תוצאת חיפוש

Mixed Uterine Mesodermal Tumors: Clinical and Pathological Characteristics

Samuel Ariad, Alexander Rabinovitz, Ilana Yanai-Inbar, Benjamin Piura

Depts. of Oncology and of Pathology, and Gynecology-Oncology Unit, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

During 1971-1996, 17 patients with mixed mesodermal uterine tumors were treated. Average age at diagnosis was 67.3 years, 12/17 were of European and 5/17 of Afro-Asian extraction. The overall 5-year survival was 21%. 10/17 patients had mixed mesodermal tumors with a heterologous mesenchy-mal element, and 7/17 had a homologous mesenchymal element (carcinosarcoma). 6/17 had another primary malignancy, including breast cancer (3/17), bilateral metachronous breast tumor (2/17), and malignant lymphoma of the neck region (2/17). All 3 with breast cancer had previously been treated with tamoxifen. 1 had simultaneous mesodermal tumor and ovarian thecoma. Simultaneous autoimmune manifestations occurred in 2/17, including thrombocytopenic purpura in 1, and myasthenia gravis in another. Mesodermal tumor of the uterus is a relatively rare malignancy with aggressive behavior and poor prognosis. It also had unusual associations with other primary tumors, hormonal treatment, and autoimmune manifestations.

Accessibility of Information and Informed Consent: Experiences of Breast Cancer Patients

Ephraim Tabory, Susan Sered

Dept. of Sociology and Anthropology, Bar-Ilan University, Ramat Gan

We studied the social and cultural frameworks that impact on breast cancer patients in the medical system. The subjects were 98 Jewish women who had undergone mastectomy or lumpectomy for cancer 6 months to 3 years prior to the interview. They emanated from a variety of socioeconomic and ethnic backgrounds, and reflected the age range of women with breast cancer in the general Jewish population of Israel. Patients were asked about each stage of the medical process they had experienced: diagnosis, surgery, oncological care, and follow-up care. The interview revealed a general perception of having received insufficient information regarding their medical condition and treatment. The problem tended to be most severe during the diagnostic stage, when women had not yet been officially included as patients within the system. The problem was relatively severe during follow-up care, when they often did not have an address for their questions. Few women received a schedule of follow-up care that allowed them to carry on with the many necessary tests in an orderly and comprehensive manner. Most important, systematic absence of informed consent also characterized the decision-making process regarding surgery and oncological treatment. Few women felt they had been informed about treatment options, side-effects, or long-term implications of the treatment offered. We found no indication of inequitable medical treatment that would suggest a manifest pattern of discrimination, but we did find some social variables related to a feeling of insufficient personal care and information. In particular, older women said they received less attention, support, and information from the medical staff relative to the younger women.

Patients' Opinions of the Role of Primary Care Physicians and the Organization of Health Care Services

Revital Gross, Hava Tabenkin, Shuli Bramli, Pesach Schvartzman

JDC-Brookdale Institute, Jerusalem; Dept. of Family Medicine, HaEmek Hospital, Afula; Kupat Holim Clalit, Northern District; Institute for Specialization, Ben-Gurion University, Northern Branch; and Dept. of Family Medicine, Ben-Gurion University of the Negev and Kupat Holim Clalit, Beer Sheba

Patients' opinions of the role of the primary care physician were studied. The study population consisted of Hebrew-speaking members of the Clalit Sick Fund, aged 18+, who visited primary care and specialty clinics. Interviews took place during January-March 1995 in the Emek and Jerusalem, and during August-October 1995 in Beer Sheba. A total of 2,734 interviews were conducted, and the response rate was 88%. 64% of the respondents preferred the primary care physician as the first address for most problems occurring during the day. Multivariate analysis revealed that the variables predicting this preference were: being over age 45, having completed less than 12 years of schooling, being satisfied with the physician, and when a child's illness was involved. Whether the physician was a specialist had only a marginal effect. The findings also show that among those who did go directly to a specialist for the current visit, 49% would still prefer the primary care physician to be the first address for most problems. However, half of the respondents initiated the current visit to the specialty clinic themselves. The findings also showed that a preference for the primary care physician to be the first address had an independent and statistically significant effect on the following aspects of service consumption: taking the initiative to go to a specialist, the intention to return to the primary care physician or to the specialist for continuing care, and the patient's belief that referral to a specialist was needed. The findings of the study may be of assistance to policy-makers on the national level and to sick funds in planning the role of the primary care physician, so that it corresponds, on the one hand, to the needs of the sick funds and the economic constraints in the health system, and on the other, to the preferences of the patient.

Local Treatment of Purulent Chronic Otitis Media with Ciprofloxacin

Ludwig Podoshin, Alexander Brodzki, Milo Fradis, Jacob Ben-David, Josef Larboni, Isaac Srugo

Dept. of Otolaryngology, Head and Neck Surgery, Microbiology Unit and Dept. of Pharmacology, Bnai-Zion Medical Center, and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

We evaluated the efficacy of ciprofloxacin eardrops compared to tobramycin and to a placebo in the treatment of chronic suppurative otitis media. 60 ears were randomly assigned to treatment for 3 weeks with ciprofloxacin, tobramycin or placebo eardrops. The organism most commonly isolated from the ear discharge was Pseudomonas aeruginosa. The clinical responses were 78.9% and 72.2%, respectively, in the ciprofloxacin and tobramycin groups, while it was only 41.2% in the placebo group. Treatment with ciprofloxacin eardrops seemed to be at least as efficient as treatment with tobramycin. Considering the lack of ototoxicity of ciprofloxacin, this treatment may be best for chronic otitis media.

Percutaneous Ablation of Malignant Kidney Tumors in Rabbits by Low Frequency Radio Energy

Boaz Moskovitz, Ofer Nativ, Edmond Sabo, Yousef Barbara, Daniel Mordohovich, Yoseph Kaftori, Arie Shalhav, Benad Goldwasser

Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Radio-frequency (RF) current has been used successfully to ablate normal human tissue. To investigate further the clinical application of this modality in tumors, we studied the potential of using RF percutaneously to destroy experimental kidney tumors. 35 outbred albino rabbits underwent direct-implantation of renal VX2 tumor during open surgery. After 21 days, ultrasonography was performed to show tumor presence and size. A shielded RF needle was designed to be inserted percutaneously through an introduction needle. An electrical insulation shield covering the RF needle was retractable, controlling the length of exposure of the RF needle inside the tissue. 22 days after tumor implantation, RF was applied via this special needle using a ZoMed International RF generator. In one group of rabbits the procedure was performed under direct vision during open surgery, while in another group treatment was percutaneous, the needle guided by palpation of the tumor. Rabbits were killed 3 days later and revealed 4-25 mm intra-tumoral RF-induced lesions. A direct relation was found between lesion size and the power and duration of RF applied (at 7.5 W, R=0.48, and P=0.32). Based on our preliminary results we can conclude that RF may have clinical applications in the near future for percutaneous local tumor control in parenchymal organs.

ATLS Course for Surgery Residents - Should it be Mandatory?

Ron Ben-Abraham, Michael Stein, Yoram Kluger, Gideon Paret, Avraham Rivkind, Joshua Shemer

Medical Corps, Israel Defense Forces; Sourasky Medical Center and Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University; and Hadassah Medical Center, Jerusalem

Senior surgeons were asked about mandatory participation of general surgery residents in the advanced trauma life support (ATLS) course. Although trauma care in Israel is given by surgical residents, in the opinion of their senior mentors the course should continue to be mandatory for them.

Acquired Torticollis in Hospitalized Children

Alexander Blankstein, Felix Pavlotsky, Hector Roizin, Abraham Ganel, Aharon Chechick

Depts. of Orthopedics, Dermatology, Pediatrics and Pediatric Orthopedics, Chaim Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University

Torticollis results from various pathological mechanisms, and its elucidation depends on identifying diseases of musculoskeletal, neural and ocular tissues. This study characterized the underlying diseases of children hospitalized with torticollis, excluding congenital torticollis. Records of 36 children with torticollis seen during 4 years were reviewed and categorized according to presumed etiology. Most could be classified into 2 categories: in 39% it was due to trauma and in 36% to upper respiratory tract infection. Most girls were in the first group and most boys in the second group. There were 3 cases of ocular torticollis due to superior-oblique muscle palsy, 1 with a post-burn eschar, 2 with neurological disorders (intramedullary cervical astrocytoma and leukodystrophy with macrencephaly), and in 3 no associated cause was found. There was a clear seasonal trend with 58% of cases presenting from November through February, 33% from April through July, and the rest, of neurological or ocular origin, during the rest of the year. In cases of post-traumatic torticol21% had neurological symptoms such as weakness of the limbs, headaches or incontinence. Only a few had prior upper respiratory tract infection. All children whose torticollis was assigned to infection had had fever. Only 8% had had neurological complaints or vomiting, half of whom presented with fever exceeding 37.5oC. 46% had restriction of movement and 38% had tenderness. In over 60% of those in this group there were signs of an upper respiratory tract infection, such as lymphadenopathy or a white blood cell count exceeding 15,000/microliter. 3 patients with recurrent torticollis were diagnosed as having severe neurological diseases. Mean hospitalization time was 4 days (range 1-28). Hospitalization periods were similar for all kinds of patients and treatment by traction or fixation did not affect this period.

Primary Subclavian Vein Thrombosis after Intensive Physical Exertion

Ora Shovman, Jacob George, Yehuda Shoenfeld

Dept. of Medicine B and Autoimmune Disease Research Unit, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Subclavian vein thrombosis accounts for approximately 1-2% of recorded deep venous thromboses. It may be primary or secondary, and insertion of a central venous catheter is the most common cause of secondary subclavian vein thrombosis. Traumas, anatomic abnormalities and carcinoma are important additional risk factors for secondary thrombosis. Primary thrombosis of the subclavian veins is known as Paget-Schroetter syndrome. New criteria for its diagnosis include a history of increased upper extremity use prior to onset of symptoms, the presence of a venographically demonstrated thrombus and absence of any definable causes. We describe a 42-year-old woman with a history of intensive physical exertion admitted with swelling, pain and difficulty moving her arm. The diagnosis of primary subclavian vein thrombosis was established from the history of physical effort, results of Doppler ultrasound, and exclusion of other causes of subclavian vein thrombosis. This case suggests that primary subclavian vein thrombosis should be considered in young patients with subclavian vein thrombosis after exclusion of secondary disease.

Evolving Role of Radiation Therapy in Nonmalignant Disorders

Rami Ben-Yosef

Bone Marrow Transplant Dept., Hadassah Hospital, Jerusalem

Various nonmalignant disorders have traditionally been treated with radiation therapy. It has almost completely been discontinued due to reports of secondary malignancy. During the past 15 years there has been an evolving role for radiation therapy in various nonmalignant disorders such as meningioma, A-V malformation, prevention of vascular restenosis and heterotopic bone formation. Appropriate follow-up of such patients for diagnosis of secondary malignancy is recommended. Radiation therapy should be carefully considered in diseases not successfully treated with conventional means.

Compulsory, Ambulatory Psychiatric Treatment

R. Durst, A. Teitelbaum, Y. Bar-El, M. Shlafman, Y. Ginath

Arie Jaros Jerusalem Mental Health Center and Talbieh Mental Health Center (Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem) and Israel Ministry of Health, Jerusalem District

The Treatment of Mentally Sick Persons Law of 1955, was repealed and replaced by the Law of 1991. Under the latter, the Order for Compulsory Ambulatory Treatment (OCAT) was addressed for the first time (Section 11, a-d). According to this law, the district psychiatrist instead of issuing a hospitalization order, may issue an OCAT, under which the required treatment is given within the scope of a clinic which he designates, for up to 6 months and under conditions which he specifies. This is done on the basis of psychiatric examination, or an application in writing from the director of a hospital or clinic, when continued ambulatory treatment is needed after discharge from hospital or instead of compulsory hospitalization. The district psychiatrist may extend the period of treatment for further periods, none of which is to exceed 6 months. Compulsory ambulatory treatment is to enable patients to benefit from the positive aspects of living freely in the community, while receiving prompt treatment under compulsory conditions. The concept offers a partial solution, achieving a balance between civil liberties and clinical needs, between over-confinement and under-treatment which might be dangerous or neglectful. The clinical impression has been that the OCAT has not fulfilled expectations. The purpose of this study was to examine the topic in a systematic way in Jerusalem and the soutern districts for the 4 years since inception of the law. In 44.4% of cases OCAT was proven to be effective, while in 33.1% it was found to be ineffective and did not prevent compulsory hospitalization, one of its main goals. It was partially effective in the rest of the cases. It is recommended that suitable means for the enforcement of the law be allocated and that the subject of forceful hospitalization and OCAT be made a mandatory subject in the residency program of psychiatrists.

Radiotherapy of Localized Prostatic Carcinoma

Eliahu Gez, Yael Netzer-Horowitz, Einat Waiman, Raphael Rubinov, Yoram Cohen, Abraham Kuten

Northern Israel Oncology Center and Oncology Dept., Rambam Medical Center and Lin Medical Center, Haifa; and Soroka Medical Center, Beer Sheba

112 patients with localized prostate cancer, clinical stage A2-C, were treated by definitive radiotherapy between 1982-1988. Radiation volume encompassed the prostate, seminal vesicles and pelvic lymph nodes. The 10-year actuarial survival figures were: overall 51%; stage A2 87%; stage B 50%; stage C 36%; well differential tumors 67%; moderately differentiated 50%; poorly differentiated 32%; patients with local tumor control 55%; and patients with minimal local control 36%. It is concluded that external beam irradiation is effective in localized prostatic cancer. Stage and grade are prognosticators of survival.

Bromocriptine for Refractory Rheumatoid Arthritis

Reuven Mader

Rheumatic Disease Unit, HaEmek Medical Center, Afula

In recent years prolactin (PRL) has emerged as an important immunomodulator in various autoimmune disorders. Bromocriptine (BRC) is a dopamine agonist that suppresses secretion of PRL. Good clinical response to BRC has been reported in patients with psoriatic arthritis, Reiter's syndrome, and systemic lupus erythematosus. 5 mg of BRC at bedtime were given to 5 patients (aged 35-50) with refractory rheumatic arthritis (RA) who had failed to respond to previous treatment with at least 2 disease-modifying antirheumatic drugs. Patients were assessed at 4-6 week intervals for 6 months. 3 showed more than 25% improvement in the number of tender and swollen joints at 12 weeks of treatment. However, in only 2 of them was improvement maintained till the end of the 6 months. There were no changes in other measures of disease activity. 1 patient dropped out of the study due to acute exacerbation of her disease 4 weeks after initiation of BRC and required intra-articular injections of corticosteroid. The remaining patient did not show any significant clinical changes. No correlation was found between serum PRL levels and disease activity over time. It is suggested that some patients with refractory RA might improve with BRC. Its use in larger doses in larger groups of patients may help elucidate its role in the treatment of RA.

Preliminary Experience with Laparoscopic Repair of Inguinal Hernias

Herbert R. Freund, Dan Seror, Dan Eimerl, Oded Zamir

Surgery and Anesthesiology Depts., Hadassah-University Hospital, Mount Scopus, Jerusalem

During 1992-1996 we performed 163 laparoscopic hernia repairs in 100 men and 2 women. The mean age was 50.6; and in 61 the operation was bilateral. 66 were by transabdominal preperitoneal approach and 36 btotal extra-peritoneal approach. There were only a few minor complications and total recurrence rate was only 4.3%, partly attributable to our learning curve. Laparoscopic inguinal herniorrhaphy reduces postoperative incisional and muscular pain and causes less disruption in the postoperative period than open repair. Return to normal activity and work is faster for laparoscopic than for open repair, but operating room costs are higher (time and equipment). However, economic advantages for the national economy should be considered.

Incomplete Penile Amputation: Diagnostic and Therapeutic Challenge

D. Leibovici, B. Yaffe, A. Zisman

Urology Dept., Assaf Harofeh Medical Center and Microsurgery Dept., Chaim Sheba Medical Center, Tel Hashomer

Traumatic penile amputation is a severe injury associated with a potential for multidisciplinary dysfunction. Since such injuries are rare, diagnostic and therapeutic experience is minimal. While complete penile amputation is a straight-forward diagnosis, incomplete amputations are not as evident and diagnosis may be delayed. The therapeutic endpoint includes restoration of an acceptable appearance of the phallus and a urethral meatus that allows normal voiding. Other objectives include re-establishment of sexual potency and fertility. As in other amputations, the treatment of choice is meticulous microsurgical replantation, including re-anastomosis of dorsal and cavernosal arteries, the deep dorsal vein, the urethra and nerves, as well as suturing the tunica albuginea. While appropriate cosmetic results and normal voiding can be achieved in most cases, potency is less frequently achieved due to neurological deficit leading to impaired erection and loss of sensation. Penile amputation is thus a complex therapeutic challenge, as meticulous anatomic reconstruction of blood vessels and nerves is essential for restoration of function. Since incomplete penile amputation may be overlooked when other more obvious injuries draw attention, this injury should be suspected in all cases of penetrating injury of the male genitalia. We present a 17-year-old man who sustained an incomplete penile amputation in a traffic accident.

Surgical Approach to Benign Cecal Ulcer

J. Haik, A. Judich, I. Barshack, M. Ben-Haim, M. Shabtai, A. Ayalon

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

Benign cecal ulcer is a rare lesion, usually diagnosed during operation for suspected acute appendicitis or peritonitis of unknown origin. In the past, right hemicolectomy was recommended as the treatment of choice because of the difficulty in differentiating malignant lesions from benign cecal ulcers. However, in recent reports a more conservative approach has been suggested, consisting of selective colectomy followed by frozen section biopsy. This approach is aimed at preventing unnecessary excision of the colon and conserving the ileocecal valve. We present a 47-year-old woman operated for right lower quadrant peritonitis, believed to be due to acute appendicitis. On exploration, a biopsy-proven benign cecal ulcer was found and resected.