[EVALUATION OF THE DIZZY PATIENT - FROM THE VESTIBULAR IMPAIRMENT TO THE PATIENT'S FUNCTIONAL ABILITY].

INTRODUCTION: The vestibular system - the sixth sense - allows humans to preserve balance, stable vision, and body orientation in space. This system performs a continuous integration of the activity of the vestibular end-organ in the inner ear, the sense of sight, and the proprioceptive sense. Damage to the components of the vestibular system causes dizziness, imbalance, and poor orientation in space. Following vestibular injury, central compensation mechanisms are recruited to reduce the symptoms and improve the functional ability of the dizzy patient. Dizziness is a subjective complaint. Yet, the development that has taken place in the field of vestibular function testing allows accurate diagnosis, targeted treatment, and disability assessment of the dizzy patient. The dizzy patient must be examined meticulously, taking into account all the levels on which the vestibular impairment can affect (physiological, behavioral, and functional). Meaning, clinical and laboratory evaluation of the vestibular function together with functional testing of the patient. In this article, the authors present the range of existing innovative tests of the vestibular system. Vestibular tests are accepted in advanced vestibular laboratories in Israel and around the world, and enable assimilation in vestibular clinics and medical committees in Israel.

[Is there an indication for parenteral nutrition support in the terminally ill cancer patient?].

Cancer cachexia is mediated by cytokines affecting intermediate metabolism of energy, proteins, carbohydrate and lipid. It is aggravated by common therapeutic measures: surgery, chemotherapy and radiotherapy that reduce oral intake as well as increase catabolism. Enteral or parenteral nutrition support decreases the catabolic rate of the patient, helping the patient withstand the side effects of the therapeutic measures, but do not reverse to anabolism. Terminally ill cancer patients who are refractory to the different therapeutic measures need palliative care. Nutrition is a basic human right and is conceived by the patient and his family, as well as by the medical community and human society, to be vital for survival. We obviously make every effort to feed our cancer patients as long as they can tolerate food via the alimentary system. However, we are reluctant to administer parenteral feeding, due to fear of accelerated tumor growth, complications, cost and futility, thereby leading to unnecessary prolongation of suffering. However, there is a group of patients who, although they are not candidates for any antineoplastic therapy, are still in good physical and mental condition, with expected life spans of three months or more, suffering from conditions such as intestinal obstruction, fistulas or any condition which makes the preferred route of enteral nutrition impossible. In these specific patients, palliative parenteral nutrition should be considered. The functional status of the patient has to be reasonable (Karnofsky status > 50, ECOG< 3). The decision should be taken after careful multidisciplinary discussion. The patient and caregivers should be aware that this is not a cancer-specific treatment and probably will not prolong the patient's life. Total parenteral nutrition (TPN) in this situation is best if provided at the patient's home.

Dental complications following gastric restrictive bariatric surgery.

BACKGROUND: Morbid obesity is a scourge of the 21st century. The effective therapeutic measure is bariatric surgery. The medical literature has inadequately reported the potential deleterious effects of such surgery on dental health. Acidic levels in the oral cavity, which are known to be one of the postoperative side-effects of bariatric surgery, directly result in dental caries and tooth erosion. We investigated the self-assessment of postoperative bariatric patients with regard to their dental health and associated variables. METHODS: 113 patients (25% compliance), who had been operated on in three Jerusalem hospitals, responded to a mailed questionnaire. RESULTS: Patients' average age was 40+/-10 years; bariatric surgery had been performed 5+/-4 years previously. Of the patients, 37% reported eating more sweet foods after surgery, only 20% reported improved oral hygiene, only 34% reported increased frequency of visits to the dentist, and 37% reported greater dental hypersensitivity after surgery. Significant associations were found between reported dental hypersensitivity and vomiting (P=0.013), and also dental hypersensitivity and indigestion (P=0.021). Patients from the three hospitals reported different patterns of visits to the dentist. The most common variable (80% of the subjects) associated with visits to the dentist after surgery was dental hypersensitivity. CONCLUSION: Medical teams need to consider potential dental problems after bariatric surgery, and to supply their patients with the appropriate information and instructions regarding oral hygiene maintenance, healthy dietary patterns and regular dental health monitoring by a dentist or dental hygienist.

Unique features of laparoscopic cholecystectomy in Beta thalassemia patients.

Beta Thalassemia patients suffer from a high incidence of gallstones as well as systemic complications of iron overload. We performed laparoscopic cholecystectomy in 8 beta thalassemia patients and describe their specific features. Diagnosis was based on patients' clinical presentation and sonography. Trocars were readjusted due to the hepatomegaly. No intraoperative cholangiograms were performed. Follow-up included clinical assessment and abdominal sonography. All procedures were completed laparoscopically. Pigment cirrhosis and fibrosis around the cystic duct were noted in all patients. No biliary injury occurred. Post operatively, 4 patients suffered fluid leakage through the trocar site, treated conservatively. No major cardiopulmonary complications occurred. During a mean follow-up time of 65 months, all patients are symptom free and without evidence of biliary lithiasis. Thalassemia patients are difficult and often high-risk patients. Improvement in anesthesia and monitoring enables better management of these patients. Laparoscopic cholecystectomy should be advised in carefully selected thalassemia patients.

Autologous melanoma vaccine induces antitumor and self-reactive immune responses that affect patient survival and depend on MHC class II expression on vaccine cells.

PURPOSE: Autologous melanoma cells display a broad variety of tumor antigens and were used for treatment of American Joint Committee on Cancer stages III and IV melanoma as an adjuvant or active therapy. Survival data and immune response were evaluated in vaccinated patients. EXPERIMENTAL DESIGN: Forty-seven patients received 2,4-dinitrophenyl-conjugated autologous melanoma vaccine as an adjuvant (23 patients) or therapy (24 patients). CD4 and CD8 T-cell response in blood sampled before vaccination and after five or eight vaccine doses was evaluated against melanoma cells and autologous peripheral blood mononuclear cells using IFNgamma enzyme-linked immunospot. Serum levels of antilivin, an inhibitor of apoptosis, and anti-gp100 IgG were determined. RESULTS: The immunologic effect of the vaccine differed between the two groups of patients. In the adjuvant group, there was a significant increase in CD8 melanoma-reactive T cells (P = 0.035) after vaccination and an increase in antimelanoma CD4 T cells correlating with improved overall survival (P = 0.04). In the therapeutic group, there was no objective tumor regression; antimelanoma T-cell reactivity increased by a small amount, stayed the same, or in some cases decreased. In all patients, a significant increase was noted in CD4 T-cell reactivity against autologous peripheral blood mononuclear cells (P = 0.02), which did not affect survival. Increased antilivin IgG was associated with improved survival. Expression of MHC class II on melanoma cells was vital for the immunogenicity of the vaccine. CONCLUSION: Autologous melanoma cell vaccine is capable of inducing effective antimelanoma CD4 T-cell activity associated with improved survival. Patients with active metastatic disease generally displayed reduced immune response and gained little from active immunization.

Bleeding, obstruction, and perforation in a series of patients with aggressive gastric lymphoma treated with primary chemotherapy.

BACKGROUND: The management of patients with gastric lymphoma has evolved, with a shift toward nonsurgical treatment. The rates of surgical complications in patients receiving chemotherapy have been insufficiently studied. The objective of this study was to assess the frequency of bleeding, perforation, and gastric outlet obstruction in patients who received chemotherapy as primary treatment for gastric diffuse large B cell lymphoma (DLBCL). METHODS: We reviewed files of all patients with gastric DLBCL who were diagnosed and treated primarily with chemotherapy in our hospital between 1990 and 2005. RESULTS: Eighteen (25%) of 73 patients experienced surgical complications, of whom 6 (8%) underwent surgery. Eight patients (11%), six with active lymphoma, experienced gastric bleeding; one required gastrectomy. Eight patients (11%) developed gastric outlet obstruction, of whom three were treated conservatively, three required surgery, one stopped treatment, and one received further chemotherapy. Six of the eight patients had no evidence of active lymphoma at the time of obstruction. Two additional patients underwent gastrectomy due to resistant or relapsed disease. Gastric perforation was not observed. Median survival was 90 months for the entire series, 94 months for patients with gastric outlet obstruction, and 11.5 months for patients with gastric bleeding. CONCLUSIONS: Given the rate of surgical complications, especially gastric bleeding and gastric outlet obstruction, there is still an important role for the surgical consultant in the treatment of patients with gastric DLBCL receiving chemotherapy. Gastric perforation, although frequently cited as a complication, is in fact rarely observed.