תוצאת חיפוש

Elastofibroma, a Rare Cause of Snapping Scapula Syndrome

Ilan Cohen, Yehuda Kolender, Josephine Isakov, Aaron Chechick, Yitzhak Meller

Dept. of Orthopedic Surgery, Sheba Medical Center, Tel Hashomer and Depts. of Orthopedic Oncology and Pathology, Sourasky Medical Center, Tel Aviv

Scapular pain is a common complaint in daily orthopedic practice. A different type of scapular discomfort, the snapping scapula syndrome that occurs when smooth gliding motion of the scapula upon the chest wall is interfered with is much less common.

We studied the syndrome of periscapular pain and discomfort, and present a rare etiology: elastofibroma dorsi, a unique, benign, soft tissue-tumor with unique characteristics.

Elastofibroma appears deep to the lower scapular pole, is often bilateral, and consists of a mixture of collagen, elastic fibers and fibroblasts. We present 6 cases, in 3 men and 3 women aged 51-65.

Limited Percutaneous Surgical Drainage in Severe Neonatal Necrotizing Enterocolitis in Low Birth Weight Prematures

Robert Finaly, Zahavi Cohen, Vadim Kapuller, Agneta Golan, Edna Kurtzbart, Abraham Mares

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

The usual treatment of complicated neonatal necrotizing enterocolitis (NEC) is resection of the necrotic bowel, lavage of the peritoneal cavity and diversion enterostomy. Low-birth-weight premature neonates with this condition are in special danger if general anesthesia and full exploratory surgery is contemplated.

A relatively simple alternate procedure is percutaneous insertion under local anesthesia of a soft abdominal drain, most often in the right lower quadrant. The procedure is done in the neonatal intensive care unit without moving the whole set-up to the operating room.

4 such cases have been treated within the past year. 3 were discharged home as they did not require additional surgical treatment, not having developed intestinal stenosis or obstruction. 1 recovered from the acute episode, but succumbed to a severe intraventricular hemorrhage and respiratory failure 7 days after the procedure.

Our limited but most gratifying experience, in addition to similar experience of others, encourages us to recommend this simple surgical approach in the very sick low-birth-weight premature with fulminant NEC.

Many Faces of Parvovirus

George Habib, Leon Cohen

Carmel Medical Center, Haifa

2 women, aged 31 and 37 years, respectively, suffered from acute febrile illness due to acute infection with human parvovirus B19. 1 also had a maculopapular rash and articular symptoms after her fever stopped, a clinical picture typical of erythema infections. The other had leukopenia and thrombocytopenia and had received dipyrone. Although acute infection with human parvovirus usually occurs in childhood, it may also occur in adults, with protean manifestations.

Adjuvant Therapy of Large Bowel Carcinoma

G. Ezekiel, S. Walfisch, Y. Cohen*

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

The National Institutes of Health (NIH) held a consensus conference which recommended 5-FU and levamisole as adjuvant chemotherapy for colon cancer MAC (Modified Astler Coller) stage C.

From 1991-1994, 37 such patients diagnosed here were treated with 5-FU (intravenous dose of 450/mg/m²/d for 5 days and from day 29, once a week for 48 weeks) and oral levamisole (50 mg 3 times/d. for 3 days, every 2 weeks for a year), as suggested by NIH guidelines.

16 patients were males and 21 were females, mean age was 62 years and median 64. Cancer locations were: right colon (in 16, 43%), left colon (19, 51%), multiple colon primaries (2, 1%). 25 (68%) had 1-3 positive lymph nodes and 12 (32%) had 4 or more positive lymph nodes.

Only 20 (54%) finished treatment as prescribed. In the others, 1 or both drugs caused side-effects for which the drugs had to be stopped. 6 patients relapsed while on treatment.

The most common side-effects were diarrhea, stomatitis and bone marrow suppression. 3 were hospitalized due to neutropenic fever. 5-year actuarial survival of all patients was 61%; 5-year relapse-free survival was 61%; 5-year relapse-free survival of right versus left colon was 41% and 82%, respectively (p<0.01). There was no significant difference in 5-year survival of those with 1-3 positive lymph nodes as compared to those with 4 or more (62% and 56%, respectively). 5-year survival in those who finished or did not finish treatment (excluding those who stopped treatment because of progressive disease) was 83% and 70%, respectively (NS).

The 5-year survival of our series was similar to that of patients treated similarly elsewhere. The 5-FU and levamisole treatment was not tolerated well by our study population. It has recently been replaced in our service by a 5-FU and leucovorin regimen given for 6 months.

* Jules E. Harris Chair in Oncology.

Laparoscopic Spermatic Vein Ligation for Varicocele in Adolescents

Zahavi Cohen, Alon Yulevich, Vadim Kapuler, Niza Newman, Abraham J. Mares

Pediatric Surgery Dept., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

We report our initial experience with laparoscopic ligation of spermatic veins in the treatment of varicocele in adolescence. 19 boys, 13 to 18 years old, underwent this treatment between I 1997 and III 98. The varicocele was always on the left side. 12 complained of scrotal discomfort and pain, but in 7 it was found incidentally during routine medical examination by the family or school physician. The diagnosis was based only on physical examination.

There has been no morbidity related to the laparoscopic procedure and all returned to normal activity within a few days. Follow-up 2-12 months after surgery showed no varicocele in any. We conclude that laparoscopy is useful in the treatment of varicocele in adolescents.

Diagnostic and Therapeutic Laparoscopy for Non-Palpable Testis

Zahavi Cohen, Niza Newman, Edna Kurzbart, Vadim Kapuller, Abraham J. Mares

Dept. of Pediatric Surgery, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

From January 1994 to July 1997, 20 boys 1.5-13 years of age underwent laparoscopic examination and treatment for non-palpable testis. In 1 there was bilateral nonpalpable testis. Only 3 had intra-abdominal testes viable for orchiopexy. In 8 atrophic testicles were removed and in 9 laparoscopic examination revealed intra-abdominal blind ending of the spermatic cord and no testicular tissue.

We conclude that laparoscopy is a useful and safe technique for accurate diagnosis and may avoid additional intervention in treating non-palpable testes. Furthermore, intra-abdominal testes may be managed laparoscopically under the same anesthetic.

Diarrheal Disease among Care-Givers at Children's Day- Care Centers 

S. Koton, D. Cohen, M.S. Green

Israel Center for Disease Control, Ministry of Health and Gertner Institute, Chaim Sheba Medical Center, Tel Hashomer; Medical Corps, Israel Defense Forces; Dept. of Epidemiology and Preventive Medicine; Sakler Faculty of Medicine, Tel Aviv University

Diarrheal disease tends to spread from infected children to their families. Due to the increased risk of exposure, children's caregivers in day-care centers may have a higher incidence of diarrhea, particularly when caring for very young children. We therefore examined the incidence of diarrhea and antibodies to Shigella among caregivers in day-care centers, according to age groups of children in their care (<18, 18-34, and >35 months) and in comparison with the general population. 2 studies with a retrospective cohort and seroepidemiological cross-sectional design were carried out. Questionnaires were completed by 401 caregivers in 36% of all WIZO day-care centers. As a measure of past exposure to Shigella, levels of S. sonnei and S. flexneri antibodies were examined in the blood of 110 caregivers (ELISA method).

There was a higher incidence of diarrhea among young children, increasing the potential exposure to diarrheal agents among their caregivers. Nevertheless, no statistically significant differences in diarrhea incidence were found among caregivers of the various age groups during the previous year (p=0.768) and during the previous month (p=0.319), nor in absenteeism due to diarrhea during the last month (p=0.761). Levels of Shigella antibodies were similar among caregivers in all 3 groups. Diarrheal incidence was higher among women in the population control group than among caregivers during the previous year (p=0.005) and month (p=0.067). No statistically significant differences in levels of S. sonnei and S. flexneri antibodies were found between caregivers and women in the control group.

There was no evidence that diarrhea is an occupational hazard for caregivers of young children. An explanation may be the development of protective immunity against common diarrheal agents due to recurrent exposure.
 

Self-Limited Lymphadenopathy Mimicking Lymphoma or Lupus

I. Solt, N. Gatas, Y. Cohen, D. Rimon

Medical Dept. B and Pathology Dept., Western Galilee Regional Hospital, Naharia and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Kikuchi-Fujimoto disease in a self-limited lymphadenopathy that can be confused histologically and clinically with lymphoma or systemic lupus erythematosus. It was diagnosed in a 37-year-old woman presenting with fever, cervical, submandibular and axillary lymphadenopathy, weight loss and recurrent urinary tract infections. Lymph node biopsy was consistent with the diagnosis of a histiocytic necrotizing lymphadenitis. Early diagnosis of Kikuchi-Fujimoto disease can prevent harmful treatment.

Ultrasonographic Imaging of Superior Sagittal Thrombosis

Ilan Shelef, Avi Cohen, Yehiel Barki

Depts. of Radiology and Neurosurgery, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Ultrasonographic findings of superior sagittal sinus thrombosis include dilated and hyperechoic sinus (direct imaging of the thrombus). No flow should be demonstrated by the various Doppler techniques. In the deeper sinuses, if the thrombus can not be visualized after a negative Doppler study, MR imaging is recommended. Recanalization and reflow can be demonstrated on follow-up study.

Use of Restraints in a General Hospital

Bella Bar-Cohen, Orly Rotem-Picker, Zvi Stern

Nursing Services and Administration, Hadassah University Medical Center, Jerusalem

28 in-patient units were surveyed during a 5-day period to determine the extent of the use of physical restraints in hospitalized patients. Information was gathered on the characteristics of restrained patients and indications for use and removal of restraints, patterns and means of restraints, monitoring, and written notations. 31 different patients (6% of those surveyed) were restrained in 13 units during the 5 days of the survey, an average of 15 (3%) daily.

Characteristics of restrained patients were: age 70 and over requiring emergency hospitalization, reduced level of consciousness, limitation of mobility, incontinence, history of 2 or more chronic diseases, requiring multiple drugs, and use of multiple medical devices. Bilateral, soft hand restraints were most often used to prevent patients from removing tubes. Nurses initiated the decision to apply or remove restraints, which were usually removed as the patients' condition improved. Written policies were lacking regarding monitoring and follow-up of restrained patients. Clearly written policies and increased staff awareness of potential hazards may reduce the use of restraints and the length of time they are employed.

Autonomic Dysregulation in Post-Traumatic Stress Disorder: Power Spectral Analysis of Heart Rate Variability

Hagit Cohen, Uri Loewenthal, Mike A. Matar, Hanoch Miodownik, Zeev Kaplan, Yair Cassuto, Moshe Kotler

Mental Health Center, Israel Ministry of Health; Anxiety and Stress Research Unit, Faculty of Health Sciences; Dept. of Life-Sciences, Ben-Gurion University of the Negev, Beer Sheba

Spectral analysis of heart rate variability (HRV) has been shown to be a reliable noninvasive test for quantitative assessment of cardiovascular autonomic regulatory response, providing a dynamic map of sympathetic and parasympathetic interaction. In a prior study exploring the state of hyperarousal that characterizes the post traumatic stress disorder (PTSD) syndrome, we presented standardized heart rate analyses in 9 patients at rest, which demonstrated clear-cut evidence of a baseline autonomic hyperarousal state.

To examine the dynamics of this hyperarousal state, standardized heart rate analysis was carried out in 9 PTSD patients, compared to a matched control group of 9 normal volunteers. 20-minute ECG recordings in response to a trauma-related cue, as opposed to the resting state, were analyzed. The patients were asked to recount the presumed triggering traumatic event, and the control subjects recounted a significant stressful negative life event.

Whereas the control subjects demonstrated significant autonomic responses to the stressogenic stimulus of recounting major stressful experiences, the patients demonstrated almost no autonomic response to the recounting of the triggering stressful event. The patients demonstrated a degree of autonomic dysregulation at rest comparable to that seen in the control subjects' reaction to the stress model.

The lack of response to the stress model applied in the study appears to imply that PTSD patients experience so great a degree of autonomic hyperactivation at rest, that they are unable to marshal a further stress response to the recounting of the triggering trauma, as compared to control subjects. A subsequent study of the effect of medication on these parameters showed that they are normalized by use of selective serotonin re-uptake inhibitors (SSRI's).

Neither the clinical implications of these findings, nor their physiological mechanisms are clear at present. We presume that they reflect a central effect, as the peripheral automatic effects of SSRI's are relatively negligible.

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.

Nasopharyngeal Colonization with Streptococcus Pneumoniae in Pediatric Respiratory Infections

Isaac Srugo, Irena Chystiakov, Ella Cohen, Yoram Tal, Michael Jaffe

Clinical Microbiology and Pediatric Depts., Bnai Zion Medical Center and Technion Faculty of Medicine, Haifa

During the winter of 1995, nasopharyngeal colonization of Streptococcus pneumoniae was evaluated in 204 children with respiratory infection and 107 normal control children. There was no difference in gender or mean age between the groups, and no difference in carrier rate between sick (24.5%) and normal (22%) children (p=0.6). Carrier rates were 19%, 32%, 31% and 17% at 6, 12, 24 and 48 months, respectively. Penicillin-resistant pneumococci (PRP) were found in 42% of sick and 16.6% of normal children, (p<0.05). Resistance to more than 2 antibiotics was found in 28% of sick and in 12.5% of normal children. PRP were found in 67% and 34% of sick children with and without prior antibiotic treatment (p<0.05). We conclude that there is no difference in the carrier rate of Streptococcus pneumoniae between sick and normal children. However, the high prevalence of PRP in children with respiratory infections is probably due to prior antibiotic treatment.

Follicle-Stimulating Hormone in Azoospermia in Prediction of Spermatogenic Patterns

David B. Weiss, Shoshana Gottschalk-Sabag, Zvi Zukerman, Elchanan Bar-On, Zvi Kahana

Kupat Holim Me'uhedet; and Dept. of Pathology and Cytology and Male Infertility Unit, Shaare Zedek Medical Center, Jerusalem; Andrology Unit, Rabin Medical Center (Beilinson Campus), Petah Tikva; and Paper Research Consultant Institute, Jerusalem

Follicle-stimulating hormone (FSH) is considered to be the most important plasma hormone correlated with spermatogenesis. Elevated FSH plasma levels were shown to be associated with complete damage to testicular seminiferous tubule germinal epithelium. Recently, there have been conflicting reports with regard to the value of FSH plasma levels in predicting seminiferous tubule histology in the azoospermic patient and hence, as a guide for therapy in assisted reproduction using testicular sperm retrieval. The aim of this study was to evaluate whether FSH plasma levels can predict spermatogenic pattern in the testes of the azoospermic infertile patient. 69 infertile men with non-obstructive azoospermia and 18 with very severe oligospermia were studied. In all, plasma levels of testosterone, free testosterone, prolactin, luteinizing hormone and follicle-stimulating hormone were measured by enzyme immunoassay. In the azoospermic patients the seminiferous tubule spermatogenic pattern was determined in testicular aspirates obtained by multiple fine needle aspiration and categorized according to the most mature spermatogenic cell type in the aspirates: Sertoli cells only, spermatogenic maturation arrest or full spermatogenesis. There were no significant differences in plasma levels of any hormone measured except in very severely oligospermic and azoospermic patients. Both normal and elevated levels were detected in all, regardless of seminiferous tubule cytological pattern or plasma FSH in azoospermic patients. It is concluded that plasma levels of FSH can not be used as a predictive parameter, neither for the presence of spermatozoa nor for any other seminiferous tubule cytological pattern in azoospermic infertile men. They cannot serve as guides for selection of azoospermic men for trials of testicular sperm retrieval in assisted reproduction.

Intravenous Lignocaine for Chronic Pain

Alex Cahana, Victor Shvelzon, Orit Dolberg, Florella Magora, Yoram Shir

Pain Treatment Services, Depts. of Anesthesiology of Sheba Medical Center, Tel Hashomer and of Hadassah-University Hospital, Jerusalem

Intravenous injection of lignocaine relieves pain in animals with experimentally induced pain, and in man, mainly those with neuropathic pain. 106 patients were treated with intravenous lignocaine during a period of 18 months (212 treatment sessions). Blood pressure, heart rate and pain scores were continuously monitored after an intravenous bolus of lignocaine, 1 mg/kg, followed by continuous infusion of lignocaine, 5 mg/kg during 1 hour. There was significant pain relief after each session in most patients, lasting from a few hours to 4 weeks. There were no significant side effects. We present 2 of our patients. Due to its simplicity, efficacy and safety, intravenous lignocaine injection is recommended for those with neuropathic pain unrelieved by other therapeutic modalities.