תוצאת חיפוש

Fibrosarcoma after Silicone Breast Augmentation: Associated?

Anabel Aharon-Maor, Yair Levy, Yehuda Schoenfeld

Medical Dept. B, Chaim Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University

We describe a 42-year-old woman in whom bilateral fibrosarcoma of the breast was diagnosed 15 years after bilateral breast augmentation with silicone implants. 3 years prior to admission the implants were replaced and 2 years prior to admission mammography showed a nodule in the left breast which biopsy showed to be fibrosarcoma. The implants were removed from both breasts and she was given chemotherapy but later that year underwent bilateral mastectomy. Despite chemotherapy, as well as adjuvant radiotherapy, the disease progressed, with involvement of the lungs and the skin of the left hemithorax. She was admitted repeatedly for severe anemia caused by bleeding from the malignant skin lesions, and died less than 2 years after diagnosis of the disease.

Not all reports in the literature find a significant connection between silicone implants and subsequent development of breast cancer, but there are reports that do connect them. Breast fibrosarcoma is not significantly more frequent after silicone augmentation, but still there is controversy as to whether there is a connection between silicone implants and breast malignancy. In the patient we present, the prolonged exposure to silicone may have been a predisposing factor for the development of bilateral fibrosarcoma, since other known risk factors for breast cancer were denied.

Prevalence of Pigmentary Dispersion Syndrome in Israel

D. Gaton, A. Barak, S. Segev, Y. Yassur, G. Treister

Ophthalmology Dept., Beilinson Medical Center, Petah Tikva and Ophthalmology Dept. and Institute for Medical Screening and Assessment, Sheba Medical Center, Tel Hashomer

Pigmentary dispersion syndrome is a precursor of pigmentary glaucoma whose prevalence in the urban population of USA was found to be 2.45%. We evaluated its prevalence during ocular screening examinations among normal Israelis. We screened for excessive pigmentation on the corneal endothelium with the slit-lamp and determined in each patient best corrected visual acuity, intra-ocular pressure (after mydriasis), condition of the anterior segment, cup-disk ratio, posterior segment abnormalities and questioned about history of any ocular disease and family history of glaucoma. 374 patients (mean age 49±11) were examined on 10 consecutive days. In 5.9% excessive corneal endothelial pigmentation was found. Intra-ocular pressure (after mydriasis) averaged 15.52±1.93 mm Hg as compared to 14.73±2.04 among the rest of our study population, (p=0.01). The prevalence of suspected pigmentary dispersion syndrome among young adults in Israelis is high.

Pelvic Lytic Lesion and Osteoporosis-Related Fractures

Yaron Weisel, Ehud Rath, Nissim Ohana, Dan Atar

Orthopedic Dept., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Insufficiency fractures of the pelvis may be overlooked as a cause of hip or groin pain. These fractures occur in the elderly, usually those with pronounced osteopenia of the pelvis. Predisposing factors include corticosteroids, local irradiation and postmenopausal osteoporosis. These fractures are difficult to detect clinically and plain radiographs and other studies may be misleading, delaying diagnosis and treatment. A 65-year-old woman had left groin and hip pain for 2 months with no history of trauma. Plain radiographs showed lytic lesions in the left pubic rami. Bone scan revealed increased uptake in that region, suggesting metastatic bone disease. Computed tomography and magnetic resonance imaging demonstrated fractures in the left superior and inferior pubic rami, with callus formation with no involvement of soft tissues. Quantitative computed tomography indicated low calcium concentration, below fracture threshold. The diagnosis of insufficiency fractures of the pelvis was confirmed by the favorable clinical and radiographic outcome. It is therefore important to be familiar with the appearance and location of these fractures.

Recurrent Syncope as a Presenting Symptom of Systemic Mastocytosis

Iris Barshack, Ginette Schiby, Ofer Shpilberg, Yechezkel Sidi

Pathology Dept., Hematology Institute and Medical Dept. C, Chaim Sheba Medical Center, Tel Hashomer

A 48-year-old man presented with recurrent syncope which was preceded by facial edema and difficulty in breathing. Physical examination, laboratory tests, abdominal CT and bone scan were all within normal limits. Bone marrow biopsy was consistent with mastocytosis. Systemic mastocytosis consists of a spectrum of disorders characterized by aberrant proliferation of tissue mast cells, and are mainly related to mast cell mediator release.

Screening for Transitional Cell Carcinoma of the Bladder with Trophoblastic Differentiation

M. Moldavsy, A. Sazbon, N. Kuchersky, H. Turani

Division of Cytology and Depts. of Urology and of Pathology, Rebecca Sieff Government Hospital, Safed

Urinary bladder carcinoma with trophoblastic differentiation (TD) is a variant of urothelial (transitional cell) carcinoma (TCC) which secretes placental proteins, predominantly beta-human chorionic gonadotropin (HCG). An aggressive clinical course and a poor prognosis are characteristic of this tumor. We evaluated the frequency and clinical and pathological appearance of TCC-TD in the Upper Galilee and Golan Heights between 1988 and 1995 inclusive. Beta HCG, human placental lactogen (HPL), pregnancy specific beta-1 glycoprotein (SP-1) and placental alkaline phosphatase were determined immunohistochemically in paraffin-embedded TCC of urinary bladder. Tumor grade, stage and patient survival were also determined. There was beta-HCG immunostaining in 13 of 62 cases (20.9%). TD was correlated with higher grades of TCC and with advanced stages of disease. No cases of TCC-TD were found in grade 1, stage 0. Co-expression of beta-HCG and HPL was displayed in 2 cases, beta-HCG and SP-1 in 9, and beta-HCG, HPL and SP-1 in 2. Disease-free survival and overall survival were shorter in TCC-TD.

Does Testicular Volume Reflect Spermatogenic Pattern in Azoospermia?

David B. Weiss, Elchanan Bar-On, Shoshana Gottschalk-Sabag, Zvi Zukerman

Kupat Holim Mehuhedet and Male Infertility and Cytology Units, Shaare Zedek Medical Center, Jerusalem; and Andrology Unit, Rabin Medical Center (Beilinson Campus) Petah Tikva

The aim of this study was to determine whether testicular volume can serve to predict patterns of spermatogenesis in azoospermia. In 27 tests of azoospermic infertile men, cytological specimens from several sites from each testis were obtained by fine needle aspiration. Testes were classified according to the most mature spermatogenic cell type. Classifications were testes with spermatozoa, with arrested spermatogenic development, and with only Sertoli cells. Prior to fine needle aspiration the 3 dimensions of each testis were determined ultrasonically and its volume calculated. Mean testicular volume (±‏SD) was 7.71 (±5.95) ml for testes with spermatozoa and 7.55 (±2.35) and 7.31 (±4.42) ml for testes with spermatogenic maturation arrest and with only Sertoli cells, respectively (differences not significant). It is concluded that testicular volume can not be used as a predictive parameter, neither for the presence of spermatozoa nor for the cytological pattern of the testes of azoospermic infertile men.

Enhancing Cultural Sensitivity of Psychiatrists from Russia

Haim Y. Knobler, Shlomit Katz, Inessa Poliakova, Rimona Durst

Jerusalem Mental Health Center, Kfar Shaul Hospital, Jerusalem

The importance of understanding the local culture and enhancing cultural sensitivity became evident during supervision of immigrant psychiatrists from the former Soviet Union. The aim of the present study was to describe enhancement of this cultural sensitivity in the supervision of 2 immigrant psychiatrists. In the first, understanding the patient's cultural world helped the immigrant psychiatrist form the therapeutic alliance. In the second, the immigrant psychiatrist's understanding of the patient's cultural background led him to change both diagnosis and treatment. In both cases, development of cultural sensitivity through supervision enabled successful treatment. Enhancement of cultural sensitivity may accelerate absorption of the immigrant psychiatrists themselves. Discussing cultural issues during work may accelerate the absorption of all immigrant physicians.

Correlation between Success in Specialty Examinations and Learning Methods of Family Medicine Residents

Netta Notzer, Dahlia Megiddo, Ruth Abramowitz, Michael Weingarten

Medical Education Unit, Family Medicine Section, Sackler Faculty of Medicine, Tel Aviv University

Learning methods chosen by residents in family medicine during their residency and the correlation between them and achievement in the written specialty exams (Stage 1) were investigated. The learning patterns studied were: structured learning (certification course, study with a tutor, staff meetings, conferences) and self-learning (textbooks, journals, the Hebrew publication "Update," and audio tapes). Of 184 residents who took the examination in 1994-5, 104 responded to a questionnaire as to preferences for the various learning aids and satisfaction with their use. There was no correlation between use of a given learning method and success in the examination. Significantly more candidates preferred self-learning, especially among those who were successful, but also among some who failed the examination. There was no direct connection between the examination and the high level requirements of the residency program, for which up-to-date, integrated knowledge based on self-learning is needed.

Epidermoid Cyst of the Spleen

Dan Bar-Zohar, Yaniv Sherer, Hana Manor, Amir Peer, Simon Strauss, Ariel Halevy

Dept. of Surgery B and Institute of Radiology, Assaf Harofeh Medical Center, Zerifin, and Sackler Faculty of Medicine, Tel Aviv University

Splenic cysts are rarely found or diagnosed. Excluding cases of trauma, the events preceding their development have not been fully understood. We describe a 22-year-old woman in her 34th week of pregnancy in whom ultrasound revealed a cystic lesion 8610 cm. in diameter in the left upper abdomen. Further imaging tests followed by laparotomy confirmed the splenic origin of the cyst. Splenectomy was performed and the lesion was histopathologically defined as an epidermoid cyst.

Propofol Anesthesia for Craniotomy in Patients who are Awake

Ron Ben Abraham, Noah Lieberman, Zvi Ram, Sylvia Klempner, Azriel Perel

Depts. of Anesthesia and Intensive Care and of Neurosurgery, Chaim Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University

During craniotomy, the patient's cooperation is needed during procedures in which continuous neurological examination and mapping of crucial regions close to the area to be resected area are required. We report our experience in 9 patients who underwent such procedures under intravenous propofol as the main sedating agent. This short-acting hypnotic was administered prior to and during the painful stages of the procedure. Patients were fully asleep when the skull was opened and the dural flap raised or excised. During the rest of the operation patients were lightly sedated but remained responsive and cooperative. This enabled precise intra-operative mapping of the brain and surgery-related neurological deficits were avoided. Respiratory depression or hemodynamic compromise were not encountered. All patients were comfortable during the operation and there were no additional neurological deficits after operation. We believe that propofol should be the main sedating agent used for these procedures.

Recurrent Tuberculosis in a Psychiatric Hospital

A. Zeenreich, B. Gochstein, A. Grinshpoon, M. Miron, J. Rosenman, I. Ben-Dov

Pulmonary and Radiology Institutes, Chaim Sheba Medical Center, Tel Hashomer and Tel Aviv University; Israel Ministry of Health; and Gan Meged Hospital

During 1987-1996, 39 of 720 patients hospitalized (most for severe schizophrenia) were diagnosed as having active pulmonary tuberculosis (5.4%, 975 per 105 per year). In 1992-1993, after a cluster of 5 cases was found, all patients were screened by PPD skin test and chest X-ray and 16 more cases were identified. Diagnosis was confirmed bacteriologically in only 10 of them but there were typical radiological findings in the others. 39 were treated with a multi-drug regimen. In addition, 333 exposed patients and 21% who had converted their skin tests were given isoniazid preventive therapy. A small increase in levels of liver enzymes was common, but significant abnormality (over 4 times the upper limit of normal) was found in only 7 patients, in whom therapy was therefor stopped or changed. During a follow-up period of 4 years, 2 more developed tuberculosis and 33 converted their PPD reactivity status. We conclude that an outbreak of tuberculosis in a psychiatric hospital can be controlled with a relatively low rate of side-effects by using systematic diagnostic and therapeutic measures. However, single step screening is not sufficient. Routine screening of all new patients, a high index of suspicion and contact investigation are needed.

Effects of Vertical Banded Gastroplasty on Weight, Quality of Life and Nutrition

Iris Shai, Shimon Weitzman, Izhak Levy

Depts. of Epidemiology and Surgery, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

We examined the long term results of vertical banded gastroplasty 3-10 years after operation. They were assessed by weight lost, incidence and severity of untoward effects and improvement in diet and in quality of life in 75 of 122 who had had the operation. Average weight lost was 28.5±14.9 kg (p<0.001) in 5 years and 58.6±30.4% of excess weight, which brought patients to within 32±25.2% of ideal weight. According to these measures, in 63-76% the operation had been successful in causing weight loss. The 2 criteria for successful weight loss were loss of more than 50% of weight in excess of ideal body weight and residual body weight less than 50% greater than ideal body weight. There was a greater risk of failure in unmarried subjects older than 45 (odds ratio for not losing weight was 6; in those weighing more than 120 kg it was 9). We saw evidence of this mostly 4 years after operation (odds ratio 11). The degree of success in weight loss was correlated with texture of food (softness) preferred and length of operation. Of those interviewed, only 65% were satisfied with their results. The greatest improvement in quality of life measurements was in physical activity, perception of health, and frequency of feeling depressed. Side-effects were vomiting, reflux and fatigue. Only 34.7% were able to digest solid foods, so that subjects are at risk for nutritional deficiencies.

* Based on MS thesis in epidemiology of Iris Shai.

Closed Intramedullary Nailing of Forearm Fractures in Young Patients

Moshe Salai, Eyal Segal, Yehuda Amit, Aharon Chechick

Dept. of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Hashomer

Forearm bone fractures are commonly the result of falling on the outstretched hand or of direct injury. The preferred treatment is debated. The possible modalities are: application of a cast, often necessitating repeated manipulations; open reposition and fixation by plates and screws; or closed manipulation and closed intramedullary nailing. We present our favorable results in treating these fractures in young patients by closed intramedullary nailing, and compare them with the unfavorable results of this method in mature adults.

First Year's Experience of the Post, Operative Cardiac Care Unit, Schneider Children's Medical Center

O. Dagan, E. Birk, J. Katz, B. Vidne

Cardiothoracic Pediatric Service, Schneider Children's Medical Center, Petah Tikva

In the past 10 years there has been a growing preference for early, complete correction of congenital heart disease. The first year of operation of this cardiac unit is described. 216 operations were performed: 15% in the neonatal age group and 35% in the newborn to l-year-old groups; 2% were palliative procedures. Mortality was 4.9%. Average stay in the ICU was 3.2  days, with a median of 2.25. Average length of ventilation was 35 hours, with a median of 17.5. Complications were: diaphragm paralysis in 13 (6%), 2/3 of which were recurrent operations; in 2 patients (0.9%) we had to plicate the diaphragm. There was severe neurological damage in 2, which deteriorated to brain death in 1. There was peripheral, reversible neurological damage in 4 (1.8%), and acute renal failure in 3%, with half of them requiring dialysis. 75% of these children died and there was superficial infection in 4.1%, deep wound infection in 1.3%, bacteremia in 4.1%, superior vena cava syndrome in 3 (1.3%) and chylothorax in 2 of them (0.9%). 1 patient (0.45%) required a ventricle-peritoneal shunt after acute viral meningitis. We are encouraged by our results to offer early complete correction to all children with congenital heart disease.

Are Testes in Oligo/Azoospermia Homogenous or Heterogenous?

David B. Weiss, Shoshana Gottschalk-Sabag, Elchanan Bar-On, Zvi Zukerman

Kupat Cholim Meuhedet, Jerusalem; Male Infertility and Cytology Units, Shaare Zedek Medical Center, Jerusalem; and Andrology Unit, Rabin (Beilinson) Medical Center, Petah Tikva

We determined whether a single testicular specimen is sufficient to represent qualitatively the spermatogenic process within the testes of azoospermic or severely oligospermic infertile men. In 191 testes of azoospermic patients and in 26 of those with severe oligospermia, fine needle aspirations at 3 different sites of each testis were performed. Aspirated material from each puncture was stained and in each smear all spermatogenic cells, as well as Sertoli cells, were identified. Testes were classified according to the most mature spermatogenic cell type present, or the presence of only Sertoli cells. The homogeneity of the testicular spermatogenic process was then evaluated. There was an overall intratesticular difference between aspirates in 14.1% of azoospermic testes and in 26.9% of severely oligospermic testes with regard to the most mature spermatogenic cell type. When spermatozoa were the most mature cell type, they were detected in all of the 3 aspirates in 71.4% of the testes. In 18.4% or 10.2% of this group of testes they were retrieved in only 1 or 2 of the aspirates, respectively. In testes in which spermatids or spermatocytes were the most mature spermatogenic stage, these cell types were detected in all 3 aspirates in only 36.4% and 68.0%, respectively. In azoospermic patients with full testicular spermatogenesis, the likelihood of retrieving spermatozoa from the testes was 84.3%, 92.7% and 100% in 1, 2 and 3 specimens, respectively. The following conclusions were drawn: There is a wide range of testicular heterogeneity in azoospermia or very severe oligospermia for diagnosing the testicular spermatogenic pattern. In azoospermia, specimens from several testicular sites are required. It is strongly recommended that no assisted fertilization be offered to azoospermic patients unless prior evaluation of the spermatogenic pattern in the seminiferous tubules is determined.