תוצאת חיפוש

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.

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.

Carnitine Deficiency in Inborn Errors of Metabolism

B.-A. Sela, T. Lerman-Sagie, M. Berkovitz

Institute of Chemical Pathology, Chaim Sheba Medical Center and Section of Clinical Biochemistry, Sackler School of Medicine, Tel Aviv University; Pediatric Neurology Unit, Wolfsohn Medical Center, Holon; and Children's Ambulatory Clinic, Assaf Harofeh Medical Center, Zrifin

Several conditions, considered as inborn errors of metabolism, involve severe deficiencies in carnitine in both plasma and muscle. In the absence of evidence suggesting primary carnitine deficiency due to a biosynthetic enzymatic defect in the liver, the various diseases with carnitine deficiency are related to genetic defects in organic acid metabolism leading to blocked mitochondrial b oxidation. We describe a 4.5-year-old boy and 2 female infants with glutaric aciduria type I, isovaleric acidemia, and long-chain acid dehydrogenase deficiency, in whom severe carnitine deficiency was apparent. In all 3, long-term carnitine treatment proved to be vital and eliminated most of the symptoms.

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.

Isolated Susceptibility of Streptococcus Pyogenes to 3 Macrolides

W. Sakran, R. Raz, R. Colodner, Y. Keness

Infectious Disease Unit and Microbiology Laboratory, HaEemek Medical Center, Afula

Erythromycin is considered the drug of choice in the treatment of streptococcal pharyngitis in patients allergic to penicillin. However, in recent years several publications, especially in Finland and Italy, showed high resistance rates of S. pyogenes isolates to erythromycin and other new macrolides. To evaluate the situation in Israel, we checked the MIC of isolates from patients with tonsillitis during 1996. E-test results showed an MIC-50 of 0.23, 0.13 and 0.47 mcg/ml for erythromycin, clarithromycin and roxithromycin, respectively and a MIC-90 of 0.37, 0.23 and 0.78 mcg/ml. Only 2 isolates (2.1%) were partially or completely resistant to all 3 antibiotics. We conclude that empiric therapy with macrolides in Israel is still a viable option and can be recommended in S. pyogenes tonsillitis for patients allergic to penicillin.

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.

Macroenzymes: an Interesting Laboratory Finding, without Clinical Relevance

C. Perry, H. Peretz, E. Graf, O. Ben-Tal, A. Eldor

Hematology Dept. and Biochemistry Laboratory, Tel Aviv-Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

Macroenzymes are complexes of serum enzymes with proteins which have a higher molecular weight and longer plasma half-life than the normal enzyme. The presence of macroenzymes is suggested by finding increased serum enzyme activity, not associated with symptoms. Thus, macroenzymes can cause diagnostic errors and the performance of unnecessary tests or invasive procedures. We describe 2 patients with highly elevated serum levels of lactate dehydrogenase (LDH) and creatine kinase (CK) due to formation of complexes with immunoglobulin G. 1 patient had LDH of 4500 u/L but was otherwise normal and in the second CK was elevated with no evidence of ischemic heart disease. Awareness of the phenomenon of macroenzymes may save the patient long and sometimes invasive investigation.

Combined Treatment for Adhesive Capsulitis of the Shoulder

Ofer Levy, Ehud Rath, Dan Atar

Orthopedic Dept., Soroka Medical Center and Ben-Gurion University of the Negev, Beer Sheba

Adhesive capsulitis is a problem for the orthopedic surgeon due to the difficulty of treatment. Although it is self-limited, few patients will wait for spontaneous resolutions while suffering pain and progressive loss of motion. Our aim was to modify the course of the disease and to shorten recovery time by combining intensive physiotherapy with intra-articular infiltration and gentle manipulation. 49 patients with 50 frozen shoulders were enrolled in the study. All patients were treated initially with physiotherapy for 4-8 weeks. If no improvement was noted the affected shoulder was infiltrated and gently manipulated. 27 of 49 patients (55%) improved dramatically with the initial physiotherapy regimen. They achieved full or nearly full range of motion, with significant relief of pain. 22 patients were infiltrated and manipulated. Elevation improved significantly from an average of 110.95 to 165.71 degrees (p<0.001), external rotation from an average of 9.52 to 43.57 degrees (p<0.001) and internal rotation also improved significantly (p<0.001). Self assisted physiotherapy is the corner stone of treatment in adhesive capsulitis. When pain and limitaof passive range of motion persist, infiltration and gentle manipulation dramatically shortens the debilitating process.

Blunt Trauma causing Emboli from Friable Atherosclerotic Plaques

Selma Moses, Michael Motro, Yehuda Shoenfeld

Medical Dept. B and Cardiac Rehabilitation Institute, Chaim Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University

We present a 55-year-old woman who developed a shower of emboli following a car accident. Such events may have medicolegal implications as well as preventive considerations.

Stromal Uterine Sarcoma arising from Intestinal Endometriosis after Abdominal Hysterectomy and Salpingoophorectomy

Munir Bishara, Eitan Scapa

Institute of Gastroenterology, Hepatology and Nutrition, Assaf Harofeh Medical Center, Zerifin (Affiliated with the Sackler Faculty of Medicine, Tel Aviv University)

The incidence of ectopic endometriosis is 4% to 18%. The intestinal type is quite common with the rectosigmoid the most likely part of the bowel to be involved due to its pelvic location. A 43-year-old woman, whose symptoms, X-ray and endoscopic findings suggested malignancy of the rectosigmoid, is presented. Primary malignancy of the bowel was excluded by endoscopic biopsies. Histological examination at operation showed stromal sarcoma of the uterus with foci of endometriosis. There is no report in the English literature of transformation of intestinal endometriosis into malignancy, such as stromal sarcoma of the uterus, which imitates a primary malignancy with obstruction of the rectosigmoid.

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).

Consanguinity among Arabs in Israel

Lutfi Jaber, Orli Romano, Mordechai Shohat

Bridge to Peace Community, Taiba Pediatric Center; Schneider Children's Medical Center (Beilinson Campus), Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University

In a previous nationwide study, we examined the rate of consanguineous matings in the Israeli Arab community. The average inbreeding coefficient was 0.0192, much higher than that reported for the general population of Israel, 0.0038 in 1956-7. The inbreeding coefficients of 69 Arab villages, towns and cities (excluding the Bedouin in the South) were determined. Knowledge of the inbreeding coefficients of the various local populations is of value for geneticists, pediatricians and gynecologists and for planning suitable health programs.

Orthopedic Ward Policy in Introduction of New Types of Total Hip Implants

U. Givon, M.I. Siebzhener, M. Salai, A. Chechick, H. Horoszowski, J. Shemer

Orthopedic Staff, Medical Technology Unit, Medical Dept. F, and Gertner Institute for Study of Health Services, Chaim Sheba Medical Center, Tel Hashomer

The use of different types of total hip implants in medical centers in Israel was surveyed. Questionnaires were sent to all orthopedic ward directors in Israel requesting information on the number of total hip arthroplasties performed between the years 1984-1993, the types of implants used, and whether attending physicians or residents perform the operations. 22 of 24 orthopedic wards responded but 1 ward was excluded because only the results for 1993 were reported. 5 wards reported more and 16 fewer than 50 operations a year. 15 different types of implants were in use in Israel in that period, and in 5 wards 5 or more types of implants were used. Only 1 of the wards performed more than 50 operations a year. We conclude that the indiscriminate use of multiple technologies in wards performing few operations can lead to the long "learning curves" previously associated with poor results. Orthopedic surgeons should resist the impulse to introduce new implants, thus improving results and lowering expenditure. The need for regulating the introduction of new implants is emphasized.

Brain Imaging and its Clinical Application in Psychiatry

Talma Hendler, Raz Gross, Elinor Goshen, Meir Faibel, Shmuel Hirshmann, Tzila S. Zwass, Leon Grunhaus, Joseph Zohar

Psychiatry Unit, Nuclear Medicine Institute and Diagnostic Radiology Dept., Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

The common structural and functional brain imaging techniques are described from a practical, clinical point of view. The clinical indications for brain imaging in psychiatry are reviewed in relation to the specific limitations and advantages of each technique. The clinical applications of computerized tomography (CT), magnetic resonance imaging (MRI) and single photon emission computerized tomography (SPECT) are discussed in relation to the differential diagnosis between organic and functional psychiatric disorders. In a 55-year-old man with late onset of behavioral changes but without neurological signs the application of structural brain imaging (CT and MRI) in case management was demonstrated. The imaging findings involved the differential diagnosis between depression and focal brain lesions. In a 38-year-old man with personality changes and depression following a traumatic brain injury, time interval repeated functional brain imaging (SPECT) was used. Brain imaging reflected improvement in clinical status following treatment and was able to differentiate between reversible and permanent traumatic brain injuries. The superior yield of time interval repeated functional imaging in diagnosis and management of postconcussion syndrome is discussed.

Gradenigo Syndrome and Cavernous Sinus Thrombosis, in Fusobacterial Acute Otitis Media

S. Hananya, Y. Horowitz

Pediatrics Dept., Central Hospital of the Emek, Afula

In this era of antimicrobial medication, intracranial complications following otitis media are rare. We present a 5-year-old boy who suffered from petrositis (Gradenigo syndrome) and cavernous sinus thrombosis as combined complications of acute otitis media caused by fusobacteria. The diagnosis was made using imaging methods suited to the various structures of the skull. Cure was achieved by prolonged conservative treatment with antibiotics, with gallium scan for evaluation of the bone inflammation.