תוצאת חיפוש

ראיד סלים, זהר נחום, אליעזר שלו

המח' לרפואת נשים ויולדות, מרכז רפואי העמק, עפולה והפקולטה לרפואה הטכניון - חיפה

תרומבוציטופניה (ת"ר) מוגדרת כמספר טסיות דם מתחת ל-150,000 למיקרוליטר, ושכיחה ב-7%-5% מההריונות, 75% מכלל מצבי ת"ר בהריון, הם תוצאה של תרומבוציטופניה הריונית (ת"ה), ב-20%-25% מהחולות ת"ר היא חלק מתיסמונת HELLP (hemolysis, elevated liver enzymes, low platelets) בנשים עם רעלת הריון. ארגמנת תרומבוציטופנית חיסונית (את"ח) מהווה פחות מ-4% מסך אירועי ת"ר בהריון. אבחנה מדויקת חשובה לשם מתן טיפול הולם מחד גיסא, ולשם מניעת פעולות מיותרות ומסוכנות, מאידך גיסא.

Diagnostic Laparoscopy for Abdominal Lymphoma

D. Lev-Chelouche, D. Margal, J.M. Klausner, A. Szold

Dept. of Surgery B, Tel Aviv-Sourasky Medical Center (Affiliated with Sackler Medical Faculty, Tel Aviv University)

Imaging-guided (CT/US) percutaneous biopsy has significantly improved diagnosis of intra-abdominal lymphoma. However, in many cases the tissue retrieved may be inadequate for specialized studies such as immunophenotyping or cytogenetic analysis that may be required for a complete analysis of lymphoma or determination of therapy.

The success of diagnostic laparoscopy in the diagnosis and staging of gastrointestinal malignancies suggests that it could be used for intra-abdominal lymphomas as well. We describe our experience in 15 patients with suspected lymphoma who underwent diagnostic laparoscopy during 1995-98.

Preoperative investigation performed in all included percutaneous FNA in 9 without conclusive diagnosis. Laparoscopy was diagnostic for lymphoma in 14 (93%) while in 1 there was a false negative result due to sampling error and the lymphoma was only diagnosed at a second laparoscopy.

There was no mortality nor any major complication. Average hospital stay was 2 days and patients were then referred for further oncological treatment. Our experience shows that diagnostic laparoscopy is a safe and efficient tool and without major complications in diagnosing abdominal lymphoma.
 

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.

Preservation of the Larynx in Advanced Cancer

Edward Rosenblatt, Nava Siegelmann-Danieli, Jemal Zidan, Nisim Haim, Abraham Kuten

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

The effectiveness of sequential chemo-radiotherapy in preserving the larynx in advanced laryngeal carcinoma was assessed. 4 Unselected patients (19 men and 2 women, mean age 60 years) with advanced squamous cell carcinoma of the larynx (T3-4/N0-3) received induction chemotherapy consisting of 2-3 cycles of cisplatin (100 mg/m²) and 5-flourouracil (1000 mg/m²/day) as a continuous infusion on days 1-5 followed by definitive radiotherapy: 50 Gy to the whole neck, 70 Gy to the larynx and clinically involved nodes, using a combination of 6 MV photons and 9-12 MeV electrons.

19 of The 21 patients responded to combined therapy but there was no response to induction therapy in 2 (10%) and 2 did not complete therapy due to severe toxicity. At a mean follow-up of 40 months, 7 had undergone total laryngectomy (33%), for an overall 5-year laryngeal preservation rate of 66%. Reasons for total laryngectomy in 2 patients were no response and in 5 tumor recurrence.

Mean survival was 39 months (range 11-46 months); at last follow-up 17 of 21 were alive and disease-free, 11 of whom had a functional larynx (65% of survivors). 2 died due to disease progression and 1 due to a cardiovascular event. Sequential chemo-radiation allows laryngeal preservation in about 2/3 of surviving patients without compromising survival.

Relationship between Occupation and Clinical Characteristics during Pregnancy and Recommendation to Stop Working

S. Gazit-Nissim, E. Sheiner, M. Mazor, I. Shoham-Vardi

Depts. of Epidemiology and Health Services Evaluation, and of Obstetrics and Gynecology, Soroka University Medical Center and Ben-Gurion University of the Negev, Beer Sheba

We examined the relationship between occupation and clinical characteristics during pregnancy and medical recommendations to stop working. Using a case-control design, we compared 58 working women who had preterm births, with 126 who had delivered at term. All women were interviewed postpartum while still in hospital.

There were no differences between the groups with regard to physical activity outside the home, weekly work hours, nor duration of work. Only a small proportion had been exposed to unusually difficult working conditions, to hazardous agents or to a very uncomfortable working environment. Women who had had preterm births were advised more often to leave their jobs or modify their working patterns. Multivariate analysis revealed that the physician's decision to recommend cessation of work was influenced primarily by complications during the current pregnancy.

It appears that our patients at risk for preterm birth are probably correctly identified, and receive appropriate guidelines as to working patterns. It is possible that a poor obstetric history or previous abortions may paradoxically have a protective effect, as they influence the physician to recommend cessation of work.

Benign Paroxysmal Positional Vertigo: Diagnostic Pitfalls 

C.R. Gordon, O. Zur, R. Furas, E. Kott, N. Gadoth

Depts. of Neurology and of Physical Therapy, Meir General Hospital, Kfar Saba, and Sackler Faculty of Medicine, Tel Aviv University

Benign paroxysmal positional vertigo (BPPV) is a common but often unrecognized cause of treatable vertigo. Possible causes of misdiagnosis of BPPV were studied by review of the records of 191 patients referred to our neurology clinic; 36 were identified as having BPPV not previously diagnosed. On referral the patients carried the following diagnoses: unspecified dizziness/vertigo (33%), transient ischemic attacks (28%), cervicogenic vertigo (19%), psychogenic dizziness/vertigo (11%), and others (8%).

The paroxysmal nature of the vertigo and position-precipitating factors were not spontaneously reported by 31%. Atypical, even bizarre, symptoms including dizzy sensations were reported by 19%, and neck pain and headache were cardinal symptoms that accompanied vertigo.

The Dix-Hallpike maneuver, which is essential for the diagnosis of BPPV, was not performed in any of the patients prior to referral. 30 (83%) experienced complete resolution of signs and symptoms after the first physical treatment session.

We conclude that non-paroxysmal, non-positional vertigo does not rule out BPPV. Atypical and even bizarre complaints of dizziness, as well as neck pain and headache could be cardinal symptoms of BPPV. The Dix-Hallpike maneuver is mandatory in those complaining of dizziness and vertigo.

Scaphoid Fractures in Children  

Shalom Stahl

Hand Surgery Unit, Rambam Medical Center and Rappaport Faculty of Medicine, Israel Institute of Technology, Haifa

The scaphoid is the most common carpal bone fractured in adults. In children the fracture is distinctly uncommon. We present our experience with 23 children treated between 1987-1998, 19 of them with fractures in the distal third of the wrist; there were 11 avulsions, 4 waist fractures, and 12 were undisplaced. The mechanism of injury was a direct blow or a fall onto the outstretched hand. Immobilization in a plaster cast led to union in all except 1 case.

Based on our experience and study of the literature, it is evident that scaphoid fractures, although uncommon, do occur. Thorough clinical and radiological examination of children with a forearm or wrist injury is important in detecting such fractures.

Relationship Between Preterm Birth and Exertion During Pregnancy

S. Gazit-Nissim, E. Sheiner, M. Mazor, I. Shoham-Vardi

Depts. of Obstetrics and Gynecology, Epidemiology and of Health Services Evaluation, Soroka-University Medical Center, and Ben-Gurion University of the Negev, Beer Sheba

The relationship between physical activity at home and at work during pregnancy and preterm birth was studied. Using a case-control design, 99 women who delivered preterm were compared with 189 women who had term deliveries. The risk of preterm birth was tested in relation to characteristics of work in and outside the home. All women were interviewed post-partum before discharge.

There were no statistically significant differences between the groups in relation to sociodemographic and obstetrical factors, but level of education was significantly lower in the study group versus the control group (p=0.001).

Women who delivered preterm had devoted less time 3 months prior to delivery to household chores (mean of 3.7 hours vs. 4.8 hours in the control group, p=0.002). They also had spent less time walking around the home than the controls (1.2 vs. 1.5 hours, p=0.02). There were no differences between the groups in relation to physical activity outside the home, not during working hours, nor in duration of work. Significantly fewer women who delivered preterm were active in sports (odds ratio 0.22; 95% confidence interval 0.50-0.65; p=0.002).

A low level of education was significantly related to the risk of preterm birth, which may have resulted from lesser compliance with their physician's recommendations. It appears that in women not used to significant physical activity but who had access to adequate prenatal care, physical effort during pregnancy was not related to a higher risk of preterm birth.

Carcinoma of the Cecum Presenting as Intussusception

Mordechai Shimonov, Oleg Kaminsky, Maya Cohen

Depts. of Surgery and Radiology, Beilinson Campus, Rabin Medical Center, Petah Tikva

In intussusception a proximal bowel segment (intussusceptum) invaginates into the lumen of a distal bowel segment (intussuscipiens). In adults intussusception represents a rare cause of intestinal obstruction and is usually secondary to an identifiable lesion that requires surgical treatment other than that of the intussusception itself.

We present a 57-year-old woman with metastatic colonic carcinoma of the ileocecal valve and intussusception of the ileum into the cecum. Right hemicolectomy was performed.

Symptom Severity among Chronic Schizophrenics in Hospital and in the Community

Haim Y. Knobler, Dorit Ben Ami, Orna Intrator, Shlomit Katz, Daniela Moshe, Yaacov Lerner

Jerusalem Mental Health Center, Falk Institute of Psychiatric and Behavioral Studies, and Dept. of Statistics, Hebrew Universitry of Jeruselam

We compared severity of symptoms of chronic schizophrenics in a psychiatric hospital with those treated in its outpatient clinics.

The Positive and Negative Syndrome Scale and the Mini-Mental State examination were used to assess the schizophrenic symptoms and cognitperformance, respectively, of 25 chronic schizophrenic inpatients matched for gender, age and education with 25 chronic scoutpatients. The Global Assessment Scale and the Clinical Global Impression Scale were used to test global functioning. Assessment included psychiatric and medical history and treatment and demographic characteristics.

In-patients had significantly more positive, negative and general psychiatric symptoms. Their cognitive and general functioning were impaired. Most in-patients also had medical problems. Age of onset of schizophrenia among the in-patients was younger.

Results show a marked difference in severity of symptoms and level of functioning between chronic schizophrenic in-patients and out-patients. These differences should be considered in the planning of discharge of chronic in-patients from psychiatric hospitals into the community.

Measuring Residual Urine by Portable Ultrasound Scanner

Santiago Richter, Rachel Hag'ag, Moshe Shalev, Israel Nissenkorn

Urology Dept. and Outpatient Clinic, Meir Hospital, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University

Urethral catheterization, the standard method of measuring residual urine, is uncomfortable and associated with risk of infection and trauma to the urethra. It has also been reported as inaccurate to a certain extent. We compared catheterization with ultrasound scanning in a prospective study of 52 men and 3 women.

100 measurements of postvoiding residual urine by portable ultrasound scanner, were each followed immediately by urethral catheterization (both procedures performed by an experienced nurse in our outpatient clinic). A difference of >25€ml between measurements by scanner and by catheter was considered significant.

The range of residual urine measured by scanner was 1-425 ml, and by catheter 1-410 ml. There was good matching between the 2 methods in 85 of 100 measurements (scanning accuracy 85%). In 30/85 matching was excellent while in 55 cases the mean difference was 8.5±6.2 ml, range 1-24 ml. The accuracy of scanning was 85%; there was perfect matching between the 2 methods in 30 cases. In the remaining 15 cases the mean difference was 41.8±13.6 (range 25-56).

Each catheterization took 4-5 minutes and scanning 30 seconds. There were no complications after catheterization, but all reported discomfort and dysuria for 1-2 hours thereafter. Scanning was absolutely uneventful in all.

The cost per catheterization, including medication, disposable materials and personnel time was approximately 80 NIS. Our 80-90 measurements of residual urine a month require annually about 80 hours and a budget of about NIS 80,000. Scanning requires only 8 hours, while the cost of the portable scanner is significantly less than NIS 80,000 and it can be used for more than a year.

We conclude that measuring urine residual with the noninvasive scanner instead of by catheterization is easier, more accurate, and more cost-effective.

Osteoid Osteoma of the Hand: a Rare Location

Nahum Rosenberg, Shalom Stahl

Dept. of Orthopedics A, and Hand Surgery Unit, Rambam Medical Center, Haifa

Osteoid osteoma is a benign bone tumor. It is rare in the hand where it may cause local swelling and pain. Marginal resection is almost always curative, without residual functional disability. Because it is rare in this location, osteoid osteoma is not usually considered in the differential diagnosis of painful lesions of the hand, which may delay treatment. Osteoid osteoma in the hand has characteristic clinical, roentgenologic and scintigraphic features. Early diagnosis of this lesion may be improved by recognition of these features. An algorithm for decision-making that may help is proposed. We describe our experience in 3 cases involving, respectively, the capitate bone, a proximal, and a distal phalanx, in which cases marginal resection was curative.

Conversion Total Hip Replaceafter Failed Internal Fixation of Intertrochantric Fracture

M. Kligman, M. Roffman

Dept. of Orthopedic Surgery, Carmel Medical Center, Haifa

Between 1933-1995, 16 patients underwent conversion-total hip replacement after internal fixation of an intertrochanteric fracture failed. Clinical results were unsatisfactory compared to primary total hip replacement. There was a high incidence of intra- and postoperative complications, including femoral fracture, wound infection, and aseptic loosening. This study should increase the surgeon's awareness of the difficulties encountered in conversion of failed intertrochanteric fractures to total hip replacement.

Enhancing Cultural Sensitivity of Psychiatrists from Russia

Haim Y. Knobler, Shlomit Katz, Inessa Poliakova, Rimona Durst

Jerusalem Mental Health Center, Kfar Shaul Hospital, Jerusalem

The importance of understanding the local culture and enhancing cultural sensitivity became evident during supervision of immigrant psychiatrists from the former Soviet Union. The aim of the present study was to describe enhancement of this cultural sensitivity in the supervision of 2 immigrant psychiatrists. In the first, understanding the patient's cultural world helped the immigrant psychiatrist form the therapeutic alliance. In the second, the immigrant psychiatrist's understanding of the patient's cultural background led him to change both diagnosis and treatment. In both cases, development of cultural sensitivity through supervision enabled successful treatment. Enhancement of cultural sensitivity may accelerate absorption of the immigrant psychiatrists themselves. Discussing cultural issues during work may accelerate the absorption of all immigrant physicians.

Postoperative Ulnar Nerve Palsy of the Elbow

Shalom Stahl, Doron Norman, Chaim Zinman

Hand Surgery Unit and Dept. of Orthopedic Surgery B, Rambam Medical Center and Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Ulnar nerve neuropathy of the elbow is a recognized complication of surgery involving general anesthesia. In 13 patients, aged 21-76 years, ulnar nerve palsy developed at various times and of varying degrees of severity during the postoperative period. Diagnosis was based on clinical and electrophysiological findings. 3 patients had subclinical entrapment of the ulnar nerve. All were treated conservatively by rest, splinting and physical therapy: 10 improved slowly with time and 3 were operated on, but only 1 recovered fully. Preventive measures, such as proper positioning on the operative table, use of elbow pads, avoiding adduction of the arm, pronation of the forearm and prolonged elbow flexion, may reduce the incidence of ulnar nerve palsy. Unfortunately, treatment of established lesions has yielded mixed results.