A pregnant woman with hepatitis A and Guillain-Barré.

Guillain-Barré syndrome (GBS) is often preceded by an infectious disease. A case of GBS after hepatitis A in a pregnant woman is described. The patient was treated with intravenous immunoglobulin and had full recovery with no neurologic sequelae. She gave birth in term to a healthy baby. This is the first reported case in the English literature of a triple condition of hepatitis A, GBS, and pregnancy.

[Patient satisfaction and hospital services evaluation: comparison of and private patients].

"Sharap" is a private medical service integrated within our public clinic and hospital services. Clients may choose their physician by paying a fee in addition to what their health insurance agency (Kupat Holim) pays for. All other hospital services are supplied to all patients alike. The main purpose of this study was to evaluate the extent to which this declared policy is maintained in practice. During 5 months in 1997, 198 Sharap patients and 198 regular patients were interviewed in the the general surgery, cardiac surgery, ENT, cardiology, newborn and gynecology wards of this hospital. Both groups were similar in regard to cause of hospitalization, gender, age group (10-year age ranges), and length of hospitalization (at least 24 hours). Similar levels of satisfaction with hospitalization in general and with the nursing service and with supportive services were found in both groups. However, Sharap patients were more satisfied with their physicians than regular patients (87% vs 74%, respectively). Similar results were also found using indirect measures of satisfaction. About 86% in both groups reported having achieved the goal of improvement in health. A high proportion of respondents from both groups (82% and 88%, respectively) could not distinguish between Sharap and regular patients in the ward. However, a greater proportion of regular patients (35% vs 21%) wanted more extensive explanations from their physicians regarding their treatment. Sharap patients belonged to higher socio-economic classes than regular patients. Our evaluation indicates that although the Sharap service enables the affluent to choose their preferred physician, resulting in a different doctor-patient relationship, the service does not create a significant feeling of discrimination among hospitalized patients, and does not interfere with the high level of health services available to the public at large.

Infective endocarditis associated with upper endoscopy: case report and review.

We describe a 73-year-old male who developed native valve infective endocarditis due to Staphylococcus capitis as a consequence of repeated oesophageal dilatation. The patient was treated with appropriate antibiotic therapy but his condition deteriorated and he died. We review 10 previously reported cases of infective endocarditis associated with upper endoscopy and discuss the issue of prophylaxis of high risk patients prior to upper endoscopy involving various invasive procedures, e.g. biopsy, dilatation and sclerotherapy.

Lipoamide dehydrogenase deficiency: a newly discovered cause of acute hepatitis in adults.

Lipoamide dehydrogenase deficiency is a rare disease, manifested in early childhood by lactic acidemia, progressive neurological damage and death in most cases. We report a case of lipoamide dehydrogenase deficiency in a 34-year-old Ashkenazi-Jewish woman. The deficiency manifested as acute hepatitis without cognitive impairment or acidosis. The patient's brother also had lipoamide dehydrogenase deficiency, diagnosed at the age of 20, and manifested as hepatocellular damage, lactic acidemia and myoglobinuria. We assume that the trigger for this hepatocellular damage was prolonged fasting, and that otherwise the patient might have gone undiagnosed. Other cases in Ashkenazi Jews of mild lipoamide dehydrogenase deficiency with hepatocellular injury but without central nervous system involvement are reviewed.

A genogram with an attitude.

The approach described in this paper is predicated on the fundamental belief that in order to become competent and ethical practitioners, students must understand themselves and how they see others. They must be given tools and skills that facilitate examination of their own assumptions and beliefs about themselves, others, and how the world works. It is also essential that students examine how these assumptions and beliefs will influence the way they choose to conduct therapy. Once they are aware of their biases, they must learn to choose to consciously influence themselves in a way that permits their clients the largest room for change within the clients' own contexts of belief, understanding, experience, and possibility. In this paper I describe the use of the genogram as a tool to facilitate the process of gaining self knowledge. This tool has been used in a multicultural counseling course, as well as in professional development workshops for psychologists, mental health counselors, and marriage and family therapists.

Regression of hepatic tumors during transdermal estradiol replacement therapy.

A 39 year-old patient with long-standing diagnosis of pelvic endometriosis had been treated for over twenty years with oral contraceptives (OCs). A year prior to admission to the gynecological ward, an ultrasonographic examination revealed three hepatic lesions, which were not reported in previous liver sonography. These lesions progressed during OC use, over the next six months. Liver function tests were normal. Liver scan, CT and ultrasound imaging techniques supported the diagnosis of solid hepatic tumors. These lesions developed concomitantly to long-term use of OCs, therefore discontinuation of therapy was mandatory. Six months later, the patient was hospitalized due to pelvic pain. She underwent total abdominal hysterectomy and left salpingo-oophorectomy (the right adnexa had been removed years before). Due to the patient's young age, hormone replacement therapy was indicated. The preferred preparation was transdermal estradiol due to the fact that systemic absorption has no hepatic first-pass effect and therefore exerts minimal influence on liver enzymes and functions. Serial ultrasonographic examinations, performed while under treatment with transdermal estradiol, showed complete regression of the hepatic lesions over a period of two years. Our report demonstrates regression of multifocal hepatic tumors despite transdermal estradiol replacement therapy.

Prevalence of HBsAg carriers in pregnant women in Jerusalem: risk for horizontal transmission to family members.

A prospective study was undertaken in Jerusalem to quantitate the HBsAg prevalence rate in pregnant women, to assess the effect of ethnic origin on HBsAg prevalence rates, and to determine the impact of HBsAg carrier state on hepatitis B virus horizontal transmission in the family. Of the 6,572 women screened at the time of delivery, 42 (0.64%) were found to be HBsAg positive. Although the percentage of Moslem women was 3.4% of the total study population, they accounted for 23.8% of the HBsAg positive mothers. This resulted in a prevalence rate of 4.48% as compared to only 0.5% in the Jewish population (P < 0.01). Nine percent of siblings born to HBsAg positive mothers and 29% of the husbands were found to be horizontally infected.

A giant tuberculous lymphangioma extending from the mediastinum to the inguinal region.

A 23-year-old Ethiopian new immigrant presented with a giant lymphangioma extending from the posterior mediastinum through the retroperitoneum, ending as a herniated fluid-filled sac in the inguinal region. Chylous fluid aspirated from within the lymphangioma was cultured positive for Mycobacterium tuberculosis. Considerable regression occurred following 6 months of antituberculous treatment.

A comparison of fentanyl, esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction.

The purpose of this randomized, double-blind study was to compare the ability of a combination of fentanyl and esmolol to blunt the haemodynamic effects of intubation with that of either agent alone. Patients received fentanyl or saline four minutes before, and esmolol or saline two minutes before rapid-sequence induction of anaesthesia. The F2 group (n = 24) received fentanyl 2 micrograms.kg-1, the E2 group (n = 24) received esmolol 2 mg.kg-1, the F2/E2 group (n = 25) received a combination of fentanyl 2 micrograms.kg-1 and esmolol 2 mg.kg-1, and the F5 group (n = 26) received fentanyl 5 micrograms.kg-1. Following tracheal intubation, the maximum percent change from baseline heart rate was less in the F2/E2 and F5 groups (12% and 16% respectively) than in the E2 group (34%)(P < 0.05). The maximum percent changes from baseline systolic blood pressure in the F2/E2 and F5 groups (15% and 6% respectively) were less than in the F2 and E2 groups (24% and 33% respectively) (P < 0.05). The combination of a low dose of fentanyl and esmolol provides an alternative to a higher dose of fentanyl for blunting the haemodynamic responses to laryngoscopy and tracheal intubation during rapid-sequence induction in healthy patients.

Pharmacokinetics and pharmacodynamics of vecuronium in the obese surgical patient.

The effect of obesity on the disposition and action of vecuronium was studied in 14 surgical patients. After induction of anesthesia with thiopental and maintenance of anesthesia by inhalation of nitrous oxide and halothane, seven obese patients (93.4 +/- 13.9 kg, 166% +/- 30% of ideal body weight, mean +/- SD) and seven control patients (60.9 +/- 12.3 kg, 93% +/- 6% of ideal body weight) received 0.1 mg/kg of vecuronium. Plasma arterial concentrations of muscle relaxant were determined at 1, 3, 5, 10, 15, 20, 30, 45, 60, 90, 120, 150, 180, 210, 240, 300, and 360 min by a spectrofluorometric method. Simultaneously, neuromuscular blockade was assessed by stimulation of the ulnar nerve and quantification of thumb adductor response. Times to 50% recovery of twitch were longer in the obese than in the control patients (75 +/- 8 versus 46 +/- 8 min) as were 5%-25% recovery times (14.9 +/- 4.0 versus 10.0 +/- 1.7 min) and 25%-75% recovery times (38.4 +/- 13.8 versus 16.7 +/- 10.3 min). However, vecuronium pharmacokinetics were similar for both groups. When the data were calculated on the basis of ideal body weight (IBW) for obese and control patients, total volume of distribution (791 +/- 303 versus 919 +/- 360 mL/kg IBW), plasma clearance (4.65 +/- 0.89 versus 5.02 +/- 1.13 mL.min-1.kg IBW-1), and elimination half-life (119 +/- 43 versus 133 +/- 57 min) were not different between groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional adaptation of rat remnant colon after proximal hemicolectomy.

Functional adaptation of the remnant intestine after extensive resection of small bowel is well documented. The effects of partial resection of large bowel on the remaining colon have not been characterized. Transepithelial potential (VT), tissue resistance (RT), and short-circuit current (Isc) were measured in vitro across distal colonic tissue of rats three weeks after proximal hemicolectomy with ileotransversotomy and compared to the same parameters measured in the distal colon of control animals. In a second series of experiments, an in vivo perfusion technique was used to measure changes in sodium, potassium, and water transport in distal colon following proximal hemicolectomy. A 2.5-fold increase in VT (P less than 0.01), a 62% increase in RT (P less than 0.001), and a 35% increase in Isc (P less than 0.05) were observed three weeks following hemicolectomy when compared to control animals. A 64% increase in net sodium absorption (P less than 0.025), no significant change in net potassium transport, and a 115% increase in net water absorption (P less than 0.01) were demonstrated in hemicolectomized animals when compared to control. It is concluded that in the rat the distal colon is capable of functional adaptation to increase net sodium and water absorption within three weeks after proximal hemicolectomy. The mechanism responsible for this adaptive process has yet to be defined. Our findings may explain the lack of chronic diarrhea in patients undergoing right hemicolectomy.

Multiple bone fractures following an epileptic seizure in renal osteodystrophy.

Seizure induced bone fractures in patients with renal osteodystrophy are uncommon. A case is described where multiple bone fractures occurred following convulsions which appeared shortly after haemodialysis.

Accelerated recovery from doxacurium-induced neuromuscular blockade in patients receiving chronic anticonvulsant therapy.

STUDY OBJECTIVE: To determine whether a drug interaction exists between doxacurium and anticonvulsants. DESIGN: Open-label controlled study. SETTING: Inpatient neuroanesthesiology service at a university medical center. PATIENTS: Three groups of nine patients each, consisting of those chronically receiving carbamazepine, phenytoin, or no anticonvulsant therapy. INTERVENTION: Intravenous administration of doxacurium 60 micrograms/kg during anesthesia with nitrous oxide (N2O), fentanyl, and droperidol. MEASUREMENTS AND MAIN RESULTS: The adductor pollicis mechanical response to single 0.2-millisecond supramaximal pulses delivered to the ulnar nerve at 0.15 Hz was recorded. Patients receiving phenytoin or carbamazepine recovered neuromuscular function more quickly than did the control group. The times from doxacurium injection to 50% recovery of mechanomyographic response, for example, were as follows: control group, 161 +/- 55 minutes (mean +/- SD); phenytoin group, 76 +/- 31 minutes; and carbamazepine group, 66 +/- 27 minutes (p less than 0.05). The time for recovery from 75% to 25% blockade (recovery index) was decreased by 53% in the phenytoin group and by 67% in the carbamazepine group as compared with the control group (41.0 +/- 18.0 minutes and 28.6 +/- 8.6 minutes vs 86.4 +/- 45.2 minutes, respectively). CONCLUSION: Chronic treatment with anticonvulsants results in more rapid recovery from neuromuscular blockade produced by doxacurium.

Recombinant alpha-interferon may be efficacious in acute hepatitis B.

Whereas, in chronic type B hepatitis, the therapeutic effect of alpha-interferon has been studied extensively, data on the effect of interferon on the course and prognosis of acute hepatitis B are scarce in the literature. We report a case of acute type B hepatitis complicated by life-threatening extrahepatic manifestations where recombinant alpha-interferon facilitated clinical, biochemical, and serological recovery.