תוצאת חיפוש

Empirical Treatment of Urinary Tract Infections in the Delivery Room

Peter Jakobi, Orly Goldstick, Renato Finkelstein, Joseph Itzkovitz-Eldor

Obstetrics and Gynecology Dept. and Infectious Disease Unit, Rambam Medical Center, Haifa

Urinary tract infection (UTI) is the most common bacterial infection during pregnancy. In prenatal and delivery wards treatment is usually started at once in pregnant women with symptoms suggesting UTI, but there is no uniformity as to treatment. We surveyed such treatment in the delivery rooms throughout Israel, and whether the treatment differed in simple cystitis as opposed to pyelonephritis. Results of positive urine cultures from symptomatic parturients admitted here during 1995-1996 were examined.

There were 17 different empiric treatment protocols in 28 delivery rooms, whose daily cost ranged from 1-119 NIS. We present the antimicrobial sensitivity of 156 bacteria isolated from the urinary cultures from pregnant women in our prenatal ward. Based upon urinary flora, sensitivity and daily cost, we suggest a protocol for empiric treatment. We recommend first and second generation cephalosporins for treatment of simple lower (UTIs), while gentamicin is suggested for treatment of clinical pyelonephritis during pregnancy. There is no medical nor economic justification for the multiplicity of empiric treatment protocols currently used. Considering our results, our protocol is cost-effective for the empiric treatment of UTI in hospitalized parturients and in the community as well.

The Diagnosis and Treatment of Fournier's Gangrene

M. Cohen, E. Tamir, S. Abu-Abid, Y. Galili, M. Giladi, S. Avital, R. Shafir, Y. Klausner

Surgery and Infectious Disease Depts. and Division of Surgery, Tel Aviv-Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

We treated 2 women and 8 men suffering from Fournier's gangrene during 1990-96. 2 had diabetes, 1 suffered from ulcerative colitis and 1 was an alcoholic. In 8 of them the infection was triggered by a mixture of aerobic and anaerobic bacteria. Treatment consisted of repeated wide debridement and early colostomy. This aggressive approach resulted in relief of the septic signs within 24 hours and permitted early skin grafting of the wounds. 2 patients died due to sepsis that caused multiple organ failure. The 8 who survived were hospitalized for an average of 35 days. On follow-up examination 1-5 years later all patients had undergone closure of the colostomy and were completely rehabilitated.

Fournier's gangrene is not rare in the geriatric population. We believe that early diagnosis and aggressive wide debridement, combined with early colostomy, are the keys to successful treatment.

Optic Glioma in Children with Type 1 Neurofibromatosis

M. Ben-Arush, H. Goldberg, A. Kuten, J. Guilbord, R. El-Hassid

Pediatric Hematology-Oncology Unit, The Northern Israel Oncology Center, and Division of Neurosurgery, Rambam Medical Center; and Technion School of Medicine, Haifa

During the period 1985-95 we treated 5 girls and 13 boys with optic glioma associated with Type 1 neurofibromatosis (median age 3 years, range 2-10 years). 6 were treated with radiotherapy alone, 1 with surgery and radiation therapy and 1 with chemotherapy in order to postpone irradiation to an older age; 1 is being followed with no therapy. All children are alive, 2-10 years from diagnosis (mean follow-up time 5.4 years). 3 had improvement of vision following therapy and in 4 visual ability stabilized, including the child being followed without treatment. In 1 vision deteriorated despite therapy.

Combinations of Vasoactive Agents by Penile Injection for Erectile Dysfunction

E. Segenreich, S. Israilov, J. Shmueli, D. Simon, J. Baniel, P. Livne

Andrology Unit, Institute of Urology, Rabin Medical Center (Beilinson Campus), Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University

In the past 15 years there has been continuous increase in the use of injections into the corpora cavernosa of different vasoactive drugs for treatment of erectile dysfunction (ED). However, some of these drugs are very expensive, are not available everywhere, and have side effects. We therefore compared the success rate of the most widely used compounds, papaverine and regitine, in 452 patients (age range 26-85) with different types of ED. Each patient received in the clinic injections of papaverine, 6-25 mg, and regitine, 0.05-1.5 mg. When maximal rigidity of the penis (MRP) was >80%, we instructed the patient to self-inject the drug at home, 5-30 minutes before coitus. If after 3 injections MRP was not >80%, prostaglandin E1 (PGE1) in an average dose of 10-25 mcg was added. If there was no response, papaverin+regitine+PGE1 were given in higher dosage, and atropine sulfate, 0.02+0.06 mg, was added if necessary.

Of 452 patients, 305 (67.4%) had MRP >80% after 3 injections of papaverine plus regitine. The other patients received PGE1 in addition. This was helpful in 61 patients (41.5%), while 55 (63.9%) required papaverine + regitine + prostin in higher doses. Of these, only 31 received papaverine + regitine + PGE1 + atropine sulfate. Of these, 20 (64.5%) reached MRP >80%, and 11 (2.4%) MRP <60. For these 11 patients, we recommended a penile prosthesis. Thus in 67.4% of the 452 patients, papaverine + regitine injections were effective; in 41.5%, PGE1; in 63.9%, papaverine + regitine + prostin + atropine sulfate. Only 11 (2.4%) did not react to intracorporeal injection.

This progressive method of treatment enabled us to select the optimal dosage and combinations of compounds in 441/452 patients (97.5%) according to the severity of their dysfunction. During follow-up of 6 months, spontaneous erections without injection were achieved in 115 (26.0%).

Changes in Structure and Process Components of Trauma Care in Emergedepartments

Rephael Joseph Heruti, Ron Ben-Abraham, Yanir Abramovitch, Michael Stein, Joshua Shemer, Baruch Marganit

Trauma Control, Israeli Center for Disease Control (ICDC), Israel Ministry of Health and Sackler School of Medicine, Tel Aviv University

In recent years there have been tremendous efforts to improve primary trauma care. The Ministry of Health and other authorities have invested in new trauma facilities in various hospitals. A nationwide survey with regard to structure and function of emergency departments was carried out. Compared to a similar survey conducted in 1992, significant progress in quality and quantity of equipment at various emergency departments was demonstrated. However, there are still differences between various hospitals. A drive to standardize trauma care will undoubtedly contribute to improvement in care of the injured.

Percutaneous Revascularization of the Left Main Coronary Artery as Coronary Artery Bypass in High Surgical Risks

Yoseph Rozenman, Chaim Lotan, Hisham Nassar, Mervyn S. Gotsman

Cardiology Dept., Hadassah-University Hospital (Ein Kerem) and Hebrew University-Hadassah Medical School, Jerusalem

Coronary artery bypass grafting is the treatment of choice for obstructive disease of the left main coronary artery. Its proximal location and easy accessibility make the left main artery an inviting target for percutaneous intervention, an approach contraindicated by the high associated risk. We describe 2 patients at high operative risk in whom the obstructed main coronary artery was successfully revascularized percutaneously. Coronary stenting and rotational ablation of calcified arteries are essential for successful outcome and minimize complications.

Cardiac Failure following Sting of Yellow Scorpion in an Adult

C. Kristal, I.Y. Shemesh, Y. Mishal, A. Bourvin

Intensive Care Unit, Dept. of Anesthesia and Medical Dept., Barzilai Medical Center, Ashkelon

3 men, aged 18, 29, and 47 had severe cardiovascular disturbances following the sting of the yellow scorpion (Leiurus quinquestriatus hebraeus), which is considered the most dangerous scorpion in Israel. Cardiovascular complications are common in children after scorpion sting, but are rare in adults. Pulmonary edema developed in 1 of those being reported and hypertension and arrhythmias in the other 2. Severe deterioration in left ventricle function was confirmed by echocardiographic measurement of diminished ejection fraction. All patients recovered completely. This is the first report of severe cardiac involvement in adults following scorpion sting. We therefor recommend that even adults who develop cardiac symptoms after scorpion sting, particularly those with chronic cardiac disease, be monitored and treated in an intensive care unit.

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.

Local Treatment of Purulent Chronic Otitis Media with Ciprofloxacin

Ludwig Podoshin, Alexander Brodzki, Milo Fradis, Jacob Ben-David, Josef Larboni, Isaac Srugo

Dept. of Otolaryngology, Head and Neck Surgery, Microbiology Unit and Dept. of Pharmacology, Bnai-Zion Medical Center, and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

We evaluated the efficacy of ciprofloxacin eardrops compared to tobramycin and to a placebo in the treatment of chronic suppurative otitis media. 60 ears were randomly assigned to treatment for 3 weeks with ciprofloxacin, tobramycin or placebo eardrops. The organism most commonly isolated from the ear discharge was Pseudomonas aeruginosa. The clinical responses were 78.9% and 72.2%, respectively, in the ciprofloxacin and tobramycin groups, while it was only 41.2% in the placebo group. Treatment with ciprofloxacin eardrops seemed to be at least as efficient as treatment with tobramycin. Considering the lack of ototoxicity of ciprofloxacin, this treatment may be best for chronic otitis media.

Surgical Approach to Benign Cecal Ulcer

J. Haik, A. Judich, I. Barshack, M. Ben-Haim, M. Shabtai, A. Ayalon

Dept. of Surgery B and Pathology Institute, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Benign cecal ulcer is a rare lesion, usually diagnosed during operation for suspected acute appendicitis or peritonitis of unknown origin. In the past, right hemicolectomy was recommended as the treatment of choice because of the difficulty in differentiating malignant lesions from benign cecal ulcers. However, in recent reports a more conservative approach has been suggested, consisting of selective colectomy followed by frozen section biopsy. This approach is aimed at preventing unnecessary excision of the colon and conserving the ileocecal valve. We present a 47-year-old woman operated for right lower quadrant peritonitis, believed to be due to acute appendicitis. On exploration, a biopsy-proven benign cecal ulcer was found and resected.

Evolving Role of Radiation Therapy in Nonmalignant Disorders

Rami Ben-Yosef

Bone Marrow Transplant Dept., Hadassah Hospital, Jerusalem

Various nonmalignant disorders have traditionally been treated with radiation therapy. It has almost completely been discontinued due to reports of secondary malignancy. During the past 15 years there has been an evolving role for radiation therapy in various nonmalignant disorders such as meningioma, A-V malformation, prevention of vascular restenosis and heterotopic bone formation. Appropriate follow-up of such patients for diagnosis of secondary malignancy is recommended. Radiation therapy should be carefully considered in diseases not successfully treated with conventional means.

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.

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.

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.