תוצאת חיפוש

Limited Axillary Thoracotomy for Recurrent Spontaneous Pneumothorax

I. Bar, M. Simha, A. Nissan, Y. Shargal, M. Kramer, G. Merin

Depts. of Cardiothoracic Surgery and of Surgery, and Pulmonary Institute, Hadassah--University Hospital, Ein Karem; and Dept. of Surgery, Hadassah--University Hospital, Mt. Scopus, Jerusalem

Recurrent spontaneous pneumothorax often requires surgical intervention. Recently, less invasive thoracic surgical techniques, such as video-assisted thoracoscopy (VAT) and limited axillary thoracotomy (LAT), have been developed and used for different thoracic procedures. We describe our results with limited axillary thoracotomy, as compared with those of video-assisted thoracoscopy as reported in the literature. From October 1994 to May 1996, 14 patients with recurrent spontaneous pneumothorax, aged 16-33 years, underwent limited axillary thoracotomy, resection of blebs and apical pleurectomy, using multifire GIA 80 staplers (Auto Suture Inc.). There were no complications or recurrences during 5-17 months of follow-up. Mean operative time was 52.2 minutes and mean hospital stay 2.3 days postoperatively. Full activity was regained within 12.1 days. In comparison with over 75 cases of VAT from the literature, LAT is safe and offers the potential benefits of decreased operative time, hospital stay and cost.

Participation of Patients with Uret-Eral Calculi in Clinical Decision Making, and Level of Anxiety

Ilana Margalith, Amos Shapiro

Hadassah-Hebrew University School of Nursing, and Dept. of Urology, Hadassah Medical Center, Jerusalem

In a study examining the relationship between patient participation in clinical decision making and levels of anxiety, patients were offered a choice of treatment for ureteral calculus. 42 received information about 2 treatment options, ultrasound fragmentation of the stone through a ureteroscope and extracorporeal shock wave lithotripsy (ESWL), and were asked to choose the method that they preferred. 54 received treatment decided on by the physician without their participation in the decision making process. Anxiety was measured before meeting with the physician, immediately after the meeting and on hospitalization for treatment. The contribution of the patient's perception of participation in the decision- making process and level of education was also examined. There was a decrease in level of anxiety after meeting with the physician only among those who did not actually participate in the decision-making process (p<0.05). There was no change in the level of anxiety among those offered choice of treatment. However, a decrease in anxiety was evident among patients who perceived that they had received information about their illness and its treatment (p<0.01). This was not the case for patients who perceived themselves as participants in decision making unless they had a relatively high-level of education (p=0.05).

Suprascapular Nerve Entrapment in a Basketball Player

Atzmon Tsur, Radi Shahin

Rehabilitation Unit and Dept. of Neurology, Western Galilee Hospital, Nahariya

A basketball player was shown to have a suprascapular nerve lesion without any history of shoulder girdle trauma. This acute neuropathy, never previously described in basketball players, is a result of repeated micro-trauma, due to nerve traction over the coracoid notch during violent movement ("dunking" most probably). Clinically, he was unable to abduct his arm and had some difficulty in external rotation. He developed atrophy in both the supra- and the infraspinatus muscles. Nerve conduction latency to the supraspinatus muscle was 8.0 ms, and to the infraspinatus, 8.5 ms. The compound muscle action potential registered in the supraspinatus was 1.224 mV, and in the infraspinatus, 1.237 mV. After 3 weeks of inactivity, recovery was spontaneous and practically complete.

Should Physical Restraints be used in an Acute Geriatric Ward?

Svetlana Barazovski, Arnold Rosin

Geriatric Dept., Shaare Zedek Medical Center, Jerusalem

A prospective study was carried out in an acute geriatric ward to determine the incidence of the use of physical restraints, the reasons for using them and the consequences. Over a period of 8 months an independent observer documented all cases in which a restraint was used and followed them until it was removed. A questionnaire was submitted to the nurses as to why they applied the restraints. 16% of patients had some form of restraint applied, in 2/3 of them for up to half of their stay in the ward. In over 90% of those restrained, functional (Barthel) and cognitive (mini-mental) scores were between 0-5. In unrestrained patients, the functional score was 0-5 in 79% and the cognitive score 0-5 in 72%. The main reason for applying restraints, usually sheets or body binders, was to prevent the patient from falling out of, or slipping from chairs, rather than to stop them from rising out of them. Other important reasons, which overlapped, were to prevent the patient from interfering with nasogastric tubes, catheters, and IV cannulas, each in 1/3 of the group. Restraints were discarded when deterioration did not allow the patient to sit out of bed, to decrease agitation, to allow enteral or parenteral treatment, and in 12%, when there was supervision by the family. Of 33 families interviewed, none opposed application of restraints, and most left the decision to the responsible ward staff. We conclude that restraints cannot be avoided in some acutely ill, old patients with severe physical and mental dysfunction. However, ways should be sought to minimize their use, as recommended in the literature, by demanding from the staff a specific reason, signed agreement of a physician, close follow-up, and favorable environmental conditions such as suitable chairs, occupational activity, and staff cooperation in removing the restraints.

Budd-Chiari Syndrome

S. Goland, S.D.H. Malnick, L. Shvidel, E. Mor, Z.M. Sthoeger, E. Evron

Medical Depts. C and B, and Hematology Institute, Kaplan Hospital, Rehovot; and Surgical Dept. B, Rabin Medical Center, Beilinson Campus, Petah Tikva

Budd Chiari syndrome is a rare disorder resulting from occlusion of hepatic venous drainage by hepatic vein thrombosis or by a membranous web in the inferior vena cava. In western countries the commonest causes are myeloproliferative disorders and hypercoagulable states. Presentation may be acute with rapid accumulation of ascites and hepatic failure, or subacute with symptoms developing over a few months. A chronic progressive form has also been described. On presentation there is usually abdominal pain, ascites, and hepatosplenomegaly; hepatic encephalopathy is found in about a third. Noninvasive, ultrasound-Doppler is recommended in diagnosis, and has a high correlation with hepatic venography. Liver biopsy is required for therapeutic decisions. Those with advanced hepatic failure or severe fibrosis on liver biopsy are referred for hepatic transplantation. When biopsy shows only hepatic congestion and inflammatory infiltrates, portosystemic shunting is recommended. We present a 61-year-old woman with ascites and hepatosplenomegaly that had developed over the courses of a few months. Budd-Chiari syndrome with chronic myelofibrosis and congenital protein C deficiency were diagnosed. Portosystemic shunt was performed but death from sepsis followed shortly.

Buschke-Ollendorf Syndrome

A. Adunsky, E. Atar, H. Trau

Depts. of Geriatrics, Radiology, and Dermatology, Chaim Sheba Medical Center, Tel Hashomer

Buschke-Ollendorf syndrome is a rare condition characterized by uneven sclerotic, osseous formations seen on X-ray (osteopoikilosis) and fibrous skin papules (dermatofibrosis lenticularis disseminata). We report an 82-year-old man with this syndrome. Awareness of the condition is important to avoid misdiagnosis and hazardous management designed for other disorders, such as prostatic metastases.
 

Radical Retropubic Prostatectomy

Ran Katz, Amos Shapiro, Shimon Meretyk, Ezekiel H. Landau, Dov Pode

Urology Dept., Hadassah,University Hospital and Hebrew University,Hadassah Medical School, Jerusalem

Radical prostatectomy may cure most patients in whom the malignant tumor has not invaded through the prostatic capsule. Advances in surgical technique and accumulation of experience have decreased the complication rate significantly. Long-term results of surgical treatment are now better than those of other forms of treatment; hence radical prostatectomy is now recommended for men with life expectancies longer than 10 years. Between 1988 and 1995, 164 men with clinical stages T1 or T2 adenocarcinoma were admitted for radical prostatectomy. Most were not offered a nerve-sparing procedure, so as to allow wider, more complete resection. Those who wanted preservation of sexual function underwent the nerve- preserving procedure. In 6 patients operation was discontinued when metastases to the iliac lymph nodes were detected and in 1 when invasion of the pelvic wall was found. 157 underwent radical prostatectomy. Preoperative biopsy revealed a low-grade lesion (Gleason 2-4) in 19.1%, intermediate grade (Gleason 5-6) in 61.8% and high-grade (Gleason 7-9) in 19.1%; however, pathologic grading revealed that only 7.0% had grade 2-4 tumor, 60.5% grade 5-6 and 32.5% grade 7-9. Pathologic staging revealed T2 tumor in 58%, T3 in 38.8% (including microscopic invasion of the capsule or seminal vesicles); microscopic lymph node metastases were found in 3.2%. Tumor invasion through the capsule was found in only 2 of 13 treated with neoadjuvant androgen blockade, compared with 40% in those who did not receive this treatment. There was no operative mortality and only 14.7% has complications. All had urinary incontinence immediately after operation, but regained continence after an average of 4-5 months. 24 were incontinent for more than 12 months, but most of them had only mild stress incontinence. Most patients were impotent after the procedure. There was tumor recurrence, diagnosed by rise in serum PSA, in 26 during an average follow-up of 26.4 months (range 3-93). Cure rate of prostatic cancer by radical prostatectomy may be increased by improved preoperative staging methods and better patient selection; long term follow up is required for determining cure rate.

Effect of the Yom Kippur Fast on Parturition

A. Wiser, E. Maymon, M. Mazor, I. Shoham-Vardi, T. Silberstein, A. Wiznitzer, M. Katz

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

Food-withdrawal has been proposed as a possible mechanism for initiating the onset of labor in animals and humans. The hypothesis was based upon the reported increase in deliveries of infants during the Yom Kippur fast. We studied the effect of the fast on full term deliveries of Jewish women, with non-fasting Bedouin women as controls (1988-1995, 1,313 Jewish and 1,091 Bedouin deliveries). To determine the effect of Yom Kippur itself, delivery rates on Sukkot and Yom Kippur were compared in both groups. The mean delivery rate in the Jewish population was significantly higher during Yom Kippur and the day after, than during the 7 days before Yom Kippur (15.1±5.1 and 14.6±4.7 vs 10.7±3.5, p<0.04 and p<0.01, respectively). There was an increase in delivery rate during the 6 hours before the end of the fast. In the Bedouin women there were no changes in delivery rate during any of these periods. There were no significant differences in the rates of deliveries during the Sukkot festival between Jewish and Bedouin women. We conclude that fasting is associated with a significant increase in the rate of deliveries at term.

Reporting Maternal Behavior during Diarrhea in Bedouin Children

Natalya Bilenko, Amalia Levy, Drora Fraser

Epidemiology and Health Services Evaluation Unit, S. D. Abraham International Center for Health and Nutrition, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Diarrhea is still a major cause of morbidity and mortality among children in developing countries. The Bedouin population of southern Israel is in transition from a nomadic to a settled life-style. We examined maternal knowledge and reported behavior when their children had diarrhea. Mothers defined diarrhea as the passing of 4-5 stools per day. The most frequent signs of the illness were an increased number of watery stools with changes in either color or form. The most frequent symptom that prompted mothers to seek medical aid was blood in the stool. All mothers reported increasing fluid intake in their children during diarrhea, and most reported giving herbal tea. About half of the women avoided milk products and used special for the treatment of diarrhea. A quarter of the women reported stopping or decreasing the frequency of breast feeding during diarrhea. Reported cessation of breast feeding during diarrhea was associated with changing to special foods, and failure to note the onset of diarrhea or to recognize signs of dehydration. The withdrawal of breast feeding during episodes of illness and diarrhea is related to lack of knowledge regarding diarrhea. These data indicate that even in this population, with free access to preventive and curative medical care, there should be greater efforts to educate mothers to detect diarrheal disease and to maintain breast feeding during the diarrhea.

Glenoid Fossa Fracture

M. Kligman, M. Roffman

Dept. of Orthopedic Surgery, Carmel Medical Center, Haifa

4 patients with displaced intra-articular glenoid fossa were treated either surgically or conservatively. After an average follow-up of 7 years, the clinical and radiographic results were satisfactory in all. The 2 treated surgically required shorter follow-up than those treated conservatively. Conservative treatment should be considered a good option for displaced intra-articular glenoid fossa fracture.

Solid Organ Retransplantation

Yaron Ilan, Dan Admon, Michael Friedlander

Division of Medicine, Dept. of Cardiology and Nephrology Unit, Hadassah Medical Center, Jerusalem

The need for solid organ retransplantation is a major factor in the shortage of available organs. Between 1972 and 1992, 56 out of 309 kidney transplants and 2 out of 20 liver transplants performed in our hospital were retransplantations. The present study evaluates local and world experience with organ retransplantations in terms of the medical and ethical issues.

Osteoid Osteoma of the Patella

I. Cohen, A. Aner, V. Rzetelny

Dept. of Orthopedics, Edith Wolfson Medical Center, Holon

Osteoid osteoma is a primary, benign, bone tumor with a typical X- ray appearance. The diagnosis is usually straightforward when it involves the long bones of the leg. However it may occur in unusual locations, such as in flat and cancellous bones. The following case demonstrates the difficulty in diagnosing it in an extremely rare site. A 25-year-old woman with long-standing anterior, right knee pain had had 3 interventions: 2 diagnostic arthroscopies and a distal, femoral biopsy. Since there had been no improvement in her condition, the diagnosis of osteoid osteoma of the patella was suggested, supported by recent X-ray and scintigraphicfindings. This rare condition was confirmed by biopsy of the upper pole of the patella, a procedure that was followed by complete recovery. 6 years later, she is now completely free of pain and has no clinical or X-ray evidence of recurrence.Review of the literature revealed only 5 previously reported cases of osteoid osteoma of the patella. All were diagnosed relatively late and in 1 the tumor was diagnosed only after total patellectomy. Diagnosis of these rare cases that mimic much more common causes of patello-femoral pain demands a high index of suspicion.

Recurrent Late Hemarthrosis after Total Knee Replacement

David Hendel, Gad J. Velan

Dept. of Orthopedics, Rabin Medical Center, Golda Campus, Petah Tikva

A patient who had a successful total knee replacement for severe degenerative osteoarthritis of the right knee had an excellent functional result. 2 years after the operation there was spontaneous intra-articular bleeding that was treated successfully conservatively. Recurrent hemarthrosis 2 months later was treated similarly and also resolved without residual functional impairment after a follow-up of over 1 year. Recurrent late hemarthrosis in the knee is a fairly rare complication following total knee arthroplasty, but is amenable to conservative measures. Frequently, persistent recurrent hemarthrosis requires debridement of the bleeding synovium of the knee.

"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.

Familial Adenomatous Polyposis: Establishing a Registry and Genetic and Molecular Analysis

R. Shomrat, R. Bruchim, Y. Galanty, Z. Samuel, C. Legum, M. Rabau, P. Rozen

Genetic Institute and Depts. of Gastroenterology and Surgery, Tel Aviv Medical Center and Sackler Faculty of Medicine, Tel Aviv University

Familial adenomatous polyposis (FAP), a dominantly inherited disease, is caused by a mutation in the adenomatous polyposis coli gene in chromosome 5q21. The gene has 15 exons, a physical length of 10 Kb and an open reading frame of 8.5 Kb. Exon 15 codes 66% of the mRNA and has a mutation cluster region which accounts for over 50% of mutations. The disease usually leads to the appearance of hundreds of adenomatous polyps in the transverse and descending colon between puberty and age 20 years and to colon cancer before the age of 40. Early detection is essential to prevent the development of metastasizing cancer. Since 1994 we have recruited 23 families for genetic counseling. DNA was obtained from 19 unrelated FAP patients and 219 high risk relatives in 19 unrelated families following confirmation of the diagnosis. In addition to linkage studies, direct mutational analysis was performed using the protein truncation test for most of exon 15 and single strand conformation polymorphism analysis for the other exons. These exons account for most of the mutations identified to date. Of 19 unrelated probands, 14 had detectable mutations. Exon 15 accounted for 6 families, exons 5, 7 and 14 for 1 each, exon 9 for 3, and exon 8 for 2. Combined mutational and linkage analysis identified 18 presymptomatic carriers who received genetic and clinical counseling. Our FAP patients did not differ significantly from those of larger studies in other countries with regard to the distribution of the mutations, gender and genotype-phenotype correlation, or ethnic distribution.