תוצאת חיפוש

Brief Preoperative Radiotherapy reduces Local Recurrences and Improves Survival in Rectal Cancer

T. Peretz, Z. Weshler,* Y. Goldberg, A.L. Durst, H.R. Freund

Depts. of Surgery and Oncology, Hadassah University Hospitals, and Hebrew University-Hadassah Medical School, Ein Kerem and Mt. Scopus, Jerusalem

Locoregional recurrence of rectal cancer ranges between 20%-50% following apparently radical surgery. Radiation has the potential of reducing this high rate of recurrence and residual disease. A retrospective analysis of 78 patients with locally advanced, biopsy proven, adenocarcinoma of the rectum treated between 1980-1987 was conducted. 28 (36%) were treated by surgery alone (surgery); 29 (37%) by surgery and postoperative radiotherapy (post-op); and 21 (27%) by surgery and preoperative radiotherapy (pre-op). 41 were females and 37 males. The median age was 62 years (range 25-90).

All tumors were resectable. 42 patients (54%) underwent abdomino-perineal resection and 36 (46%) anterior resection patients [8 Dukes B₁ (10%); 37 B₂ (47%); 2 C₁ (3%); 31 C₂ (40%]. Local recurrences were verified by transanal or ultrasound guided needle biopsy.

The 5-year actuarial survival rates by the Kaplan-Meier method for 75 evaluated patients was 55%. Overall 5-year actuarial survival was significantly higher (p=0.001) in pre-op radiotherapy (95%) compared to surgery alone (45%), or surgery with postoperative radiotherapy (32%). The data were significant (p=0.006) for patients with stage B tumors, but not stage C. This trend of improved survival held also at 8-year follow-up (80% pre-op; 32% post-op; 27% surgery). The 5-year actuarial local control was significantly better (p=0.03) for the pre-op irradiated patients (22%), compared with surgery only (56%) and post-op radiotherapy (38%). Local control was better (p=0.02) for Dukes B tumors in the preoperative group, but not Dukes C tumors.

Actuarial 5-year survival of those without distant metastases was 87% for pre-op patients, 62% for surgery alone and 48% for post-op radiotherapy. As all patients were clinically classified as advanced rectal tumors, tumor downstaging by preoperative radiotherapy seems to be paramount for local control. Improved local control translates into a siginificant advantage in overall actuarial survival.

*DECEASED.

Plication of Diaphragm for Postoperative, Phrenic Nerve Injury in Infants and Young Children

Yael Refaely, David A. Simansky, Michael Paley, Alon Yellin

Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University

Paralysis of the diaphragm may cause life-threatening respiratory distress in infants and young children because of paradoxical motion of the affected diaphragm and contralateral shift of the mediastinum during expiration. Phrenic nerve injury (PNI) may follow chest operations.

10 children with diaphragmatic paralysis and severe respiratory distress underwent plication of the diaphragm. Ages ranged from 14 days to 5 years. 9 had PNI after operations for congenital heart disease and 1 after resection of an intraspinal cervical lipoma. The right side was affected in 7, the left in 3.

Indication for surgery was inability to wean from mechanical ventilation, which had ranged from 11 to 152 days (median 35). 8 underwent plication via a thoracic approach and 2 via an abdominal approach. There were no complications directly related to the operation.

The interval from plication to weaning from mechanical ventilation ranged from 2 to 140 days (median 4). 1 patient died 2 hours after plication due to severe heart failure and 2 after prolonged hospitalization due to sepsis and multi-organ failure. 6 were extubated 2-8 days (median 4) after plication and 1 only after 40 days.

Early diaphragmatic plication is simple and avoids more serious surgery. While effective in ventilator-dependent infants and young children, it should not be used in those with multi-organ failure. Early plication may prevent the complications of prolonged mechanical ventilation.

Severe Heat Stroke in an Intensive Care Unit

Amir Halkin, Dina Lev, Oded Szold, Philip Bidermann, Sarah Bulocnic, Pinchas Halpern, Patrick Sorkine

Depts. of Medicine and Surgery, and Intensive Care Unit, Tel Aviv Medical Center

During the August 1998 heat wave in Tel Aviv we admitted many patients for acute heat-related illness; 6 had severe heat stroke and were admitted in critical condition. We describe their clinical courses during the first 5 days of hospitalization, including response to treatment and implications for future management of this disorder.

The mean APACHE II score of the 6 was 30±3.5 and mean Glasgow Coma Scale rating 3.5±0.5; they were in hypovolemic shock and respiratory failure, necessitating mechanical ventilation. Despite early effective therapy (core temperature in all was reduced to less than 398C in less than 1 hour), there was 1 death (mortality 15%) and 4 required further intensive care for life-threatening multiple organ failure.

During severe heat waves a significant number of referrals for acute heat-related illness must be anticipated, possibly overwhelming admission capacity of regional intensive-care units. Severe heat stroke complicated by multi-organ failure is not necessarily related to prior physical activity. Although important in determining prognosis, early treatment does not prevent severe complications. Mechanisms regulating body heat may remain disturbed for days following early treatment and apparent stabilization, mandating continued hospitalization.

Clinical and Immunological Characteristics of HIV-Positive AIDS in Children in Northern Israel

E. Kedem, A. Etzioni, E. Shahar, S. Pollack

Institute of Immunology, Allergy and AIDS and Dept. of Pediatrics A, Rambam Medical Center and B. Rappaport Faculty of Medicine, The Technion, Haifa

We are treating 11 children in our AIDS clinic. All were infected by vertical transmission from carrier mothers. However, among 31 HIV-carrier AIDS patients who were under follow-up during pregnancy, supposedly taking zidovudine prophylaxis, only 1 (3.3%) gave birth to a baby infected with HIV. Our children with HIV and AIDS are 3 months to 12 years of age (average 4.5 years); mean age at diagnosis was 18 months. All are either symptomatic or have laboratory evidence of progressive immunodeficiency, 1 is asymptomatic (N2), 1 has mild symptoms (A2) and the rest present significant symptoms or AIDS-defining disease. All have moderate to severe immunodeficiency, as evidenced by CD4+ cells counts. 60% have rapidly progressive disease, based on their symptomatology and immune state, whereas clinical reports in the literature point to only 10-15%. However, the average CD4+ cell count was 22% (749/mm³) at diagnosis and 22% (759/mm³) at last follow-up. These stable findings during an average follow-up of 28 months probably reflect the effect of medical and supportive treatment.

All received antiretroviral medication consisting of a combination of 2 or 3 drugs. 8 of 11 also received prophylactic treatment against opportunistic infections and 8 of 11 are clinically well. Routine follow-up and a good relationship with the patient's family increase cooperation and promote optimal medical treatment, and consequently improve the clinical condition and quality of life.

Tension-Free Repair of Inguinal Hernia with Properitoneal Mesh

Eduard Ramadan, Dan Seror, Roman Belavsky, Zeev Dreznik

Dept. of Surgery A, Rabin Medical Center, Golda Campus (Hasharon Hospital) Petah Tikvah, and Sackler School of Medicine, Tel Aviv University

The results of properitoneal mesh repair of inguinal hernia were evaluated in 38 of 43 consecutive patients operated by Stoppa's technique. In 33 patients the hernia was bilateral and in 10 unilateral; in 20 it was recurrent. In 33/43 patients the mesh was fixed either by sutures or metal clips. The overall recurrence rate after 22 (14-36) months of follow-up, was 10.5%. This result was composed of a 3.0% recurrence rate in the fixated-mesh group, and 30.0% among those with non-fixated mesh.

The outcome following the Stoppa method for tension-free properitoneal mesh repair of inguinal hernia, compares favorably with those of other methods, provided proper attention is paid to adequate mesh placement and fixation. Further prospective studies are needed to define the role and indications for this technique in the laparoscopic era.

Willingness to Donate Organs: Attitude Survey among Israeli Jews

Peri Kedem-Friedrich, Rina Rachmani

Psychology Dept., Bar-Ilan University, Ramat Gan and Information and Education Unit, Israel Transplant Center

A public opinion survey of Israeli Jewish adults (September) showed a large potential willingness to donate organs after death, while only a third of the sample was opposed. Nevertheless, only a very minor proportion held donor's cards, and over half expressed opposition to holding a donor card. As to next-of-kin's organs, when the wishes of the relative were not known, a quarter of the sample opposed, a quarter agreed, and the remaining half hesitated to make a decision.

Willingness to donate was not correlated with gender, age or income, but was related to religiosity: the more religious, the less willing to donate. And the religious reason was the salient one given for hesitation about donating, although there were many who could give no reason for their hesitation. Family members, doctors and rabbis (in ascending order) influenced willingness to consent to next-of-kin donations.

Screening Tests for Detecting Breast Cancer: Performance Rates and Characteristics of Patients

Netta Bentur, Revital Gross, Ayelet Berg

JDC-Brookdale Institute of Gerontology and Human Development, Jerusalem

Screening tests including mammograms for early detection of breast cancer are in the basket of services provided under the National Health Insurance Law. The law also defines the population groups entitled to mammograms, and sets the frequency of the test as once every 2 years. The aim of this study was to examine the screening rates for early detection of breast cancer at the inception of the law, in order to monitor future changes in performance rates, and identify the characteristics of those unlikely to undergo these tests, in order to promote the use of screening tests by them. This study is part of a comprehensive survey examining the effect of the National Health Insurance Law on the Israeli population.

The survey, carried out in the summer of 1995, included a sample of 1,400 Israeli residents aged 22 and over. To determine performance rates for clinical breast examinations a subgroup of 515 women aged 30 and over was sampled. To determine performance rates for mammograms, 173 women were aged 50-74 (the entitlement ages under the law), were sampled. 54% of women aged 30+ reported having had at least 1 clinical breast examination during their lifetime, and 56% of women aged 50-74 reported having had a mammogram during the past 2 years. Variables with an independent effect on the likelihood of having had a clinical breast examination by a physician during the past 2 years were: being over the age of 50, having at least 9 years of education, being a veteran resident of Israel (as opposed to a new immigrant), and being Jewish. Variables with an independent effect on the likelihood of having a mammogram during the past 2 years were: being a veteran resident of Israel, and having a high income צ which was found to have a borderline effect. The findings of the survey emphasize the importance of changing the behavior patterns of both women and physicians, informing women about their entitlement to the tests, and raising consciousness of the importance of having repeated clinical examinations by a physician, as well as mammograms.

Progression of Diabetic Retinopathy after Cataract Extraction

Y. Raniel, Y. Teichner, Z. Friedman

Annette and Aron Rozin Dept. of Ophthalmology, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

A prospective study of the effect of cataract extraction with intraocular lens implantation on the course of diabetic retinopathy (DR) in 44 patients (59 eyes) was carried out. It showed that in the 1-3 years following surgery, there was progression of DR (including development of newly formed retinopathy) in 35% of the patients (28.8% of eyes). Progression was more marked in patients with pre-operative bilateral DR compared to those without bilateral DR (77% and 16% respectively). Insulin dependence did not play a role in progression. Final visual acuity was better in patients without pre-operative DR, as well as in eyes without progressive retinopathy.

Traumatic Hyphema*

Tamar Talmon, Itzchak Beiran, Benjamin Miller

Dept. of Ophthalmology, Rambam Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Traumatic hyphema usually occurs in young men at the rate of 17-20/1000,000. Major complications include secondary hemorrhage, glaucoma, corneal staining and disturbances in visual acuity. Final visual acuity is predominantly the outcome of all the ocular injuries occurring during the trauma, mainly to the posterior segment of the eye. We describe all cases of traumatic hyphema treated in our department over a period of 3.5 years. Antifibrinolytic treatment is recommended in the literature in traumatic hyphema to prevent secondary hemorrhage. Our findings differ from those in the literature in that they show a lower prevalence of more severe hemorrhages and of secondary hemorrhage. In light of these differences, and with regard to possible side effects of such treatment, we suggest that antifibrinolytic treatment not be used in our population. We recommend that treatment for traumatic hyphema should include restricted activity, local corticosteroidal preparations, frequent follow-up visits and vigorous diagnostic work-up in order to find any additional eye damage. We strongly recommend the use of preventive measures (eye-shields) in high risk activities such as sports, house-hold work and military training.

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* Based on work submitted to the Faculty of Medicine, Technion-Israel Institute of Technology, by Tamar Talmon in partial fulfillment of the requirements for the MD degree.