure, and in 17 of the 27 in Group B with FP, the 1-stage procedure were performed. The indications for surgery were intractable UC in 37 patients in group A and in 5 patients in Group B (p<0.01).

         

        Postoperative infection due to bowel leakage developed in 2 in Group A and in 6 in Group B (p<0.01). Reoperation was necessary in 4 patients (15%) in Group B and only 1 (0.9%) in Group A (p<0.01). Bowel leakage in Group B occurred in 5 (19%) with UC and in only 1 with FP (p<0.05), which responded to medical treatment. All those with UC who developed this complication were relatively malnourished, with serum albumin levels lower than 3.0 g% and were regulated with corticosteroids.

         

        We therefore conclude that the 2-stage IPAA is feasible and safe for the treatment of UC and FP. The 1-stage IPAA should be limited only to FP or good risk UC patients.

        אוקטובר 1998

        עדנה פינצ'ובר
        עמ'

        Art Therapy for Hospitalized Children (Inspired by Elizabeth Kuebler-Ross's Approach)

         

        Edna Pinchover*

         

        Pediatric Wards School, Hadassah Hospital (Ein Karem and Mt. Scopus), Jerusalem

         

        This paper presents a combined strategy for coping with the emotional condition of hospitalized children, and reports the results of its implementation in pediatric wards. The strategy combines art therapy methods with the spiritual-psychological approach developed by Elizabeth Kuebler-Ross. Art therapy uses art for therapeutic and diagnostic purposes; in this study it was employed to encourage the child-patients to express their feelings, and lead them to processes of understanding of and adjustment to their conditions. Kuebler-Ross' methods, known for dealing with difficult emotional situations at the bedside of the seriously ill, were enlisted to build a relationship of trust and respect between patient and therapist.

        The population dealt with consisted of children (age 3-13) injured in road accidents, and cardiac and oncological cases. 7 case studies are brought to demonstrate the integrated therapeutic process. The process starts from the child-patient's artwork, which allows the therapist better insight into emotional conditions and to relate closely to issues brought up by the work. Through conversation with the therapist in an atmosphere of empathy and honest consideration, the patient becomes aware of her/his reactions, behavior, intentions and ambitions.

        The belief underlying this study is that the patient derives from these contacts new abilities which moderate anxieties and strengthen healthy energies. Better collaboration and sounder ways of coping with intrusive medical treatment, as well as more trust and hope seem to emerge from the relationships created by these contacts.

         

        * Principal of School.

        ניר הילזנרט ועידית ליברטי
        עמ'

        Multiple Angiodysplastic Lesions of the Colon - a Therapeutic Challenge

         

        Nir Hilzenrat, Edit Liberty

         

        Division of Gastroenterology and Dept. of Medicine E, Soroka Medical Center and Ben-Gurion University, Beer Sheba

         

        Colonic angiodysplasia is one of the most frequent causes of recurrent lower gastrointestinal tract bleeding, mainly in the elderly. In 50% of patients multiple angiodysplastic lesions were reported when they were the cause of rectal bleeding. Bleeding from angiodysplasia is more severe and less responsive to treatment in those with coagulation disorders. A 74-year-old woman with an artificial mitral valve who was treated with coumadine is reported. A few years after operation she began to develop severe recurrent rectal bleeding because of multiple angiodysplastic lesions along the right colon, proven by colonoscopy. She was frequently hospitalized for blood transfusions; endoscopic treatment was not feasible and the surgical risk of colectomy was very high. Treatwith estrogen and progesterone significantly decreased recurrent episodes of bleeding.

        ספטמבר 1998

        שמואל מייזל, ולדיסלב פיינשטיין ושרה קנדל-כצנלסון
        עמ'

        Treating Mother and Baby in Conjoint Hospitalization in a Psychiatric Hospital

         

        Shmuel Maizel, Vladislav Fainstein, Sarah K. Katzenelson

         

        Dept. B, Eitanim Mental Health Center, Jerusalem

         

        Since 1990 we have been admitting mothers with postpartum psychiatric morbidity together with their babies to our open psychiatric ward. The aim of conjoint hospitalization is to maintain and develop the bond between mother and baby while treating the mother's psychiatric disorder. The presence of the infant in the hospital allows both a thorough evaluation of the mothers' maternal ability and to use the infant as a facilitator of the mothers' recovery by engaging maternal functions. It prevents the infants from being placed in a foster home for the duration of the mothers' hospitalization. Readily available in Britain and Australia, such conjoint hospitalization is controversial and rarely available elsewhere. In the past 5 years we hospitalized 10 women with 11 babies (1 woman was hospitalized twice, after different births). All women had received psychiatric treatment prior to childbirth, but this was the first psychiatric hospitalization for 2 of them. Diagnoses (DSM-IIIR) were chronic paranoid schizophrenia (4), disorder (4), schizo-affective schizophrenia (1) and borderline disorder (1). 8 were suffering from active psychotic symptoms on admission. They were treated pharmacologically, received individual and group psychotherapy, and participated in all ward activities. Families were engaged in marital, family and/or individual therapy according to need. All participated in cognitive-behavior treatment tailored to individual need to build and enrich the mother-infant bond. All improved significantly and were able to function independently on discharge, but in 1 case adoption was recommended.

        משה ויסברוט, גד ולן ודוד הנדל
        עמ'

        Rupture of Pectoralis Major Muscle: Operative Treatment of an Uncommon Sport Injury

         

        Moshe Weisbort, Gad J. Velan, David Hendel

         

        Orthopedics Dept., Rabin Medical Center (Golda Campus), Petah Tikva

         

        Rupture of the pectoralis major muscle in an athlete is rare, but is said to be common in weight lifters. The muscle usually ruptures at the musculotendinous junction during forceful contraction of the muscle in adduction, forward flexion and internal rotation of the arm. We describe an athlete who suffered such a major tear during a rugby game. It was treated surgically and after adequate rehabilitation, athletic activities were resumed.

        הבהרה משפטית: כל נושא המופיע באתר זה נועד להשכלה בלבד ואין לראות בו ייעוץ רפואי או משפטי. אין הר"י אחראית לתוכן המתפרסם באתר זה ולכל נזק שעלול להיגרם. כל הזכויות על המידע באתר שייכות להסתדרות הרפואית בישראל. מדיניות פרטיות
        כתובתנו: ז'בוטינסקי 35 רמת גן, בניין התאומים 2 קומות 10-11, ת.ד. 3566, מיקוד 5213604. טלפון: 03-6100444, פקס: 03-5753303