תוצאת חיפוש

High Alkaline Phosphatase in Subacute Thyroiditis

Rami Kantor, Rachel Pauzner, Elena Pali, Zvi Farfel

Dept. of Internal Medicine E, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Subacute thyroiditis may be hard to diagnose, therefore patients are sometimes misdiagnosed and subjected to unnecessary work-up. We report a 37-year-old man with subacute thyroiditis and a high concentration of serum alkaline phosphatase. After aspirin treatment there was clinical improvement and decrease in rapid ESR, and in high serum thyroxin and alkaline phosphatase. The increased alkaline phosphatase, seen in as many as 50% of patients, is of hepatic origin, and is not caused by high serum thyroxin. Awareness of this relationship may help in diagnosis and may prevent unnecessary diagnostic procedures, which may be invasive.

Pelvic Floor Exercise and Biofeedback in Genuine Stress Incontinence

D. Gordon, D. Luxman, Y. Sarig, A. Groutz

Women and Children's Division, Liss Hospital, Sourasky-Tel Aviv Municipal Medical Center and Sackler Faculty of Medicine, Tel Aviv University

Stress urinary incontinence is a medical and social problem. In the past decade there has been increased awareness of this condition and the number of those affected who seek help is increasing. Treatment is usually surgical - elevation of the bladder neck. Pelvic floor exercise is an accepted conservative treatment modality used for mild to moderate cases that have not yet completed their families.

We present our results in 30 women, aged 28-71 years, av. 49% with genuine stress incontinence treated with pelvic floor exercise and biofeedback. 14 patients (46.7%) were completely cured and 15 (50%) were improved. In only 1 was there no improvement.

Our results show significant improvement in the duration and intensity of pelvic floor contractions after treatment. Pelvic floor exercise with biofeedback is a very important treatment modality, requiring a highly motivated patient and a physiotherapist specialized in pelvic floor exercise.

Treatment of Retroperitoneal Sarcoma

Dina Lev-Chelouche, Subhi Abu-Abeid, Mordechai Gutman, Yoram Kluger, Moshe Michovitch, Isaac Meller, Moshe Inbar, Joseph M. Klausner

Depts. of Surgery B, Orthopedic Oncology and Oncology, Tel Aviv - Sourasky Medical Center (Affiliated with Sackler Faculty of Medicine, Tel Aviv University)

Soft tissue sarcomas are exceedingly rare, making up less than 1% of all solid malignancies. In the retroperitoneum, they tend to be large when diagnosed and are a therapeutic challenge to the surgical oncologist. Our experience with 51 patients with retroperitoneal sarcomas operated on during the past 4 years is presented. 37 were primary and 26 presented as recurrent tumors. The group included many different histological sub-types, the majority being high grade tumors.

Complete resection was achieved in 84%, necessitating extensive surgery, but was not possible in 8 patients (16%) who underwent partial resection or biopsy only. There was 1 perioperative fatality (2%). 18 (35%) suffered complications, all of which were reversible. The estimated 5-year survival in the complete resection group is 40%, while none of those who underwent partial resection survived more than 2 years. There was significantly better survival in patients with primary, low grade sarcomas which were smaller than 8 cm, compared to those with high-grade, recurrent sarcomas larger than 8 cm. Local recurrence developed in 8 patients of the complete resection group (18%), 2 months to 3 years after surgery.

These data show that despite the concept of retroperitoneal sarcomas as being aggressive, invasive tumors with a poor prognosis, the prognosis is not unusually bad. With proper surgical technique, resectability may be high, with improved overall survival.

Malignant Lymphoma of the Bladder

Y. Mor, Z. Dotan, J.H. Pinthus, I.S. Engelberg, J. Golomb, J. Ramon

Depts. of Urology and Pathology, Chaim Sheba Medical Center, Tel Hashomer

Urinary tract lymphoma is usually reported when the secondarily stem is affected by widespread non-Hodgkin lymphoma. We describe an 83-year-old woman who presented with secondary lymphoma of the bladder 3 years after diagnosis when it initially infiltrated her breast. Treatment included local transurethral excision followed by chemotherapy, during which she died of disseminated disease.

CT-Guided Excision of Osteoid Osteoma

A. Peyser, S. Porat, T. Sasson, J. Apelbaum, J. Bar-Ziv, E. Sucher

Orthopedic Surgery and Radiology Depts., Hadassah University Hospital, Ein Kerem, Jerusalem

CT-guided excision of osteoid osteoma is a new surgical technique that enables accurate resection of the nidus during 1-day hospitalization. We present 5-year results in 42 patients (26 males and 16 females, mean age 18 years, range 3-46). In 40 out of 42, complaints disappeared immediately after the procedure. The recovery period was short and the return to normal activity was faster than in the open surgical approach. Complications were minimal and transient.

Clinical and Immunological Characteristics of HIV-Positive AIDS in Children in Northern Israel

E. Kedem, A. Etzioni, E. Shahar, S. Pollack

Institute of Immunology, Allergy and AIDS and Dept. of Pediatrics A, Rambam Medical Center and B. Rappaport Faculty of Medicine, The Technion, Haifa

We are treating 11 children in our AIDS clinic. All were infected by vertical transmission from carrier mothers. However, among 31 HIV-carrier AIDS patients who were under follow-up during pregnancy, supposedly taking zidovudine prophylaxis, only 1 (3.3%) gave birth to a baby infected with HIV. Our children with HIV and AIDS are 3 months to 12 years of age (average 4.5 years); mean age at diagnosis was 18 months. All are either symptomatic or have laboratory evidence of progressive immunodeficiency, 1 is asymptomatic (N2), 1 has mild symptoms (A2) and the rest present significant symptoms or AIDS-defining disease. All have moderate to severe immunodeficiency, as evidenced by CD4+ cells counts. 60% have rapidly progressive disease, based on their symptomatology and immune state, whereas clinical reports in the literature point to only 10-15%. However, the average CD4+ cell count was 22% (749/mm³) at diagnosis and 22% (759/mm³) at last follow-up. These stable findings during an average follow-up of 28 months probably reflect the effect of medical and supportive treatment.

All received antiretroviral medication consisting of a combination of 2 or 3 drugs. 8 of 11 also received prophylactic treatment against opportunistic infections and 8 of 11 are clinically well. Routine follow-up and a good relationship with the patient's family increase cooperation and promote optimal medical treatment, and consequently improve the clinical condition and quality of life.

Knowledge and Practice of Primary Care Physicians Relating to Streptococcal Pharyngitis

S. Leshem, H. Tabenkin, E. Dan, A. Tamir

Family Medicine Dept., Emek Medical Center and Northern District of Kupat Holim; and Northern Branch of Specialization Institute, Faculty of Life Sciences, Ben-Gurion University of the Negev, Beer Sheba

Knowledge and practice of primary care physicians as to diagnosis and treatment of group A, b-hemolytic streptococcal pharyngitis, and the degree to which they agreed with the medical literature and current clinical guidelines were examined. The study was conducted in a group of 195 general physicians, pediatricians, and family medicine specialists and residents. The data were collected using questionnaires which included personal information and questions relating to b-hemolytic streptococcal pharyngitis and were analyzed by chi-square and t-tests, and logistic regression, as appropriate. A new dependent variable, good clinical practice (GCP), was defined as the total number of correct answers to the questions in the questionnaire. 147 of the 195 eligible physicians returned completed questionnaires, a compliance rate of 76%.

96.6% cited pV as the drug of choice at a daily dosage of 1 g (43.7%) or 2 g (25.4%), for 10 days (90%). 133 physicians (90%) stated that the goal of penicillin therapy for beta-hemolytic streptococcal pharyngitis is to prevent late complications. 116 physicians (82%) cited rheumatic fever as a complication of group A beta-hemolytic streptococcal pharyngitis, preventable by appropriate antibiotic therapy. However, only 84 (59%) cited glomerulonephritis as a preventable complication.

When the knowledge and attitudes of the respondents was analyzed in terms of the new variable, GCP, a significant association (p<0.001) was found between physicians’ attitudes and variables such as where they had studied medicine, and work seniority. Those with less seniority and or medical graduates of the Americas demonstrated greater knowledge and better clinical judgment than their more senior colleagues and graduates of European and Asian medical schools. Most primary care physicians in northern Israel treat group A b-hemolytic streptococcal pharyngitis as recommended in the medical literature.

The level of medical studies in Israel and the Americas and the quality of training of residents in family medicine and pediatrics, have a positive influence on the degree of knowledge of as common a subject as b-hemolytic streptococcal pharyngitis. Emphasis should be placed on continuing medical education among primary care physicians, particularly veteran general physicians and those who studied in European or Asian medical schools.

Circadian Fluctuations in Efficacy of Streptokinase Thrombolysis

E. Goldhammer, L.Kharash, E.G. Abinader

Cardiology Dept., Bnei-Zion Medical Center and Technion Faculty of Medicine, Haifa

This study was designed to assess possible diurnal fluctuations in the efficacy of thrombolysis with streptokinase. 156 consecutive patients treated with streptokinase during the period 1.1.95-1.7.96 were studied retrospectively. Success or failure of thrombolysis was determined according to the accepted clinical and angiographic criteria starting at midnight, 12 times at 2-hour intervals, then 8 times at 3-hour intervals, and then 6 times at 4-hour intervals. A definite peak for successful thrombolysis was found in the late afternoon and early evening hours. Between 16:00-20:00 PM, in 30.23% successful thrombolysis were observed, compared to 6.98% between 20:00-24:00 PM (p<0.05) and in 10.53% between 00.00-04:00 AM (p<0.05).

Multiple regression analysis showed that the independent factor with the greatest impact on successful reperfusion was the actual time until thrombolysis (p=0.037); then came the interval from pain onset to streptokinase administration (p=0.020), while age and gender had much lesser impacts (p=0.328 and 0.215, respectively), and individual risk factors even less.

These findings may have several clinical implications: dose adjustment for the time of day may be required, with larger doses needed during morning hours, or preference for primary coronary angioplasty to avoid increase in bleeding complications due to higher doses of thrombolytic agents.

Balloon Angioplasty of Native Coarctation of the Aorta

Benjamin Zeevi, Galit Bar-Mor, Michael Berant

Cardiac Catheterization Unit, Schneider Children's Medical Center, Petah Tikva, and Sackler School of Medicine, Tel Aviv University

The use of balloon dilatation to treat native coarctation of the aorta is gaining acceptance among interventional pediatric cardiologists, but is still controversial. We describe our experience with this procedure in 21 children, mean age 5.6 years and mean weight 21.1 kg. Most had an additional congenital heart defect, most commonly a bicuspid aortic valve. 17 were asymptomatic, 3 had tachypnea and 1 infant had severe congestive heart failure and was ventilated. The mean systolic blood pressure was 129.7 mm Hg.

Balloon dilatation was successful in 90% (19), decreasing the mean maximal systolic gradient from 35.3 to 9 mm Hg (p<0.001), and increasing the narrowest area from 3.9 to 8.2 mm (p<0.001), with a mean balloon-to-coarctation width-ratio of 2.8. There were no complications. Of 15 who underwent repeat cardiac catheterization at a mean interval of 10.6 months, 2 had a maximal systolic gradient of more than 20 mm Hg. 1 of these underwent successful repeat angioplasty and the other, who also had a small aneurysm, underwent surgical repair successfully. 2 others had small aneurysms and they are being followed clinically.

All patients were seen again after a mean interval of 31 months. The mean systolic blood pressure was 104 mm Hg, significantly lower than before intervention (p<0.002). 1 had an increased pressure gradient between right arm and leg of 35 mm Hg at later follow-up, and repeat cardiac catheterization demonstrated a good result 13 months after the initial procedure. She is awaiting a third catheterization. Overall, 90% had good mid-term results.

Based on our experience and recent reports, balloon angioplasty is safe and effective in most children older than 7 months and should be considered a viable alternative to operation for discrete aortic coarctation. Further long-term evaluation is needed.

The Wandering Spleen

A. Ravid, D. Lev, V. Makarin, Y. Klausner, M. Umansky Y. Kluger

Surgery B and C Depts., Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

We describe a 26-year-old woman with thrombocytopenia discovered during gestation. On admission for evaluation of abdominal pain, torsion of an ectopic spleen was found. The spleen was removed and the thrombocytopenia resolved.

Portal and Mesenteric Vein Thrombosis after Splenectomy for Idiopathic Thrombocytopenic Purpura

Eldad Silberstein, Alexander Smolikov, Itzhac Levi

Surgery B Dept. and Nathanzon Institute of Radiology, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Mesenteric and portal vein thrombosis are rare complications of splenectomy. Their presentation depends on the underlying disease. It is most frequent in lymphoproliferative disorders but extremely rare in trauma. We describe a 22-year-old man and a 49-year-old woman who underwent splenectomy for idiopathic thrombocytopenic purpura and developed mesenteric and portal vein thromboses. Both were treated successfully with anticoagulants for 3 months until the thrombi regressed, as shown by CT scan. During a year of follow-up they were asymptomatic.

Danaparoid-Sodium for Dialysis in Heparin-Associated Thrombocytopenia

Ronen Ben Ami, Ruth Rachmimov, Shlomo Berliner

Medicine Dept. D and Anticoagulation Therapy Unit, Tel Aviv-Souraski Medical Center, and Nephrology Institute, Sheba Medical Center, Tel Hashomer

Danaparoid sodium is an anticomposed of 3 glycosaminoglycans: heparan sulfate, dermatan sulfate and chondroitin sulfate. Similar to heparin, operates by activating antithrombin 3, but does not contain heparin or heparin fragments, and is therefore antigenically distinct.

Danaparoid has been advocated as a safe and effective anticoagulant for heparin-associated thrombocytopenia. However, there is little experience in its use as a substitute for heparin in hemodialysis.

We report 2 men, aged 82 and 73 years, respectively, who developed thrombocytopenia while undergoing hemodialysis with heparin, and who subsequently underwent successful dialysis with danaparoid. There was a rise in platelet levels in both while receiving danaparoid, and dialysis was completed without hemorrhagic or thrombotic complications. Danaparoid is a safe and effective substitute for heparin, and may be used as an anticoagulant in hemodialysis.

Nerve Palsies Following Prolonged Use of Limb Tourniquets

G. Volpin, R. Said, W. Simri, B. Grimberg, M. Daniel

Depts. of Orthopedic Surgery and Neurology, Western Galilee Hospital, Nahariya

Nerve paralysis following the use of tourniquets, regular or pneumatic, for limb surgery is rare. We describe a 19-year-old male soldier who had tourniquets applied for 3 1/4 hours to his arm and both legs due to penetrating injuries. As a result, he suffered palsy of the radial nerve and both common peroneal nerves. Nerve palsy in such cases has not been described in the literature. It is not clear whether the cause is direct mechanical pressure on the nerve, nerve ischemia, or a combination of both.

We recommend that tourniquets should not be used continuously for more than 2 hours. If evacuation of the injured is delayed, the medical team should consider loosening tourniquets for short intervals or changing for a pressure bandage. This is providing the patient's condition is stable and bleeding does not start again on release of the tourniquet.

Operative Laparoscopy in Pregnancy

Eylon Lachman, Abraham Schienfeld, R. Boldes, Samuel Levin, Michael Burstein, Michael Stark

Depts. of Obstetrics and Gynecology, Misgav Ladach Hospital, Jerusalem

The development of laparoscopic surgery in gynecology and general surgery has greatly advanced over the past decade, and recently has been successfully performed in pregnancy. In the English literature we found that of the 518 cases reported (mean age 32 years) the most common was for cholecystectomy (45%), followed by operations on the adnexae (34%), appendectomy (15%) and others (6%). To these we add 3 cases of cholecystectomy and 1 of an adnexal tumor. Of all the reported cases, 33% were performed in the 1st trimester, 56% in the 2nd and 11% in the 3rd.

This review demonstrates a definite trend to laparoscopy in pregnancy. It appears to be safe when performed by experienced surgeons, but further studies addressing safety of laparoscopic surgery during pregnancy are needed to reach definitive conclusions.

Brucellosis Presenting as Acute Abdomen

Nathan Kaufman, Noga Reichman, Edith Flatau

Dept. of Medicine B, HaEmek Medical Center, Afula

Usually symptoms of brucellosis are nonspecific and characterized by a wide range of complaints. Although the disease in Israel is almost exclusively food borne (caused by Brucella melitensis in unpasteurized goat milk products) so the main route of infection is the gastrointestinal tract, but gastrointestinal complications are rare, and only sporadic cases of ileitis or colitis have been described.

We present a 43-year-old woman with an acute abdomen, probably due to diverticulitis. It was diagnosed only after blood cultures were positive for Brucella melitensis. We believe that its protean manifestations should be consin addition to the other bizarre presentations of this disease, important in our region.