Israel Medical Association Journal

Background: Despite advances in cancer therapy the treatment of liver tumors remains a challenge. Most patients are poor candidates for surgical resection; both chemotherapy and irradiation have a low success rate and neither is without complications. New minimally invasive techniques for ablation of unresectable tumors have gained attention as effective treatment alternatives. Among these are percutaneous ethanol injection and radiofrequency ablation; both are effective for primary liver tumors and RFA is also effective for hepatic metastases.

Objective: To report our experience with PEI and RFA in the treatment of hepatic lesions.

Methods: The study included 49 lesions in 27 patients: 23 primary lesions in 13 patients treated with PEI and 26 lesions (22 secondary and 4 primary) in 14 patients treated with RFA. PEI was performed on an outpatient basis in the ultrasound suite; RFA was done in hospitalized patients (9 in the ultrasound suite and 4 in the operating room). Patients were followed with triphasic spiral computerized tomography 1 month after treatment and every 3±6 months thereafter.

Results: Complete necrosis was achieved with PEI on the first attempt in 11 of 23 primary lesions (91.3%). In 8.7% (2/23) a second series of treatments was required. Using RFA, complete necrosis was achieved in 85% of lesions (22/26) and partial necrosis in 15% (4/26). Complications included low fever (3 patients), high fever and abscess formation (1 patient), peri-tumoral necrosis (1 patient ) and portal vein thrombosis (1 patient ).

Conclusions: Our preliminary results confirm that PEI and RFA are an effective and safe option for treating hepatic tumors in patients unfit for surgery.
 

Background: Experimental and clinical protocols are being developed for the cryopreservation of human hematopoietic progenitor cells. However, the effect of these procedures on the potential for HPC[1] to repopulate bone marrow is unknown.

Objectives: To examine the effect of cryopreservation on the ability of fetal human liver HPC, which include CD34+ cells and long-term culture-initiating cells, to repopulate immunodeficient non-obese diabetic/severe combined immunodeficiency mouse bone marrow.

Methods: Groups of sublethally irradiated NOD[2]/SCID[3] mice were injected intravenously with cryopreserved or freshly isolated fetal human liver HPC.

Results: Seven weeks after transplantation, flow cytometric analysis of bone marrow samples showed that mice that received the transplanted cells (either cryopreserved or freshly isolated) demonstrated both lymphoid and myeloid differentiation as well as the retention of a significant fraction of CD34+ cells. Conclusions: Cryopreserved fetal human liver-derived HPC appear to be capable of initiating human cell engraftment in NOD/SCID mouse bone marrow and open the possibility of using cryopreserved fetal human liver HPC for gene manipulation, gene transfusion therapy, and transplantation purposes.

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[1] HPC = hematopoietic progenitor cells

[2] NOD = non-obese diabetic

[3] SCID = severe combined immunodeficiency

Background: Percutaneous transluminal septal ablation was recently introduced as an alternative to surgical treatment of hypertrophic obstructive cardiomyopathy. In this procedure, alcohol is injected into a proximal septal artery to create a localized myocardial infarction.

Objectives: To characterize the immediate and mediumterm results following PTSMA.

Methods: Of 13 patients referred for PTSMA, 8 were found suitable for the procedure. Hemodynamic parameters were evaluated prior to and following the procedure, and clinical and echo-Doppler parameters at 2 weeks and 9 months later.

Results: The procedure was technically successful in all patients. Resting left ventricular outflow gradient at rest (by Doppler) fell from 82 + 37 to 15 + 8 mmHg (P<0.001) 9 months later. Late post-procedural gradient after the Valsalva maneuver was 2 + 24 mmHg. The degree of mitral regurgitation fell from 2.0 + 0 to 1.5 + 0.5 (P<0.05). New York Heart Association class for dyspnea improved from 2.8 + 0.5 to 1.8 + (P<0.01) and Canadian Cardiovascular Society class for angina from 2.0 + 1.3 to 1.3 + 1.2 (P=0.08). Complete right bundle branch block developed in six patients, temporary complete atrioventricular block in three, and persistent block requiring permanent pacing in one. No flow in the distal left anterior descending coronary artery (presumably due to spilling of alcohol) was seen in one (with development of a small antero-apical infraction) and ventricular fibrillation 2 hours post-procedure in one. None of the patients died.

Conclusion: PTSMA provided a substantial reduction in left ventricular outflow gradient associated with an improvement in symptomatology. Serious complications are not uncommon. Long-term follow-up is unknown.
 

Background: At the start of the Bone and Joint Decade 2000-2010, a paleopathologic study of the physically disabled may yield information and insight on the prevalence of crippling disorders and attitudes towards the afflicted in the past compared to today.

Objective: To analyze “The procession of the Cripples,” a representative drawing of 31 disabled individuals by Hieronymus Bosch in 1500.

Method: Three specialists - a rhumatologist, an orthopedic surgeon and neurologist - analyzed each case by problem-solving means and clinical reasoning in order to formulate a consensus on the most likely diagnosis.

Result: This iconographic study of cripples in the sixteenth century reveals that the most common crippling disorder was not a neural form of leprosy, but rather that other disorders were also prevalent, such as congenital malformation, dry gangrene due to ergotism, post-traumatic amputations, infectious diseases (Pott’s, syphilis), and even simulators. The drawings show characteristic coping patterns and different kinds of crutches and aids.

Conclusion: A correct clinical diagnosis can be reached through the collaboration of a rheumatologist, an orthopedist and neurologist. The Bone and Joint Decade Project, calling for attention and education with respect to musculoskeletal disorders, should reduce the impact and burden of crippling disease worldwide through early clinical diagnosis and appropriate treatment.
 

Although a depressive state is known to occur following the resolution of an acute psychotic episode, little research has investigated its etiology, course, prognosis and treatment. Very often the depression is mistaken for an extrapyramidal­like syndrome — the secondary effect of antipsychotic medica­tion - as a sense of inevitability assails both the patient and therapist. Post-psychotic depression, far from being an obscure and undefined clinical picture, has the characteristics of a clear-cut syndrome. Nevertheless, it was only recently referred to as a distinct entity in psychiatric classification systems. As a result, different researchers used varying criteria for the definition of the phenomenon, and the data collected in the different studies are therefore difficult to compare. We present a critical review of the data published to date, with emphasis on the importance of early recognition and treatment of post-psychotic depression.

Background: Cryosurgery is a minimally invasive treat­ment option for prostate cancer.

Objectives: To report on the first series of cryosurgical ablation for prostate cancer performed in Israel.

Methods: Cryosurgical ablation of the prostate was undertaken in 2 patients aged 53-72 diagnosed with adenocarcinoma of the prostate. The procedures were performed percutaneously and were monitored by real-time trans-rectal ultrasound. The CRYOHIT machine applying Argon gas was used with standard or ultra-thin cryoprobes. The average follow-up was 12.8 months postsurgery (range 1- 24 months).

Results: No rectal or urethral injuries occurred and all patients were discharged from hospital within 24-48 hours. The duration of suprapubic drainage was 14 days in 10 patients and prolonged in 2. Early complications included penoscrotal edema in four patients, perineal hematoma in three, hemorrhoids in two and epidydimitis in one. Long-term complications included extensive prostatic sloughing in one patient and a perineal fistula in another, both of whom required prolonged suprapubic drainage. Minimal stress incontinence was noted in two patients for the first 8 weeks after surgery. None of the patients has yet regained spontaneous potency. A prostate-specific antigen nadir of less than 0.5 ng/ml was achieved in eight patients and an undetectable PSA level below 0.1 ng/ml in five patients.

Conclusion: Cryoablation for prostate cancer is safe and feasible, and the preliminary results are encouraging. Further study is needed to elucidate the efficacy of the procedure.