תוצאת חיפוש

Living-Related Liver Transplantation

N. Bar-Nathan, Z. Shapira, E. Shaharabani, A. Yussim, Y. Ben-Ari, T. Sheinfeld, I. Zehavi, R. Shapira, G. Dinari, Z. Ben-Ari, R. Tur-Kaspa, E. Mor

Dept. of Transplantation and Liver Institute, Rabin Medical Center (Beilinson Campus), and Pediatric Intensive Care and Pediatric Gastroenterology Units, Schneider Children's Medical Center, Petah Tikva

Our experience with living-related liver transplantation is described. In 2 boys and 1 girl, aged 4-4.5 years with acute, fulminating hepatitis A, the presence of very severe jaundice (bilirubin levels > 18 mg%) associated with severe coagulopathy (INR>10) and encephalopathy indicated the need for urgent liver transplantation. In all 3 cases the left lateral hepatic segment of a matched blood type parent was transplanted. None of the donors suffered a serious complication postoperatively and all returned to full activity in 6-16 weeks. The post-transplantation course was uneventful in 1 child, but in the other 2 there was hepatic arterial thrombosis in 1 at 1 day and in the other at 8 days post-transplantation. Early detection of arterial thrombosis by Doppler sonography permitted salvage of the 2 hepatic grafts after thrombectomy and re-anastomosis. In 1 of these 2 children an anastomotic biliary stricture was found 2 months after transplantation. It was corrected at surgery and a percutaneous stent was inserted. All 3 children are alive with normal graft function at 2, 7 and 8 months post-transplantation, respectively. This initial experience indicates that living-related liver transplantation is feasible in Israel. The technique might help to solve our severe organ shortage for children awaiting liver transplantation.

Clinical Characteristics of those who Leave the Emergency Room Against Advice

A. Carmel, H. Amital, Y. Shemer, A. Sahar

Emergency Dept. and Dept. of Medicine B, Gertner Institute for Medical Service Research, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

The object of this study was to characterize those who leave the emergency department agmedical advice and to examine the short-term consequences. The study was conducted retrospectively 1992 and prospectively during May-August 1993 by telephone interviews. About 0.5% of all the patients who applied to the emergency department left against medical advice. Their main characteristic was that they were mostly young, single men. A wide range of complaints had brought them to the emergency department, very similar to that of the control group, but with a higher tendency to abuse drugs and alcohol. Most of those who left against medical advice had less severe disease than the controls. However 10% of them had to be hospitalized within the subsequent 2 weeks, in comparison with 4% of the controls. This study suggests that improving the efficiency of the emergency department will decrease the number leaving against advice.

Skeletonized Internal Mammary Arteries for Coronary Bypass Grafting

Jacob Gurevitch, Yosef Paz, Menachem Matsa, Amir Kramer, Dimitri Pevni, Oren Lev-Ran, H. Locker, Raphael Mohr

Dept. of Thoracic and Cardiovascular Surgery, Sourasky-Tel Aviv Medical Center

The skeletonized internal mammary artery (IMA) is longer, and its immediate spontaneous blood flow is greater than that of the pedicled IMA, thus providing increased versatility for complete, arterial myocardial revascularization without the use of saphenous vein grafts. From April 1996 to May 1997, 583 patients underwent coronary artery bypass grafting here and in 415 (71%) complete arterial revascularization was achieved using bilateral skeletonized IMA. The right gastroepiploic artery was used in 57 (13%); there were 329 males (79%) and 86 women (21%); average age was 64 (30-87) and 175 (36%) were older than 70; 131 (32%) were diabetics. Average number of grafts was 3.2 (range 2-6 grafts). At 30 days, 5 (1.2%) had died and there had been 6 perioperative infarcts (1.4%), 5 CVA's (1.2%), and 6 had sternal wound infections (1.4%). Up to 1-12 months of follow-up was achieved in 409 (99%). Late mortality was 1.4% (of which 3 were noncardiac). 394 (97%) were angina-free at latest follow-up. We conclude that arterial revascularization using bilateral skeletonized IMA is safe, as postoperative morbidity and mortality are low, even in old and diabetic patients.

Diagnosis of Cerebral Embolism by Transesophageal Echocardiography

A. Mahagney, D. Sharif, B. Weller, E. Abineder, B. Sharf

Depts. of Neurology and Cardiology, Bnai Zion Hospital, Haifa

Cerebrovascular events have high mortality and morbidity, especially in the elderly. Ischemia is the main cause and 30% of the ischemic events are embolic and of cardiac origin. The clinical picture is not always typical of the type of stroke, but diagnosis of the mechanism of the event determines treatment. Transesophageal echocardiography (TEE) is a sensitive procedure more appropriate for diagnosing emboli of cardiac origin than transthoracic echocardiography (TTE). We therefor compared TEE and TTE in the determination of the source of emboli in 65 patients with ischemic stroke but without significant atherosclerotic changes in their carotid arteries, and compared these findings with those in 50 patients without stroke. 68% of the patients had potential sources of emboli according to TEE, compared to only 15% according to TTE. In the control group only 24% had potential sources of emboli by TEE. The findings were: clots in the left atrium, severe aortic atheroma, patent foramen ovale with paradoxical shunt, spontaneous echocardiography contrast, vegetations and mitral valve prolapse. The study showed that TEE is better than TTE in detecting the etiology of embolic stroke in those with normal carotid arteries, thus determining appropriate management.

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.

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.

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.

Circadian Fluctuations of the Signal-Averaged ECG

Ehud Goldhammer, Edward Abinader

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

Circadian periodicity for the time of onset of acute myocardial infarction has been shown; the early morning peak of infarction coincides with the onset of other related phenomena, including sudden cardiac death, ventricular arrhythmias, thrombotic stroke, etc. Late potentials detected by the signal-averaged ECG are considered to be independent markers of vulnerability to ventricular arrhythmias. The signal-averaged ECG enables the amplifying and recording of small bioelectric signals of cardiac origin, while eliminating extraneous electrical "noise." To determine whether late potentials are themselves subject to circadian influence, 31 patients (age range 41-79) who had had an old or recent myocardial infarction underwent late potential assessment by the signal-averaged ECG. 4 indices were studied: duration of late LPD potentials (LPD), total QRS duration (TQRS), and root mean square voltage of the last 40 msec, and of the last 50 msec (RMS 40 and RMS 50). These indices were assessed 3 times, during the early morning hours, at noon and during the evening. Morning LPD differed significantly from noon and evening LPD and the morning RMS 40 similarly differed from noon and evening values. TQRS and RMS 50, even though remaining in the normal range, also showed a tendency to abnormal values during morning hours. These findings could possibly be related to the early morning incidence peaks of severe ventricular arrhythmia and sudden cardiac death, since abnormal late potentials constitute the physiopathological basis for certain ventricular arrhythmias.

Traumatic Hyphema*

Tamar Talmon, Itzchak Beiran, Benjamin Miller

Dept. of Ophthalmology, Rambam Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Traumatic hyphema usually occurs in young men at the rate of 17-20/1000,000. Major complications include secondary hemorrhage, glaucoma, corneal staining and disturbances in visual acuity. Final visual acuity is predominantly the outcome of all the ocular injuries occurring during the trauma, mainly to the posterior segment of the eye. We describe all cases of traumatic hyphema treated in our department over a period of 3.5 years. Antifibrinolytic treatment is recommended in the literature in traumatic hyphema to prevent secondary hemorrhage. Our findings differ from those in the literature in that they show a lower prevalence of more severe hemorrhages and of secondary hemorrhage. In light of these differences, and with regard to possible side effects of such treatment, we suggest that antifibrinolytic treatment not be used in our population. We recommend that treatment for traumatic hyphema should include restricted activity, local corticosteroidal preparations, frequent follow-up visits and vigorous diagnostic work-up in order to find any additional eye damage. We strongly recommend the use of preventive measures (eye-shields) in high risk activities such as sports, house-hold work and military training.

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* Based on work submitted to the Faculty of Medicine, Technion-Israel Institute of Technology, by Tamar Talmon in partial fulfillment of the requirements for the MD degree.

Analgesia in Breast Surgery with Interpleural Bupivacaine

Z. Crystal, Y. Katz

Dept. of Anesthesiology, HaEmek Medical Center, Afula and B. Rappaport Faculty of Medicine, Technion, Haifa

A control group of 15 patients undergoing breast surgery was given general anesthesia. In 15 other patients an interpleural block with 0.4 ml/kg bupivacaine, 0.5%, was performed 20 minutes before induction of general anesthesia for pre-emptive analgesia. This was extended further by continuous administration of bupivacaine 0.25%, 0.125 ml/kg/hr by automatic infusion pump, with supplements of opiates for postoperative pain management. The combined technique was associated with significantly reduced perioperative opiate requirement with better emergence from anesthesia, fewer side effects, a prolonged pain-free period, and overall better quality of postoperative recovery.

Urgent Need for Prevention of Alcohol Drinking among Arab Youth

Shoshana Weiss

Dept. of Prevention, Israel Society for the Prevention of Alcoholism

A study was conducted in the winter of 1996 among 2,220 Arab adolescents in northern Israel. This fourth study among Arab youth dealt with frequency of drinking and amounts of alcohol drunk during a drinking bout. Among Christian, Druze and Moslem males there were 81.72%, 49.61% and 31.93%, respectively, who drank. The figures for females were 36.75%, 11.25% and 12.78%. About 4% of Moslem males drank 5 drinks or more consecutively, daily or every 2-3 days. The need for preventive efforts in the Arab sector is stressed.

Left Atrial Ball Thrombus

Carlos Cafri, Reuben Ilia, Benjamin Goldfarb

Cardiological Services, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

An 80-year-old hypertensive woman with chronic atrial fibrillation was hospitalized because of recurrent syncope. Echocardiography revealed a large left atrial ball thrombus. Operative findings confirmed the echocardiographic diagnosis.

Liver Allografts from Donors older than 60: Benefits and Risks

Eytan Mor, Dan Shmueli, Ziv Ben-Ari, Nathan Bar-Nathan, Ezra Sharabani, Alexander Yussim, Boris Dorfman, Ran Tur-Kaspa, Zaki Shapira

Transplantation Dept. and Institute of Liver Diseases, Rabin Medical Center, Beilinson Campus; and Sackler School of Medicine, Tel Aviv University

With limited organ resources and an increasing number of candidates for liver transplantation, the world-wide trend is towards using liver allografts from donors older than 60 years. This strategy, however, may be hazardous because of the known correlation between advanced donor age and graft dysfunction. Since January 1996, each of 5 patients received a liver allograft from a donor older than 60 years. Preservation time in these cases was shortened as much as possible and liver allografts were used only if there were no other potential risk factors for primary nonfunction. Mean cold ischemic time was significantly shorter in this donor group (7.8 hrs) than for livers from 28 younger donors (10.2 hour; p<0.01). 3 of the 5 grafts from older donors had normal function immediately. The other 2 initially had biochemical features of preservation injury, but graft function returned to normal within the first week after transplantation. All 5 patients currently have normal graft function, with follow-up ranging from 3-8 months. There was no difference between the 5 recipients of grafts from older donors and 28 adult recipients of grafts from younger donors in extent of preservation injury and in immediate graft function. We conclude that in countries with limited organ resources, such as Israel, liver allografts from older donors can be used within defined limits and minimal preservation time.

Recurrent Chronic Multifocal Bone Infection

Mordechai Kligman, Benny Bernfeld, Moshe Roffman

Dept. of Orthopedic Surgery, Carmel Medical Center, Haifa

We present a 9-year-old girl who had chronic recurrent multifocal osteomyelitis. The bones involved were: right clavicle, distal fibula (bilateral), left sacroiliac and right wrist. After 10 years of follow-up, she is asymptomatic but presents radiological evidence of lesions in the right clavicle and left sacroiliac joint. The diagnosis was made by exclusion criteria. The biopsy and results of cultures from various bones were negative 4 times. Although chronic recurrent multifocal osteomyelitis is rare, it should be considered in the differential diagnosis of acute or chronic osteomyelitis and neoplasms. Its recognition avoids unnecessary laboratory tests and antibiotic therapy.

Seminiferous Tubule Cytological Pattern in Infertile, Azoospermic Men in Diagnosis and Therapy

David B. Weiss, Shoshana Gottschalk-Sabag, Elchanan Bar-On, Zvi Zukerman, Yigal Gat, Benjamin Bartoov

Male Infertility and Cytology Units, Shaare Zedek Medical Center, Jerusalem; Andrology Unit, Rabin Medical Center (Beilinson Campus), Petah Tikva and Male Infertility Laboratory, Dept. of Life Sciences, Bar-Illan University, Ramat Gan

We determined spermatogenic patterns of seminiferous tubules in azoospermic infertile men and evaluated the prevalence of bilateral testicular homogeneity. 185 azoospermic men underwent bilateral testicular fine-needle aspiration (TFNA) in which each testis was punctured at 3 different positions. Aspirated material was stained and classified according to the most mature spermatogenic cell type present or whether only Sertoli cells were present. 35.7% had spermatozoa in their testes, 36.2% had spermatogenic maturation arrest, and 28.1% had only Sertoli cells in their seminiferous tubules. In 15.6% of all patients, the diagnosis in 1 testis differed from that in the other. In only 73.2% of those with testicular spermatozoa was it bilateral. In the remaining 26.9%, only Sertoli cells, spermatocytes or spermatids were found as the most mature cell type in the other testis. The study definitely indicates that fertilization with retrieved testicular spermatozoa should not be offered to azoospermic patients without prior evaluation of the seminiferous tubue spermatogenic pattern in both testes.