תוצאת חיפוש

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.

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.

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.

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.

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.

Technetium 99-M Sestamibi Bone Scan in Musculo-Skeletal Neoplasms

Dror Robinson, Lena Pinkas, Lilia Mindlin, Nahum Halperin, Tifha Horn

Dept. of Orthopedics and Nuclear Medicine, Assaf Harofeh Medical Center, Zerifin

It is often difficult to assess accurately the nature of a skeletal lesion. Problems include differentiating a malignant from a benign bone tumor, as well as determining the cause of a pathologic fracture. Such fractures may occur through osteoporotic bone as well as through neoplasm-affected bone. Thus, development of an imaging modality capable of distinguishing between such lesions is of importance. During 1996, we ran a prospective study in which results of Tc-99m-methyl-diphosphate (MDP) bone scans were compared with those of sestamibi (MIBI) bone scans and with subsequent biopsy and clinical course. The results of the bone scans were assessed by 2 independent "blinded" observers, and the ratios of counts in lesions to those in normal tissue (L/N ratios) were calculated. In cases of malignant (7) and benign (8) tumors, intensity of uptake in MDP scans were not predictive of degree of aggressiveness. On the other hand, MIBI bone scans demonstrated significant difference in intensity of uptake between benign and malignant bone tumors (L/N ratios 2.05 vs 2.75). In 5 of 8 benign lesions the L/N ratio was 1. In the others, increased uptake was minimal. In 2 patients changes in uptake in MIBI bone scan following chemotherapy appeared to be related to the degree of tumor necrosis achieved. While the MIBI bone scan cannot replace tissue biopsy as a definitive diagnostic modality in bone neoplasms, it does appear to allow better preoperative assessment and prognosis.

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.

-----------------

* 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.

Gynecologic Problems of the Lower Genital Tract in Children and Young Adolescents

Giulia Barda, Dino Bernstein, Sagit Arbel-Alon, Haim Zakut, Joseph Menczer

Dept of Gynecology and Obstetrics, Edith Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University

Hospital records of 46 girls under the age of 17 years, hospitalized for lower genital tract problems in 1986-95 were reviewed. The most common conditions were results of unintentional injuries (43.5%), imperforate hymen (28.2%) and infections (19.6%). The median age for unintentional injuries was significantly lower than for other conditions (7.0 vs 11.4; p<0.001). Most injuries were external and occurred during outdoor activities. Mean volume of estimated bloody fluid drained in those with imperforate hymen was greater when the diagnosis was made after the age of 12 (783 vs 433; not significant). It has been suggested that hematocolpos and hematometra should be prevented, but the possible unfavorable sequelae have not been documented. The relative order of frequency of the various diagnostic groupings and the diagnoses of labial adhesions and imperforate hymen are specific for the age of the study group.

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.

High Dose Oral Prednisone for Hemangiomas in Infants

Nahum Sadan, Baruch Wolach

Pediatrics Dept., Meir General Hospital, Sapir Medical Center, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University

Over a 24-year period, 62 infants (47 girls) with hemangiomas were treated with an initial dose of either 3 or 5 mg/kg/day of oral prednisone for 2 weeks, after which the dose was gradually tapered off during 6-8 weeks. Few patients required longer treatment. Results were judged to be excellent in 68% of infants and good in 25%. Treatment was considered a failure in only 7%. The initial dose of 5 mg/kg/day was more effective than the smaller dose (p<0.001). Of the 62 patients, 49 received 1 course of treatment, 8 required 2 courses and 5 required 3 courses. Retreatment was given whenever significant regrowth occurred. Side-effects were not serious, and resolved when treatment was discontinued. Treatment was indicated when the location of the lesions caused interference with important functions or when the lesions were likely to damage anatomic structures. Special attention was paid to early treatment of eye and subglottic hemangiomas. In all 22 children with hemangiomas of the eye (most with an orbital component), shrinkage of the lesion was observed within 24 hours of initiating treatment. In 19 of the 22 there was no residual of the hemangioma 1-18 years later. Such lesions deserve early treatment, not just as cosmetic emergencies, but to prevent secondary amblyopia. Early treatment of subglottic hemangiomas is also mandatory because they are potentially life- threatening. We conclude that oral prednisone is very effective in the treatment of hemangiomas of infants when given at a high dose for an adequate period of time.

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.

Superficial Dorsal Penile Vein Thrombosis (Mondor's Disease)

Ran Katz, Arye Blachar

Depts. of Urology and Radiology, Hadassah Medical Center, Hebrew University of Jerusalem

Superficial venous thrombosis of the chest wall was first described by Mondor in 1939. Braun-Falco reported in 1955 superficial penile vein involvement in diffuse thrombophlebitis of the abdominal wall and in 1958 Helm and Hodge first described isolated superficial dorsal penile vein thrombosis. Since then, fewer than 50 cases have been reported. The clinical presentation is usually redness and swelling of the dorsum of the penis, accompanied by a palpable, tender thrombotic vein. This acute and painful disease frightens the patient, who is concerned about his fertility and sexual function. The main cause of this disease is frequent sexual intercourse. Diagnosis is based upon anamnesis, physical examination and penile sonography with color Doppler imaging. It is usually a benign disease which resolves quickly under appropriate medical therapy. We present a man who was admitted for this condition and was successfully treated.

Insertion of Hickman Catheters in an Interventional Radiology Suite

Eli Konen, Alex Garniak, Binyamina Morag, Izhar Hardan, Zalman Rubinstein

Depts. of Radiology and Hemato-oncology, Chaim Sheba Medical Center, Tel Hashomer

In the past 20 years Hickman catheters have gained increasing acceptance for many uses, including bone marrow transplantation, long-term chemotherapy, total parenteral nutrition, dialysis, and administration of antibiotics and fluids. Until the past decade these catheters were inserted in the operating room. We present our experience in the percutaneous placement of 203 Hickman catheters in an interventional radiology suite in 190 consecutive patients within a period of 30 months. Catheter placement was successful in 202 (99.5%). The main complications were infections, necessitating removal of the catheter in 11 cases (5.4%) and unintentional dislodgement of the catheter in 8 (3.9%) - all in women and most on the right side. Pneumothorax and thrombosis in the catheter each occurred once. In another patient the guide wire broke during insertion and had to be percutaneously removed from the pulmonary artery. Late fracture of the catheter occurred in 2 others in whom the intravascular fragment was removed percutaneously. We believe that percutaneous Hickman catheter placement in the radiology suite offers advantages over traditional surgical placement.

Angioplasty and Stenting of the Carotid Artery

Eli Atar, Alexander Garniek, Issam Rabi, Benymina Morag, Zallman Rubinstein

Dept. of Diagnostic Imaging, Interventional Radiology Unit, and Dept. of Vascular Surgery; Chaim Sheba Medical Center, Tel Hashomer (Affiliated with the Sackler Faculty of Medicine, Tel Aviv University)

Percutaneous endovascular techniques are well established procedures in the management of peripheral vascular disease and visceral arterial stenosis. They are now being adapted for use in the carotid artery as well. 8 patients with 9 extracranial carotid artery stenoses were successfully treated by percutaneous angioplasty, following which in 4 of them 5 stents were inserted. The stenotic lesions were situated in the proximal internal carotid artery and in its bifurcation and also in the common carotid artery. The indications for angioplasty in these patients were the same as for surgery. There were no major complications. 1 patient had transient hemiparesis lasting a few hours, and another had bradycardia following balloon dilatation in the region of the carotid body. Percutaneous endovascular treatment of carotid artery stenosis is becoming a safe, feasible alternative to surgery.

"Charge" Association

Asher Barak, Lidia Gabis, Biniamin Mogilner, Shulamit Gelman-Kohan

Pediatric and Neonatal Depts., and Clinical Genetic Unit, Kaplan Hospital, Rehovot

CHARGE association represents a group of congenital anomalies with no clear etiology. The broad array of abnormalities, which involves several systems, has been the basis for the acronym CHARGE: coloboma, heart anomaly, choanal atresia, retarded growth and development, hypoplastic genitalia and ear malformation. We present 3 children with CHARGE association to illustrate the phenotypic variability and note the multidisciplinary treatment they received. It is recommended that this entity be approached in an interdisciplinary, integrated way to allow for faster diagnosis and better prognosis.