תוצאת חיפוש

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.

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.

Central Cord Syndrome in the Elderly Who Fall: a Diagnostic Trap

A. Adunsky, H. Semo, S. Levenkrohn

Geriatric Rehabilitation Dept., Chaim Sheba Medical Center, Tel Hashomer

Acute post-traumatic spinal injury is common and usually poses no diagnostic difficulties. Following a low-energy fall, the onset of acute central cord syndrome in the elderly is not common and is frequently misdiagnosed. Men aged 60 and 81, and a woman aged 75 are described, in whom central cord syndrome was overlooked. Awareness of this condition is important to avoid incorrect diagnosis and hazardous management.

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.

Fish Spine Infection

Alexander Nudelman, Gordon Edelson, Amos Linden, Raoul Raz

Orthopedic Dept., Poriya Hospital and Dept. of Infections Diseases, HaEmek Hospital, Afula

Vibrio vulnificus is a Gram-negative bacterium living in warm salty water that produces a spectrum of human disease which may progress to devastating, sometimes fatal infections in susceptible individuals. Such infections have rarely been reported in Israel. However, over the past few months we have been seeing a sharp increase in V. vulnificus infections with a common history of injury to extremities by the sharp spines of Tilapia zillii, ("amnon" or St. Peter's fish). Clinical suspicion and prompt intervention prevent the untoward consequences of misdiagnosis or delay.

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.

Penetrating Ocular Injuries: a Retrospective Study

M. Schneck, S. Weitzman, T. Lifshitz, B. Biedner

Dept. of Ophthalmology, and Epidemiology and Health Services Evaluation Unit, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Penetrating injuries of the eye are an important cause of unilateral visual loss. We studied a series of 82 cases of penetrating injuries treated here from 1987 through 1993. The injuries were caused by sharp objects in 66% and blunt trauma in 6%. The prognosis after a penetrating injury is greatly influenced by the nature of the injury and the extent of the initial drainage. Among factors associated with an unfavorable visual outcome were diminished preoperative visual acuity and scleral wounds with dense vitreous hemorrhage.

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.

Gram-Negative Enteric Bacteremia in Children in the Negev

Michal Maimon-Greenwald, Eugene Leibovitz, Nimrod Maimon, Nechama Peled, Ron Dagan

Pediatric Infectious Disease Unit and Clinical Microbiology Laboratory, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

During 1989-1994, there were 322 episodes of Gram-negative enteric bacteremia in 308 children. The incidence increased from 31/100,000 in children younger than 15 years of age during 1989-1991, to 50/100,000 during 1992-1994. The most common pathogens were Klebsiella, E. Coli, Salmonella and Enterobacter. 39% of episodes were nosocomial and a significant increase was recorded for each species during the last 3 years of the study. Klebsiella represented the most common pathogen causing nosocomial bacteremia, while E. coli and Salmonella were the main pathogens causing community-acquired bacteremia. In this study in southern Israel, the incidence of Gram-negative enteric bacteremia was significantly higher in Bedouin children, with the exception of bacteremia due to Salmonella, which occurred mainly in Jewish children.

Quality of Life in Younger Adults after First Stroke

Shenka Alfassa, Revital Ronen, Haim Ring, Aida Dynia, Ada Tamir, Reuben Eldar

Fleischman Unit for Study of Disability, Neurological Ward, Loewenstein Hospital, Ra'anana

To study the effect of stroke on the quality of life in younger adults, 199 patients 17-49 years of age who had sustained a first stroke between 1.11.92 and 31.10.93 were followed up. They were interviewed by telephone at 3, 6, 12 and 24 months after the event. 2 died during the first year of follow-up, and 8 had recurrent strokes. After 2 years, 8 additional patients had died and 4 had sustained recurrent events. Gradual improvement was reported within all age groups and in all areas. During the 3-6 months period, a mean of 4% improvement occurred in functional capability, 15% in social and recreational activity and 8% in return-to-work. The 6-12 month period showed an increase of 3% in improvement in mean functional capability, 10% in social and recreational activity and 2% in return-to-work. 1 year after the stroke 27% remained with moderate to severe disability, but over 86% were functionally independent in their daily living activities. There were no significant changes during the second year of follow-up in these statistics. 67% of those employed prior to their stroke returned to work and approximately 70% reported a return to prestroke social and recreational activity. These results demonstrate that the relatively high recovery rate and functional improvement during a year of follow-up were not accompanied by similar rates of improvement in emplyment and in social integration. They indicate the need for increased emphasis on long-term psychosocial rehabilitation services within the community.

An Achondroplastic Dwarf with Paraplegia

A. Rakier, G. Sviri, M. Feinsod

Dept. of Neurosurgery, Rambam (Maimonides) Medical Center, Rappaport Faculty of Medicine, The Technion, Israel Institute of Technology, Haifa

A 30-year-old female achondroplastic dwarf developed a progressive gait disturbance erroneously attributed to her hydrocephalus and deformities of both legs. Her condition deteriorated into flaccid paraplegia with anal and urinary incontinence. CT revealed extreme spinal stenosis typical in achondroplasia (shallow vertebbody, short pedicles, and hypertrophy of intervertebral joints) together with disc protrusions. Wide laminectomy of the lumbar vertebrae resulted in complete amelioration of all the neurological deficits. Progressive paraplegia is a rare complication of achondroplasia; its early recognition and surgical treatment is very rewarding.

Gastrointestinal Angiodysplasia

D. Zamir, C. Zinger, J. Jarchovski, Z. Fireman, R. Magadle, L. Zelikovski, G. Bartal, P. Weiner

Depts. of Medicine A and B, and Gastroenterology and Nuclear Institutes, Hillel Yaffe Medical Center, Hadera

Gastrointestinal angiodysplasia is a cause of gastrointestinal bleeding in the elderly, for which surgery has been the only treatment. Estrogen has been reported beneficial in some cases in the past decade. Recurrent bleeding due to angiodysplasia occurred from the small intestine in a 75-year-old woman, and from the right colon in a 91-year-old man. The diagnoses were made by angiography in the first case and colonoscopy and erythrocyte- scanning in the second. There was aortic stenosis in both, a combination which has been reported in other cases. Both patients improved with estrogen therapy. However, after temporary stabilization, gastrointestinal bleeding recurred in the second patient and he was successfully operated on.

Surgical Approach to Benign Extradural Lesions of the Thoracic Spine

Ely Ashkenazi, Stephen T. Onesti, W.J. Michelsen

Depts. of Neurosurgery, Hadassah University Hospital, Jerusalem and Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University, The Bronx, New York

A benign epidural lesion in the thoracic spine is rare, and usually the result of intervertebral disc herniation or infection. Not long ago patients were diagnosed late in the course of their disease and the surgical results of the standard laminectomy usually performed were grave. The development of newer imaging techniques (CT and MRI) has made diagnosis much easier, so diagnosis is often earlier, when neurological deficit is minimal. Newer neurosurgical techniques and approaches to the thoracic spoine have been developed to treat these lesions, which we describe. Clinical data on 16 patients operated from January 1996 to January 1997 are presented.

Therapeutic and Toxic Theophylline Levels in Asthma Attacks

Aliza Zeidman, Joseph Gardyn, Zinaida Fradin, Gershon Fink, Moshe Mittelman

Dept. of Medicine B, Rabin Medical Center, Golda (Hasharon) Campus and Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva; and Sackler Faculty of Medicine, Tel Aviv University

Although first-line therapy for bronchial asthma has changed over the past decade to anti-inflammatory medication such as inhaled corticosteroids and cromolyn with possible addition of beta-agonists, theophylline is still useful and therefor widely used. However, several studies have raised serious questions regarding its efficacy in acute asthmatic exacerbations. These studies, the narrow therapeutic range of the drug, the frequency of side effects and interactions with common drugs, and individual variation in clearance and metabolism, have prompted its reevaluation in the management of asthma. Therapeutic serum levels of theophylline are between 10 to 20 mcg/ml. Most adults achieve these concentrations with daily slow-release oral theophylline preparations, 200-400 mg (approximately 10 mg/Kg) twice a day. However, when such a patient presents to the emergency room (ER) in an asthmatic attack, immediate intravenous theophylline is often given, regardless of maintenance treatment. Since the rationale for this common therapeutic approach has been challenged, the current study was undertaken. Serum theophylline levels were measured in 23 consecutive asthmatics presenting to the ER in an acute attack. 15 (68%) had therapeutic levels (above 10 mcg/ml) and 2 had toxic levels (above 20 mcg/ml), prior to receiving the standard intravenous theophylline dose given for an attack. These data indicate that most patients with bronchial asthma on oral maintenance theophylline do not require additional intravenous theophylline when in an attack. It probably will not benefit them and may even induce serious theophylline toxicity.

Distraction Osteogenesis for Hypoplastic Facial Bones

Adi Rachmiel, Dina Lewinson, Dror Eizenbud, Daren Rosen, Dov Laufer

Dept. of Oral and Maxillofacial Surgery, and Orthodontics and Cleft Palate Unit, Rambam Medical Center; and Division of Morphological Sciences, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Distraction osteogenesis is a well-known method for bone lengthening which stretches callus to generate new bone in the distracted area. The method was developed by Ilizarov for the lengthening of long enchondral bones. In recent years the method has also been applied to the facial bones and to the jaw.