Effect of isobaric breathing gas shifts from air to heliox mixtures on resolution of air bubbles in lipid and aqueous tissues of recompressed rats.

Deep tissue isobaric counterdiffusion that may cause unwanted bubble formation or transient bubble growth has been referred to in theoretical models and demonstrated by intravascular gas formation in animals, when changing inert breathing gas from nitrogen to helium after hyperbaric air breathing. We visually followed the in vivo resolution of extravascular air bubbles injected at 101 kPa into nitrogen supersaturated rat tissues: adipose, spinal white matter, skeletal muscle or tail tendon. Bubbles were observed during isobaric breathing-gas shifts from air to normoxic (80:20) heliox mixture while at 285 kPa or following immediate recompression to either 285 or 405 kPa, breathing 80:20 and 50:50 heliox mixtures. During the isobaric shifts, some bubbles in adipose tissue grew marginally for 10-30 min, subsequently they shrank and disappeared at a rate similar to or faster than during air breathing. No such bubble growth was observed in spinal white matter, skeletal muscle or tendon. In spinal white matter, an immediate breathing gas shift after the hyperbaric air exposure from air to both (80:20) and (50:50) heliox, coincident with recompression to either 285 or 405 kPa, caused consistent shrinkage of all air bubbles, until they disappeared from view. Deep tissue isobaric counterdiffusion may cause some air bubbles to grow transiently in adipose tissue. The effect is marginal and of no clinical consequence. Bubble disappearance rate is faster with heliox breathing mixtures as compared to air. We see no reason for reservations in the use of heliox breathing during treatment of air-diving-induced decompression sickness.

Prevention of avascular necrosis in displaced talar neck fractures by hyperbaric oxygenation therapy: a dual case report.

Talar neck fractures are a rare injury that account for less then 2% of all foot fractures. Displaced fractures are associated with an exceedingly high rate of avascular necrosis (AVN). The incidence of AVN following Hawkins Type 3 fractures of the talar neck may approach 100%, particularly if diagnosis and reduction are delayed. Severe cases may present as pain and disability of the ankle and the subtalar joints due to a talar dome collapse, resulting in degenerative changes that usually require hind foot arthrodesis. We present two cases of traumatic displaced talar neck fractures which were treated surgically more than 2 weeks following injury due to a delay in diagnosis. Both patients underwent hyperbaric oxygen therapy (HBOT) after the operation and neither resulted in AVN of the talus in a three-year follow-up. We suggest that this favorable result may be due to the beneficial effects of HBOT.

[What is the role of compulsory ECT therapy today?].

Electro-convulsive therapy (ECT) has been effective for years, but it arouses opposition among patients and especially in the general public. ECT treatment is limited and compared to other medical treatment it is considered exceptional by the law, regulations and treatment personnel. A question arises as to the position of therapists regarding compulsory ECT treatment. A questionnaire was sent on this subject to all the units utilizing ECT in Israel. Opinions ranged from complete negation of compulsory ECT, to regarding such treatment as possible in cases when the patient is compulsorily hospitalized and/or when the patient's guardian supports this treatment. The authors' opinion is that the Law of Patients' Rights regarding special treatment when the patient is in extreme danger must be followed. The law requires that three physicians agree to the treatment, and compulsory treatment is no longer applicable when the danger passes. ECT treatment is important and imperative in certain conditions, especially conditions endangering patients' lives. In these conditions the law provides the authority to physicians to make decisions regarding treatment.

Hyperbaric oxygen therapy as a treatment for stage-I avascular necrosis of the femoral head.

Avascular necrosis (AVN) of the head of the femur is a potentially crippling disease which mainly affects young adults. Although treatment by exposure to hyperbaric oxygen (HBO) is reported as being beneficial, there has been no study of its use in treated compared with untreated patients. We selected 12 patients who suffered from Steinberg stage-I AVN of the head of the femur (four bilateral) whose lesions were 4 mm or more thick and/or 12.5 mm or more long on MRI. Daily HBO therapy was given for 100 days to each patient. All smaller stage-I lesions and more advanced stages of AVN were excluded. These size criteria were chosen in order to compare outcomes with an identical size of lesion in an untreated group described earlier. Overall, 81% of patients who received HBO therapy showed a return to normal on MRI as compared with 17% in the untreated group. We therefore conclude that hyperbaric oxygen is effective in the treatment of stage-I AVN of the head of the femur.

[Representing patients hospitalized under legal commitment at district psychiatric committees].

The Tel Aviv-Central District Office of the Public Defenders' Office has begun, as a trial project, to represent patients hospitalized under enforced commitments at district psychiatric committee hearings concerning their welfare. This experimental trial was carried out at the Abarbanel Mental Health Center starting 1st January 2000. The results illustrate that the chances of a patient hospitalized under enforced commitment being discharged from hospital are better if he is represented. It is particularly better when cooperation exists between his public defender and his treating psychiatrist. The results emphasize that the inclusion of the defender in the process affects the work program of the committee and its decisions, especially the examination of facts, the hearing of witnesses, the quality of the psychiatric assessment, the examination of the legal aspects and the summing up of the findings. From feedback received, it appears that all parties involved in the process feel that representation on behalf of the patients by the legal defenders results in more just and worthy decisions in every public aspect of the process. The authors recommend that legal representation be extended to all patients who are hospitalized under enforced commitments.

[Mentally ill soldiers in the reserves--professional secrecy and therapist judgment regarding reporting incapacity to carry weapons].

Medical confidentiality is a complex subject, requiring contemplation by both therapists and patients. Medical confidentiality is conventionally regarded to be in the best interest of the individual and opposed to public demands for information, especially on issues in which danger is involved. The therapist represents both the patient and the public, belonging to both worlds and acting according to existing laws and regulations. We report six incidences, in which important medical information was transferred to the army by the patient himself, rather than by the therapist. The therapist must consider his own judgment on the subject, in conjunction with existing laws and regulations.

The insanity defense: examination of the extent of congruence between psychiatric recommendation and adjudication.

The insanity plea is a known defense often utilized in courts of law. In such cases the accused may be referred for an outpatient psychiatric examination or for hospital observation. In this study, we examined the extent of the accord between the medical recommendations of the forensic unit of the Yehuda Abarbanel Mental Health Center and judicial decisions. It was found that in 99.4% of the cases, the court accepted the psychiatric recommendation. In only 2 cases the recommendations were not accepted. We discuss this issue and recommend improvements and strengthening of the relationship between the psychiatric and court systems.

Effect of combined recompression and air, oxygen, or heliox breathing on air bubbles in rat tissues.

The fate of bubbles formed in tissues during the ascent from a real or simulated air dive and subjected to therapeutic recompression has only been indirectly inferred from theoretical modeling and clinical observations. We visually followed the resolution of micro air bubbles injected into adipose tissue, spinal white matter, muscle, and tendon of anesthetized rats recompressed to and held at 284 kPa while rats breathed air, oxygen, heliox 80:20, or heliox 50:50. The rats underwent a prolonged hyperbaric air exposure before bubble injection and recompression. In all tissues, bubbles disappeared faster during breathing of oxygen or heliox mixtures than during air breathing. In some of the experiments, oxygen breathing caused a transient growth of the bubbles. In spinal white matter, heliox 50:50 or oxygen breathing resulted in significantly faster bubble resolution than did heliox 80:20 breathing. In conclusion, air bubbles in lipid and aqueous tissues shrink and disappear faster during recompression during breathing of heliox mixtures or oxygen compared with air breathing. The clinical implication of these findings might be that heliox 50:50 is the mixture of choice for the treatment of decompression sickness.

Guardianship for the severely mentally ill.

The process of appointing a guardian in the mental health field is a complex and important one. The guardian's duty is to protect a patient who is incompetent in making his own decisions. The guardian's role can be to correct past mistakes made by the patient (i.e. loss of property), manage the patient's present affairs and prevent future undesirable consequences. Characteristics of patients who are in need of guardianship have not previously been studied in Israel. We examined the characteristics of 60 hospitalized patients for whom a guardian was appointed, comparing them with another group of patients. Variables relating to disease severity such as diagnosis, duration of illness and employment status contrasted the groups. We may tentatively conclude that patients in need of legal guardianship are more severely ill than other mentally ill.

Differences in preterm delivery rates and outcomes in Jews and Bedouins in Southern Israel.

OBJECTIVE: (1) To compare the preterm delivery rates in the Bedouin versus the Jewish population. (2) To compare risk factors for preterm delivery in the two populations. (3) To compare outcomes of preterm delivery between the two groups. STUDY DESIGN: 41669 Jewish singletons births of whom 2816 delivered preterm (23-36 weeks) and 26495 Bedouin singletons in whom 2064 preterm deliveries occurred, were compared. All births took place in Soroka University Medical Center. Data were obtained from the computerized database of birth discharge records. RESULTS: The incidence of preterm delivery in Bedouin women was significantly higher than the rate in Jewish women (7.8 vs. 6.8%, P<0.01). The grand multiparity rate was higher among Bedouin women (P<0.001), as was the rate of teenage (<19 years) mothers (P<0.001). Gestational diabetes, PIH, and PROM rates were higher in the Jewish population (P<0.001, P=0.017, P<0.001, respectively). A bad obstetric history and previous perinatal mortality is more common in the Bedouin population (P<0.001 for both). In a logistic regression model including all these factors, the ethnic difference in the incidence of preterm delivery remained significant. The neonatal mortality rate was higher in the Bedouin population (P<0.001), as was the rate of congenital malformations (P<0.001). The perinatal mortality of Bedouins was nearly twice that of Jewish neonates with congenital malformations. However, no difference was found when neonates without congenital malformations were compared. Congenital malformations were found to be the strongest predictor of mortality. Ethnicity per se was no longer a predictor of mortality once congenital malformations were included in a logistic regression model, but the interaction of Bedouin ethnicity and congenital malformation was a significant predictor of mortality. CONCLUSION: The incidence of preterm delivery was significantly higher in Bedouin women than in Jewish women. A full explanation for this difference was not found. However, there were significantly higher rates of congenital malformations in the Bedouin preterm delivered infants. There was a much higher rate of neonatal mortality in the Bedouin population and this ethnic difference was fully explained by the presence of congenital anomalies.

Pleistocene milestones on the out-of-Africa corridor at Gesher Benot Ya'aqov, israel.

The Acheulean site of Gesher Benot Ya'aqov in the Dead Sea Rift of Israel documents hominin movements and technological development on a corridor between Africa and Eurasia. New age data place the site at 780,000 years ago (oxygen isotope stage 19), considerably older than previous estimates. The archaeological data from the site portray strong affinities with African stone tool traditions. The findings also reflect adroit technical skills and in-depth planning abilities, more advanced and complex than those of earlier archaeological occurrences in the Levant.

Working with mentally ill homeless persons: should we respect their quest for anonymity?

In recent years, the homeless population has received much attention as authorities attempt to comprehend this phenomenon and offer solutions. When striving to establish a relationship with the homeless person, many problems arise. We encounter this dilemma when respecting the right of the mentally ill to dwell neglected in the streets and simultaneously observe their inability to comprehend provisions such as housing, shelter, medical and mental care which contribute to their human dignity. The polarities of autonomy versus involuntary treatment are highlighted when treating the homeless population.

The relationship between subjective sleep estimation and objective sleep variables in depressed patients.

INTRODUCTION: To our knowledge there is no evidence in the literature about the relationship between subjective sleep estimation and objective sleep variables in depression. It is not known whether the subjective estimation of sleep quality and sleep duration is directly related to any objective sleep variable in depressed patients. METHODS: Thirty patients with major depression and 10 healthy subjects have been investigated in our sleep laboratory during 1 or 2 consecutive nights after 1 night for adaptation. Every subject, after final awakening in the laboratory, answered questions concerning the subjective feelings about sleep duration, number of awakenings and sleep depth. We compared the sleep estimation in both groups and calculated the correlation between objective and subjective sleep variables in depressed patients. RESULTS: The degree of a wrong sleep estimation in depressed patients is larger than in healthy subjects. Slow wave sleep (SWS) in depressed patients correlates positively with the subjective estimation of sleep duration. Eye movement density in REM sleep correlates with the subjective estimation of the number of awakenings. CONCLUSION: SWS in depression has a positive influence on the subjective feeling of sleep duration while phasic REM sleep activity has a negative influence.

The "re-entry group"--a transitional therapeutic framework for mentally ill patients discharged from the hospital to community clinics.

An effective transition of the psychiatric patient from the hospital to the community clinic is vital to the continuity of care. This study shows a short-term group, the "re-entry group," to be more effective in this transition than are patients discharged from a psychiatric hospital by the traditional process. We used a psychoeducational approach to facilitate active participation and compliance with outpatient therapy. Outcome variables included absorption of patients into the clinic, continued therapy, compliance with treatment, rehospitalization, level of knowledge regarding illness and medication, quality of rehabilitation, and attitude towards treatment.

The therapist and the patient: coping with noncompliance.

In the mental health clinic, the psychotherapist must cope with a multitude of diagnostic and therapeutic challenges. Extensive efforts are expended in reaching a diagnosis and a decision regarding treatment. Despite these efforts, the patient may fail to comply with the recommendations for treatment. Noncompliance has a wide variety of manifestations. One of the major reasons for noncompliance concerns the relationship between the patient and the physician, forcing the therapist to take an active part. Manifestations of noncompliance usually arouse countertransference reactions in therapists, who feel that this behavior exemplifies a lack of trust in them and in the corpus of knowledge they represent. Unique to the therapist's work in the mental health clinic is the need that sometimes arises to begin intervention before a basis for treatment has been established or an initial treatment contract achieved. In certain cases, observation is the only psychotherapeutic intervention possible. Much time may elapse until a therapeutic contract is established, and sometimes it is not established at all.

Human leukocyte antigen typing, response to neuroleptics, and clozapine-induced agranulocytosis in jewish Israeli schizophrenic patients.

The atypical antipsychotic agent clozapine is known to be effective in schizophrenic patients refractory to other medications; however, it induces agranulocytosis in approximately 1-2%. In Jews, this complication is associated with the haplotype HLA B38,DR4,DQ3. The aim of the present study was to determine which human leukocyte antigen (HLA) antigens are involved in clozapine-induced agranulocytosis. We performed HLA typing in 88 Jewish Israeli schizophrenic patients and in 127 ethnically matched healthy individuals. Thirty-eight patients responsive to standard antipsychotic medications were treated with haloperidol, and 50 refractory patients received clozapine. A trend was noted for elevated rates of HLA B38 among control individuals and clozapine-treated patients of Ashkenazi origin compared to individuals of non-Ashkenazi origin, but the findings failed to reach statistical significance. No association was found between HLA class I antigens and the response to haloperidol or clozapine. Neutropenia developed in two clozapine-treated patients and agranulocytosis in one. Two of these three patients were of Ashkenazi origin, and both demonstrated the HLA B38 phenotype. Although the findings did not reach a statistical significance because of the small number of patients, they may support an association between clozapine-induced neutropenia/agranulocytosis and Ashkenazi origin and the HLA B38 phenotype. The rate of agranulocytosis in our sample (2%) is similar to the usual cumulative risk of agranulocytosis but in contrast to its high frequency among Jewish American patients. One possible explanation for this difference is the high rate of Ashkenazi patients in the American sample and the preponderance of non-Ashkenazi patients in our population.