תוצאת חיפוש

Sentinel Lymph Node Biopsy in Breast Cancer: A Validation Study and Preliminary Results

Aviram Nissan, Ram M. Spira, Roland Chisin, Oded Zamir, Diana Prus, Martin Klein, Mahmoud Badriyyah, Herbert R. Freund

Departments of Surgery. Biophysics and Nuclear Medicine, and Pathology. Hadassah University Hospital Mount Scopus and Hebrew University - Hadassah Medical School, Jerusalem

Introduction: Sentinel lymph node biopsy (SLNB) has been recently proven to be an accurate staging method for breast cancer, replacing axillary lymph node dissection (ALND) in selected cases. We present our initial experience and the process of introduction and implementation of SLNB in a University Hospital setting.

Material and methods: 46 SLNB were performed in 42 consecutive female patients with invasive breast cancer. Treatment included 0.4mCi-2mCi of Tc-99m rhenium colloid injected either 2 hours before surgery (0.4 mCi) or the night before surgery (2 mCi). Four milliliters of Patent Blue V were injected peritumoral 10 minutes prior to skin incision in all patients. Following SLNB all women underwent subsequent ALND. Sentinel nodes were processed both with multiple (10-15) H&E sections and immunohistochemistry with cytokeratin antibodies stain.

Results: Blue dye, isotope or the combination of both identified 43/46 (93%) of the sentinel lymph nodes. ALND was performed only unilaterally in 4 patients with bilateral breast cancer bringing the total evaluable SLNB to 39. In the 39 patients in whom the sentinel node was successfully identified and underwent ALND, the SLNB was true positive (TP) in 17/39 (44%) true negative (TN) in 20/39 (51%) and false negative in 2/39 [(5%), both T2 lesions] with overall accuracy of 95%. In the last 10 cases all sentinel nodes were successfully identified with 70% TP and 30% TN.

Conclusions: Experience with at least 30-40 consecutive cases for safe implementation of SLNB in clinical practice. Specific training and dedication is required for the entire team involved, including surgeons, nuclear medicine physicians and technicians and pathologists.  

Computed Tomographic Angiography of the Peripheral Vasculature - Role & Applications in Vascular Surgery

G. Szendro¹, D. Lumelsky², A. Klimov², I. Faingersh³

The department of vascular surgery Soroka Medical Center, Ben-Gurion university Beer-Sheva¹, the department of radiology Ha'Emek Medical Center Afula² and the department of surgery "B" Ha'Emek Medical Center Afula³

Computed tomographic angiography (CTA) is a relatively new diagnostic modality in the field of vascular surgery. Despite being new it has already been introduced into a wide range of diagnostic applications in this field and in many cases it can precede or replace the conventional intra-arterial angiography. During a 12 month period between 1.8.98 and 1.8.99 sixty five peripheral arterial imaging scans were performed using a CT Twin - 2 helical scanner (Spiral Twin Flash., Elscint, Israel) with a 100% technical success rate and no complications at all. Twelve patients (18.5%) were operated upon and 20 (30.7%) underwent endovascular procedures with full intra-procedural agreement with the pre-operative or pre-procedure CTA findings. Despite possible pitfalls and a few disadvantages the technique carries major benefits and significant advantages to both the patient and the clinician. Therefore we recommend considering CTA as a first line diagnostic modality whenever peripheral vasculature has to be demonstrated whether electively or urgently and to spare the conventional angiography for selected cases only.

(1,2) ניר פלד, (1,2) צ'רלס נקר, (2) שי אשכנזי, (1) פאול מרלוב

(1) המח' לילודים, מרכז רפואי רבין, קמפוס בילינסון, (2) מרכז רפואי "שניידר" לילדים, פתח תקווה, הפקולטה לרפואה סאקלר, אוניברסיטת ת"א

בשני העשורים האחרונים, נרשמו תנודות חדות בשכיחות העולמית של מחלת העגבת בכלל ועגבת הילוד בפרט. בראשית שנות התשעים, אובחנה עגבת הילוד בכל 1/10,000 לידות של ילודים חיים בארה"ב. התמותה במחלת עגבת הילוד מגיעה לכדי 40% (תוך- וחוץ-רחמית), ואף השורדים לוקים בתחלואה קשה. לפיכך, ממליץ המרכז לבקרת המחלות בארה"ב (CDC) על סקר נוגדנים בלתי סגולי לעגבת לכל אם הרה במהלך השליש הראשון להריון, או בתחילת המעקב ההריוני, הסקר נערך באמצעות תבחין בלתי-סגולי למחולל העגבת, Treponema pallidum, לרוב תבחין VDRL.

נוכח העלייה הנרשמת בשיעור חולים אלה בישראל, דנה סקירה זו במעקב ההריוני וניהול היילוד שאמו בעלת תבחין VDRL המפורש כחיובי.

גילה ברונר

המרפאה לסקסולוגיה ביחידה להפרעות תנועה – מחלקת עצבים, והשירות הסוציאלי, המרכז הרפואי סוראסקי, תל אביב

מיניות היא מימד חשוב באישיותו של האדם והיא כוללת רבים מן ההיבטים הנכללים בחוויית הזהות הגברית והנשית*. המיניות איננה רק סך של החיים הארוטיים או יחסי-המין של האדם, כי אם היא כוללת בתוכה את הצורך בקשר עם הזולת, באהבה, במגע, בחמימות ובאינטימיות. המיניות באה לידי ביטוי בכל אחת מן המחשבות, הרגשות וההתנהגויות של האדם, בין אם במודע ובין אם לא במודע. לא זו בלבד, אלא שהמיניות משפיעה אפילו על דברים יום-יומיים, כדוגמת הדרך שבה מטופל משוחח, עונה או מתייחס לרופא/ה שלו, והאופן שבו אדם עומד, נע, לוחץ יד או נוגע באחרים.

נוכח משמעותה הרחבה הזו של המיניות, ניתן בנקל להבין כיצד זו יכולה להיות מקור לאושר ושמחה, אך בו-בזמן הפרעות במיניות עלולות לגרום לכאב, תיסכול וצער רב. במילים אחרות, הבריאות המינית והתיפקוד המיני הם מרכיבים חשובים ומרכזיים באיכות חייו של כל אדם, בכל גיל, ויש לשלב את הטיפול בבריאות מינית כחלק מן הטיפול הרפואי השיגרתי.

תכליתה של הרשימה הנוכחית היא להדגיש את חשיבותו של הקשר בין מצבי בריאות וחולי לבין מיניות ולהציג דגם יישומי המאפשר לרופאים, שאינם בעלי הכשרה ייחודית בתחום הטיפול המיני, להתמודד עם מיניותם של המטופלים, כפי שזו עולה במסגרת עבודתם הרפואית הרגילה.

תחילתו של המאמר שלהלן בסקירת הקשר שבין מצבי בריאות וחולי לבין בריאות מינית. המשכו בהצגת הקשיים העלולים להתעורר בניסיון לעסוק בבעיות של בריאות מינית בקליניקה הרפואית וסופו בהצגת דגם המכונה "הדגם האינדוקטיבי", שכן דגם זה מאפשר כניסה מדורגת ומתונה לתוך שיח בנושא הבריאות המינית, בקצב המותאם לפונה ולרופא המטפל גם יחד.

* בשל מורכבותה של השפה העברית, קשה להתייחס למגוון ההתנהגויות הקיימות באוכלוסייה. עם זאת, העקרונות המוצגים במאמר זה מותאמים למטופלים מבני שני המינים, לזוגות נשואים או שאינם נשואים, לבני כל הגילים וכן לזוגות הטרוסקסואליים או הומוסקסואליים.
 

ענבר צוקר¹, לאה סירוטה¹, נחמה לינדר¹

¹המח' לטיפול נמרץ פגים, מרכז שניידר לרפואת ילדים בישראל, פתח-תקווה

ילודים, ובמיוחד פגים במשקל לידה נמוך, נמנים עם קבוצות החולים הנזקקות בשכיחות גבוהה לערויי-דם ותוצריו. על פי הערכות, כ- 80% מהילודים השוקלים פחות מ- 1500 ג', יקבלו מספר ערויי-דם בשבועות הראשונים לחייהם. ערויים אלה ניתנים כדי לתקן אנמיה תסמינית, הנגרמת כתוצאה ממישלב של חסר ייצור מספיק של דם ע"י הילוד ובמיוחד הפג הגדל, ושל איבודי דם מישניים לבדיקות. לעיתים, ניתנים ערויים במסגרת פעולות טיפוליות מיוחדות, המצריכות מתן ערויי דם בכמות גדולה, כגון ניתוחי לב וערוי חלופין. הטיפול בערויי דם יכול לגרום לשורה של סיבוכים מיידיים ומאוחרים. חלקם יכולים לחול בכל קבוצת גיל וחלקם ייחודיים לילודים. המטרה בסקירה זו היא לדווח על הסיבוכים האפשריים של ממתן ערוי-דם בילודים, תוך התייחסות למאפיינים הייחודיים לתת-אוכלוסייה זו של חולים.
 

Pneumomediastinum Following Drug Abuse

Z.G. Fridlender, A. Bloch

Medical Division, Hadassah Hospital, Ein Kerem, Jerusalem

Pneumomediastinum is termed spontaneous when not associated with trauma or other identifiable pathological process. There are several reports of pneumomediastinum following narcotic drug inhalation or smoking while applying positive pressure. We describe a 37-year-old male drug addict, hospitalized after having being found unconscious with shortness of breath. CT scan demonstrated bilateral pneumonia with pneumomediastinum. After a day of mechanical ventilation he gradually recovered and the mediastinal air disappeared.

Pneumomediastinum may occur in addicts but usually has no dangerous clinical consequences. If there is respiratory deterioration another cause should be sought.

Advantages of Standardized Protocol for Oral Rehydration in Acute Pediatric Gastroenteritis

Avi Weizman, Ahmed Alsheikh, Laura Herzog, Asher Tal, Rafael Gorodischer

Pediatric Depts. A and B, Soroka Medical Center; and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Oral rehydration (OR) for acute gastroenteritis in infants and children has been shown to be as effective as IV therapy, with less discomfort and lower costs. In this retrospective study we compared 2 pediatric wards, in 1 of which only a standardized, simplified, bedside protocol, based on American Academy of Pediatrics guidelines, was used.

There were no significant clinical characteristics in the 208 patients. In the ward which used the above protocol, OR utilization was significantly more frequent than in the other ward (48% versus 15%), thus saving equipment costs of nearly $1,000/3 months. There were no significant differences in outcome between the wards.

We conclude that introducing a standardized management protocol may increase OR utilization in hospitalized children with acute diarrhea.
 

Burch Laparoscopic Procedure for Repairing Proven Stress Incontinence

Moshe Bustan, Shabtai Romano, Raed Salim, Jacob Rosenman, Eliezer Shalev

Depts. of Obstetric and Gynecology and of Urology, HaEmek Medical Center, Afula

There are more than 200 procedures for repairing stress urinary incontinence. We evaluated the safety and efficiency of the Burch laparoscopic procedure in 32 women with urodynamically proven genuine stress incontinence.

Mean operating time was 40 minutes and mean hospitalization time after the procedure was 30 hours. The cure rate was 97%, similar to that rin other studies (80-95%). The major complications w2 cases (6.2%) of unintended bladder injury, diagnosed and repaired laparoscopically. Although follow-up has only been for 3-42 months, the high cure rate and safety and advantages of laparoscopy over laparotomy, make laparoscopic Burch colposuspension the procedure of choice for repairing stress incontinence.

The Gift of Breastfeeding 

Dorit Nitzan Kaluski, Alex Leventhal

Dept. of Nutrition, Public Health Services, Israel Ministry of Health, Jerusalem

Breast milk is the optimal food for infant growth and development, the prevention of infectious diseases and mother- child bonding. From the economic perspective, breastfeeding is cost-effective both for the family and society as a whole. The Israeli Ministry of Health encourages breastfeeding as the exclusive source of nutrition for infants in the first 4-6 months of life, with gradual addition of complementary foods thereafter. The promotion of breastfeeding in Israel requires comprehensive national activity with involvement of all the stakeholders. This includes implementation of the International Code of Marketing of Breast Milk Substitutes and joining the international "Baby Friendly Hospitals" project. Knowledge of breastfeeding should be spread, health professionals should be encouraged to become agents of change, support by breast counselors should be encouraged, post-delivery vacations from work should be prolonged and empowerment of women implemented.

Malaria in Travelers Returning from Endemic Areas

Andre Matalon, Amos Yinnon

Kupat Cholim Klalit, Dan-Petah Tikva District, and Dept. of Family Medicine, Tel Aviv University; and Infectious Disease Unit, Shaare Zedek Hospital and Hebrew University-Hadassah Medical School, Jerusalem

2 cases of malaria in family practice are described in a 26- and a 50-year-old woman. Both probably could have been prevented had common chemoprophylactic drugs been taken. The risk of malaria is greater than the risk of possible side-effects of the drugs commonly used by travelers for prevention. Family physicians must be aware of the possibility of malaria in young people with fever, especially those who have travelled to equatorial areas and special attention should be given to encourage chemoprophylaxis.

Atypical Mycobacterial Cervical Lymphadenitis in Children

B. Klin, I. Boldur, J. Sandbank, Z. Schpirer, I. Vinograd

Depts. of Pediatric Surgery, Microbiology and Pathology, Assaf Harofeh Medical Center, Zerifin, and Sackler Faculty of Medicine, Tel Aviv University

Scrofula (mycobacterial cervical lymphadenitis) has been well-known for thousands of years. Atypical mycobacteria were first categorized by Timpe and Runyon in 1954. Treatment has varied over the centuries, from exclusion therapy in ancient Greece, through digitalis, iodide, chemotherapy, and surgical excision. The varied differential diagnosis and consequent diagnostic and therapeutic challenges make reassessment of this almost forgotten disease necessary.

21 patients with typical mycobacterial cervical lymphaden„itis seen in over the past 5 years were reviewed. Age distribution ranged from 1-14 years, with peak incidence at 4 years; 9 were boys and 12 girls. Most presented with nontender, palpable neck masses and minimal constitutional complaints. Adenopathy was unilateral in all cases but 2. Mycobacterium avium-intracellulare and M. fortuitum were the main causative organisms. All underwent excision of the affected nodes. Long-term follow-up has been uneventful, except for 1 case of local recurrence requiring re-excision.

This study emphasizes the marked variability in the clinical presentation of scrofula in children, stressing the importance of the differential diagnosis between tuberculous and atypical mycobacterial cervical lymphadenitis. The treatment of choice for the latter is complete excision of the affected nodes. Other treatment is followed by recurrence and unnecessary complications and should be avoided.

Referrals and Self-Referrals to an Emergency Department

Sasson Nakar, Shlomo Vinker, Yaacov Or, Mordechai Schadel, Yosi Niego, Gavriel Plotkin

Central District of General Sick Fund and Family Medicine Dept., Sackler Faculty of Medicine, Tel Aviv University, and Emergency Dept., Kaplan Medical Center, Rehovot (Affiliated with Hebrew University-Hadassah Faculty of Medicine, Jerusalem)

The Israeli health system has been undergoing major changes in recent years. Considerations of cost containment have led sick funds to open new out-of-hours services in the community to reduce visits to hospital emergency departments.

Referred and self-referred visits to our emergency department during a 1-month period were studied. Patients after trauma or whose visits resulted in hospitalization were excluded. Of the 505 encounters 56.3% were of women; the average age was 52.5±19.3 years (range 18-96). 57.4% visits were during working hours of primary care clinics ("working hours"), while the others were "out-of-hours" visits. Only 52.7% had a referral letter, 75% of them from the family physician. The quality of the handwriting in 46% was good, in 44% fair and the remaining 10% were illegible. A specific clinical question was asked in only 16% of the letters. A third of "working-hours" visits were self- referrals, rising to 64% in "out-of-hours" visits (p<0.001).

The most common diagnoses in discharge letters were: chest or abdominal pain, asthma, back pain, headache, nephrolithiasis and upper respiratory tract infection. The rate of self-referrals was relatively high throughout the day. Cost-containment efforts did not seem to eliminate self-referrals with "primary care" problems. The quality of referral letters should be improved both with regard to format and content.

Treatment of Hypertension with Losartan

R. Zimlichman

Dept. of Medicine and Hypertension, Wolfson Medical Center, Holon

The efficacy, safety and side-effects of treatment with losartan (Ocsaar) was studied for the first time in Israel in a large group of patients with mild to moderate hypertension in several community clinics. The 421 patients (51% men) aged 30-86 years (mean 58.6) received 50 mg of losartan daily, increased when necessary to 100 mg, and/or a second antihypertensive drug was given. After 4 weeks blood pressure was normalized in 344 and after 12 weeks in 363. Side-effects were minimal and treatment was effective in all age groups.

Use of Unlicensed and Off-Label Drugs in Hospitalized Children

M. Lifshitz, V. Gavrilov, R. Gorodischer

Toxicology Unit, Pediatrics Dept. A, Soroka Medical Center, and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Many drugs used in children are based on pharmacological data obtained in adults. Therefore, many drugs are either unlicensed for use in children or are prescribed outside the terms of the product license (off-label). This pilot study assessed use of unlicensed or off-label drugs in hospitalized children.

Drug orders of patients admitted to a general pediatric ward were reviewed retrospectively in a random sample. Assessment was based on the data of the Physicians' Desk Reference and the Israel Drug Compendium. 80 different drugs and 278 drug orders were written for 92 patients (0.5 months - 11 years old, mean 26.9 months) in 97 admissions. Of these 52.9% were either off-label or unlicensed. Patients received 1 or more unlicensed or off-label drugs in 64.9% of admissions. They were more often off-label than unlicensed. The main reasons for use of off-label drugs were unusual doses and inappropriate age. The main reason for unlicensed drugs was modification of a particular formulation of a licensed drug.

This pilot study indicates that use of drugs in an off-label or unlicensed manner in children is probably quite frequent in Israel. Our data emphasize the need for licensing a large number of drugs for use in children, based on the same scientific principles as in adults. Further collaborative studies in different pediatric centers in Israel, involving different types of pediatric settings (ambulatory and in-hospital), is required to evaluate comprehensively the magnitude of this preliminary finding.

Laser Treatment of Airway Obstruction in Infants and Children

Y. Efrati, S.M. Sarfaty, S. Kromholz, G. Eshel, M. Weinberg, I. Vinograd

Depts. of Pediatric Surgery, Otolaryngology, Anesthesia and Pediatric Intensive Care, Assaf Harofeh Medical Center, Zerifin (Affiliated with Sackler Faculty of Medicine, Tel Aviv University)

Airway obstruction during infancy and childhood requiring surgical ablation is rare, and surgical intervention poses a significant challenge. During recent decades, appropriate endoscopic instrumentation, together with advanced laser beam technology have provided new operative modalities for such patients.

From 1993 to 1995 we treated 40 infants and children, 26 males and 14 females, 13 days to 11 years old (mean 3.3 years) with Nd-YAG or CO² laser. Obstructing lesions included granulation tissue or polyps (16 cases), septa or webs (27), or benign tumors (4). 7 had more than a single lesion.

All were treated endoscopically under general anesthesia without any operative or postoperative deaths. Surgical intervention removed the obstruction and related symptoms in 34. In 6, laser treatment failed, necessitating additional surgical procedures. 3 had circumferential subglottic web. Operative complications included bleeding during removal of a hemangioma in 1 and recrudescence in another. Postoperative complications were transient respiratory failure and pneumonia in 6, all of which resolved with appropriate treatment.

This series proves that laser technology is feasible in the treatment of airway obstruction during infancy and childhood, and is safe and effective.