תוצאת חיפוש

Onchocerca in Israel

A. Pressman, Y. Kandelis, Y. Bachar, G. Mogilner

Depts. of Pediatric Surgery and Pathology, Bnei-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

The parasite Onchocerca volvulus is well-known in its endemic areas in South and Central America and West Africa. It is transmitted to man by simulium flies and causes systemic infection with skin, lymphatic and ophthalmic manifestations and can cause blindness (river blindness). Treatment with Ivermectin is effective but sometimes there is need for surgical intervention to prevent or treat complications. We describe an 11-year-old girl, a new immigrant from Ethiopia, who had a firm mass in her left thigh, caused by Onchocerca volvulus. It was completely excised. This is a very rare condition in Israel, which must be considered in patients coming from endemic areas.

Fungus-Ball in a Preterm Infant Successfully Treated with Fluconazole

Mirit Hershman-Sarafov, Orora Tubi, Isaac Srugo, David Bader

Neonatal and Radiology Depts., and Microbiology Laboratory, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Very-low-birth-weight premature infants are at high risk for invasive candidiasis. The most commonly involved organ is the kidney. Renal candidiasis may present as fungus-ball obstructive uropathy. We describe unilateral renal obstruction secondary to fungus-ball in a premature infant. Noninvasive, systemic antibiotic treatment, including amphotericin B and fluconazole, resulted in disappearance of the finding.

Conservative Approach in Children with Central Line Infection 

Zvi Steiner, Yafim Kandelis, George Mogilner, Dina Atias, Isaac Srugo

Dept. of Pediatric Surgery, and Hematology and Clinical Microbiology Units, Bnei-Zion Medical Center, and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

In 1994-1995, central venous lines were placed in 47 children. All except 1 were of the Broviac type, with subcutaneous tunneling via the internal or external jugular vein. Ages were between 7 days and 16 years. Indications for central venous cannulation were chemotherapy (35 cases), TPN (5), prolonged parenteral antibiotics (4), and repeated blood transfusions (3). The catheter was the source of infection in 13 children (28%), 11 of whom were immunocompromised. The commonly identified bacteria were Staphylococcus aureus (4 cases), Pseudomonas aeruginosa (4), coagulase-negative Staphylococcus (2), and various gram-negative rods (3). All cases were treated with antibiotics through the catheter. The most commonly used were oxacillin (4), ceftazidime (4), and amikacin (4). In 10, treatment succeeded without having to remove the line. In 2 others, tunnel infection developed and the catheter had to be removed. 1 child forcefully removed his catheter before treatment could be started. There were no further complications in the group treated conservatively, except for a case of superior vena cava thrombosis in a girl with recurrent infection of the tunnel. In 7 out of 13 treatment was continued and completed at home. This saved 65 days of hospitalization out of 210. We conclude that the conservative approach to treatment is feasible in most cases of infection when the source is the central venous catheter itself. However, when the tunnel is infected, conservative treatment may be ineffective. Treatment can be carried out in the home, with economy in cost and in use of hospital beds, and is preferred by patients and their parents.

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.

Incidence, Antimicrobial Resistance and Mortality in Bloodstream Infections in the Critically Ill

Lavi Oud, Shelly Krimerman, Isaac Srugo

General Intensive Care Unit and Clinical Microbiology Dept., Bnai-Zion Medical Center, Haifa

Bloodstream infections (BSI) are 7-fold more common in patients admitted to the intensive care unit (ICU) rather than to other hospital wards. The epidemiology of BSI in critically ill patients in Israel has not been systematically addressed. We examined the annual trends in BSI in patients in a general ICU of evolving patterns of antimicrobial resistance and associated mortality rates for the years 1994-1996. The presence of the systemic inflammatory response syndrome (SIRS) when the first positive blood cultures are taken was a prerequisite for its definition as clinically significant. The unit site, staff, practice guidelines, and type of patient were unchanged during the study period. Blood cultures were positive in 220.7-332.0 patients per 1000 ICU admissions, 18-22-fold more common than in regular ward patients. SIRS was a universal finding in these ICU patients. There was multi-drug resistance for the majority of species cultured, reaching 100% in some cases. Crude hospital mortality of ICU patients, with and without positive blood cultures, was 31-54% and 5-14%, respectively. The introduction of a new blood culture system (Bactec 9240) in 1996 was associated with a 61% increase in the rate of patients with positive blood cultures, accounted for mostly by increased isolation of coagulase-negative staphylococci. However the mortality rate for the latter decreased by 59%, suggesting the possibility of a selective increase in detection of contaminated cultures. Although highly prevalent in the study population and generally defining a patient group with high mortality risk, the specificity of SIRS-associated positive blood cultures may be species and culture-system dependent. These findings re-emphasize the need for both improved control measures for the epidemic proportions of BSI and multi-drug antimicresistance, as well as more specific indicators of the clinicaof positive blood cultures in critically ill patients.

Gentamycin Distribution Volume in a Mechanically Ventilated Patient

H. Seligmann, S. Nicola, S.H. Krimerman

Clinical Pharmacology and Intensive Care Units, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Mechanical ventilation (MV) of more than 32 hours may alter the gentamycin pharmacokinetic profile by increasing its volume of distribution (VD). As a result, the standard garamycin dosage regime has to be adjusted in order to obtain an adequate peak serum concentration, which is well correlated with the efficacy of garamycin therapy. Garamycin is a water- soluble drug with negligible binding to plasma albumin, so its VD approximates the volume of extra-cellular fluid, which may be expanded by MV. MV-related fluid retention is mediated via various homeostatic compensatory systems. They are activated to combat the decrease in cardiac output and central blood volume caused by MV, due to the increase in airway and intrathoracic pressure. These phenomena are more prominent during prolonged ventilation, PEEP or C-PAP ventilation, and in previously hypovolemic patients. Patients requiring MV for more than 32 hours had an average garamycin VD of 0.36 L/Kg compared with the mean VD of 0.25 L/Kg in normal adults. In the patient presented, a similar change in garamycin VD was seen, while conventional doses given during MV failed to reach suitable clinical peak levels.

Continuous Quality Improvement in Anesthesia

Luis Gaitini, Sonia Vaida, Shahar Madgar

Depts. of Anesthesia and of Urology, Bnai-Zion Medical Center, Haifa

Slow continuous quality improvement (SCQI) in anesthesia is a process that allows identification of problems and their causes. Implementing measures to correct them and continuous monitoring to ensure that the problems have been eliminated are necessary. The basic assumption of CQI is that the employees of an organization are competent and working to the best of their abilities. If problems occur they are the consequences of inadequacies in the process rather that in the individual. The CQI program is a dynamic but gradual system that invokes a slower rate of response in comparison with other quality methods, like quality assurance. Spectacular results following a system change are not to be expected an the ideal is slow and continuous improvement.

A SCQI program was adapted by our department in May 1994, according to the recommendations of the American Society of Anesthesiologists. Problem identification was based on 65 clinical indicators, reflecting negative events related to anesthesia. Data were collected using a specially designed computer database. 4 events were identified as crossing previously established thresholds (hypertension, hypotension, hypoxia and inadequate nerve block). Statistical process control was used to establish stability of the system and whether negative events were influenced only by the common causes. The causes responsible for these negative events were identified using specific SCQI tools, such as control-charts, cause-effect diagrams and Pareto diagrams. Hypertension and inadequate nerve block were successfully managed. The implementation of corrective measures for the other events that cross the threshold is still in evolution. This program requires considerable dedication on the part of the staff, and it is hoped that it will improve our clinical performance.

Progression of Diabetic Retinopathy after Cataract Extraction

Y. Raniel, Y. Teichner, Z. Friedman

Annette and Aron Rozin Dept. of Ophthalmology, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

A prospective study of the effect of cataract extraction with intraocular lens implantation on the course of diabetic retinopathy (DR) in 44 patients (59 eyes) was carried out. It showed that in the 1-3 years following surgery, there was progression of DR (including development of newly formed retinopathy) in 35% of the patients (28.8% of eyes). Progression was more marked in patients with pre-operative bilateral DR compared to those without bilateral DR (77% and 16% respectively). Insulin dependence did not play a role in progression. Final visual acuity was better in patients without pre-operative DR, as well as in eyes without progressive retinopathy.

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.

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.

Pyogenic Liver Abscess in Children

R. Spiegel, D. Miron, Y. Horovitz

Dept. of Pediatrics A and Infectious Disease Unit, HaEmek Medical Center, Afula, and Technion Faculty of Medicine, Haifa

2 children with pyogenic liver abscesses were hospitalized during the past 2 years. A 6-year-old boy had high fever and hepatomegaly, and a large liver abscess was found in the right hepatic lobe. Streptococcus milleri was isolated from the pus. Treatment with a combination of prolonged drainage of the abscess and antibiotic therapy was successful. A 4-month-old girl who had prolonged fever was found to have osteomyelitis of 3 thoracic vertebrae and 2 liver abscesses in the right lobe. She was treated successfully with broad spectrum antibiotics. Additional workup revealed that she had chronic granulomatous disease.

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.

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.

Identification of Sentinel and Axillary Node Involvement in Breast Cancer

M.Z. Papa, D. Bersuk, M. Koler, E. Klein, M. Sareli, G. Ben-Ari

Dept. of Surgical Oncology and Breast Unit, Chaim Sheba Medical Center, Tel Hashomer

Axillary node dissection for breast cancer is important for staging and prognosis. "Sentinel nodes" are the first nodes into which primary cancer drains. Identification, removal and pathological examination of those nodes indicates whether completion of axillary lymphadenectomy is required. The sentinel nodes are identified using a vital dye injected at the primary tumor site. With this technique we were able to identify sentinel nodes in 46 of 48 (95%) women examined. An average of 2.7‏1.2 nodes were identified as sentinel nodes. In 81% of cases there was a correlation between involvement of sentinel nodes and of other axillary nodes as well. In 10% of patients sentinel nodes were involved with tumor while other axillary nodes were negative. The major problem in routine application of this is relationship in surgical decisions is reliable real time pathological identification of lymph node involvement by tumor.

Biofeedback Treatment of Raynaud's Disease

M. Birger, R. Sha'anani, F. Pavlotzki

Psychiatric Day Care and Dermatology Depts., Chaim Sheba Medical Center, Tel Hashomer and Psychiatric Service of Leumit Health Insurance Company

Raynaud's disease is characterized by intermittent peripheral vasoconstriction leading to pallor, cyanosis and reactive vasodilation of the arterioles of fingers and toes. These phenomena are accompanied by sensations of cold or warmth, pain and difficulty in manipulating the palms. Ulcerations of the fingertips can occur in severe cases. Since conservative medical treatment, consisting of preventive measures and changing various habits, results in alleviation in only half the patients, sympathectomy is often required. Psychological intervention, including biofeedback, also has a significant role. Biofeedback involving relaxation techniques, guided imagination, and in parallel, computer-assisted monitoring of sympathetic arousal, might lead to symptom reduction as a unique treatment or in conjunction with other treatment modalities.