[Show abstract][Hide abstract] ABSTRACT: The cranial base is located at a critical intersection between the vertebral spine, the brain, the respiratory system and the mastication apparatus. Therefore it can provide an insight into the evolution of the head and neck in functional and phylogenetic contexts. However, the relationship between cranial base anatomy and cervical spine alignment has not been explored deeply. There-fore the aim of this research is to study the relationship between the orientation of the foramen magnum and the degree of cervical lordosis. Based on this relationship we developed six models which enable reconstruction of the cervical lordosis angle in archeological material and in extinct hominins. 74 adult lateral cervical radiographs were examined. The orientation of the foramen magnum and the angle of the cervical lordosis were measured on each radiograph. Foramen magnum orientation positively correlates with cervical lordosis angles: moderate to high correla-tion was found between foramen magnum orientation and the total cervical lordosis (0.716 < r < 0.612); moderate correlation was also found between foramen magnum orientation and the upper cervical lordosis (0.626 < r < 0.562); and only weak correlation was found with the lower cervical lordosis (0.306 < r < 0.101). Assuming that the positive correlation between foramen magnum orientation and cervical lordosis can be applied to all bipedal hominins, cranial base morphology can provide an insight to the degree of the cervical lordosis of archeological material and of ex-tinct hominin.
[Show abstract][Hide abstract] ABSTRACT: We describe the use of an electric trigger-controlled suction-lavage device for the evacuation of empyema or clotted hemothorax. Wound debridement systems provide efficient irrigation and debris removal. It is frequently used for orthopedic procedures or infected wound rinsing. Internet search of the literature did not result in any paper describing the use of this technique for thoracic surgery. We present our experience with an electrical wound-washing device in video-assisted thoracoscopic surgery for thoracic empyema or clotted hemothorax.
The Annals of thoracic surgery 03/2014; 97(3):1091-2. · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background Neutrophils are the predominant phagocytes that provide protection against bacterial and fungal infections. Genetically determined neutrophil disorders confer a predisposition to severe infections and reveal novel mechanisms that control vesicular trafficking, hematopoiesis, and innate immunity. Methods We clinically evaluated seven children from five families who had neutropenia, neutrophil dysfunction, bone marrow fibrosis, and nephromegaly. To identify the causative gene, we performed homozygosity mapping using single-nucleotide polymorphism arrays, whole-exome sequencing, immunoblotting, immunofluorescence, electron microscopy, a real-time quantitative polymerase-chain-reaction assay, immunohistochemistry, flow cytometry, fibroblast motility assays, measurements of apoptosis, and zebrafish models. Correction experiments were performed by transfecting mutant fibroblasts with the nonmutated gene. Results All seven affected children had homozygous mutations (Thr224Asn or Glu238Lys, depending on the child's ethnic origin) in VPS45, which encodes a protein that regulates membrane trafficking through the endosomal system. The level of VPS45 protein was reduced, as were the VPS45 binding partners rabenosyn-5 and syntaxin-16. The level of β1 integrin was reduced on the surface of VPS45-deficient neutrophils and fibroblasts. VPS45-deficient fibroblasts were characterized by impaired motility and increased apoptosis. A zebrafish model of vps45 deficiency showed a marked paucity of myeloperoxidase-positive cells (i.e., neutrophils). Transfection of patient cells with nonmutated VPS45 corrected the migration defect and decreased apoptosis. Conclusions Defective endosomal intracellular protein trafficking due to biallelic mutations in VPS45 underlies a new immunodeficiency syndrome involving impaired neutrophil function. (Funded by the National Human Genome Research Institute and others.).
New England Journal of Medicine 06/2013; · 54.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abnormal differentiation of the renal stem/progenitor pool into kidney tissue can lead to renal hypodysplasia (RHD), but the underlying causes of RHD are not well understood. In this multicenter study, we identified 20 Israeli pedigrees with isolated familial, nonsyndromic RHD and screened for mutations in candidate genes involved in kidney development, including PAX2, HNF1B, EYA1, SIX1, SIX2, SALL1, GDNF, WNT4, and WT1. In addition to previously reported RHD-causing genes, we found that two affected brothers were heterozygous for a missense variant in the WNT4 gene. Functional analysis of this variant revealed both antagonistic and agonistic canonical WNT stimuli, dependent on cell type. In HEK293 cells, WNT4 inhibited WNT3A induced canonical activation, and the WNT4 variant significantly enhanced this inhibition of the canonical WNT pathway. In contrast, in primary cultures of human fetal kidney cells, which maintain WNT activation and more closely represent WNT signaling in renal progenitors during nephrogenesis, this mutation caused significant loss of function, resulting in diminished canonical WNT/β-catenin signaling. In conclusion, heterozygous WNT4 variants are likely to play a causative role in renal hypodysplasia.
Journal of the American Society of Nephrology 03/2013; · 8.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Study Design. Cross-sectional retrospective study.Objective. The purpose of this study was to provide data for the normal values of the lumbar lordotic curvature and segmental angles throughout childhood and to explore the relative contribution of the vertebral bodies and intervertebral discs to the developing lordosis during childhood.Summary of Background Data. Although early detection of spinal abnormalities such as hyper lordosis or scoliosis is important for preventative intervention, published data regarding normal lordosis development is sparse. The lumbar lordotic curvature is formed by the wedging of the lumbar vertebral bodies and of the intervertebral discs but there is no data to indicate how these two components changes during childhood development.Methods. Spinal angle parameters were measured on mid-sagittal reformatted images from 210 abdominal Computerized Tomography (CT) scans of children aged 2-20 years. Four different angles were calculated: the lordosis angle (LA); the body wedge angle (B); the total segmental angle (S) and the intervertebral disc angle (D) Measurements B, S, and D were taken for each of the five lumbar segments. Measurements B and D were used to calculate ∑B, the sum of the lumbar L1-L5 bodies; and ∑D, the sum of the lumbar L1-L5 intervertebral disc angles. CT scans were divided into 6 groups according to patients' ages.Results. The LA increased from 30 ± 6 degrees in the 2-4 years old group to 44 ± 9 degrees in 17-20 years old group. The ∑B slightly decreased (less lordotic wedging) with age while the ∑D increased significantly with age.Conclusions. Our results indicate that the lordosis angle continues to develop at least until 14-16 years of age and that this increase is the result of the increased lordotic wedging of the intervertebral discs.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: Patients with breast cancer following mastectomy and silicone implant reconstruction may have enlarged internal mammary lymph nodes with pathological uptake on positron emission tomography with (18)F fluorodeoxyglucose. This lymphadenopathy is usually considered as metastatic in nature, but has also been reported to be related to other conditions, including silicon migration. The purpose of this study was to determine the rate of metastatic disease in this unique group of patients. METHODS: A retrospective comparative study of 12 female patients with breast cancer with silicone implants referred for biopsy due to isolated internal mammary lymph node fluorodeoxyglucose uptake on positron emission tomography. RESULTS: Five patients (41.6%) had histological findings related to silicone (n = 4) or non-specific inflammation (n = 1). The remaining 7 (58.3%) had histological evidence of cancer recurrence. There was no significant difference in the fluorodeoxyglucose-standardized uptake value between the two groups. CONCLUSIONS: Fluorodeoxyglucose-positive mammary lymph nodes in patients with breast cancer following silicone implant reconstruction may be due to metastatic deposits, non-specific inflammation or silicone migration. Clinical and imaging characteristics are insufficient in differentiating between these conditions. Biopsy is recommended prior to initiation of further treatment.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 01/2013; · 2.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pediatric emergency department chest radiographs are frequently interpreted by the pediatrician, and patient management is based on this interpretation.
The purpose of this study was to assess the chest radiograph interpretation discordance rate between pediatricians and pediatric radiologists and determine its clinical significance.
This study included 1196 patients admitted off-hours to the pediatric emergency department who had chest radiographs as part of the clinical evaluation. The pediatricians' interpretations of the chest radiographs as appeared in the discharge reports were reviewed and compared with the specialist radiologist's ultimate report.
Discordant chest radiograph interpretations were found in 332 (28%) of 1196 patients. Of these, 76 (6.3%) were clinically significant. These included 59 initial diagnoses of normal or viral patterns subsequently interpreted as bacterial pattern by the radiologist and 17 radiographs with findings such as chronic lung disease or abnormal heart shadow overlooked or misinterpreted by the pediatrician.
Although the clinically significant discordant rate was relatively low, daily chest radiograph reassessment by pediatric radiologists in a joint meeting with pediatricians has an added value for patient safety, quality assurance, and mutual training.
Pediatric emergency care 09/2012; 28(10):1052-4. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to retrospectively evaluate last fluoroscopy hold (LFH) in paediatric fluoroscopy. LFH is a software program that enables dynamic storage of last fluoroscopy sequences. A hundred and ninety-four paediatric patients underwent 215 fluoroscopy examinations during a 14-month period. LFH was employed to review an equivocal finding, when last image hold did not provide an adequate diagnostic image or when a physiologic dynamic event was too fast or did not last long enough to capture. LFH was used in 29% of the examinations. The Institutional Review Board approved this study and waived informed consent.
Journal of Medical Imaging and Radiation Oncology 02/2012; 56(1):93-5. · 0.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The applicability today of Greulich and Pyle's Radiographic Atlas of Skeletal Development of the Hand and Wrist (G&P) is uncertain.
The purpose of this study was to determine whether G&P is accurate in Israeli children today.
Left-hand radiographs of 679 children (375 boys) ranging in age from 1 day to 18 years old were obtained for trauma in the period 2001-2009 and were evaluated for bone age according to G&P. Individual bone age was plotted against calendar age and smoothed to obtain the association between calendar age and bone age. Any difference was assessed with Wilcoxon signed-rank test.
In girls, there was no significant difference between bone age and calendar age (P = 0.188). G&P underestimated bone age in boys <15 years old (median difference, 2.3 months; P < 0.0001) and overestimated bone age in boys ≥15 years old (median difference, 2.9 months; P = 0.0043). The largest median difference (5.4 months; P = 0.0003) was seen in boys 6-10 years old.
The differences between calendar age and bone age according to G&P were relatively small compared with normal variance and are unlikely to be of clinical importance.
[Show abstract][Hide abstract] ABSTRACT: Recurrent spontaneous pneumothorax is widely treated by video-assisted thoracoscopic (VATS) bullectomy and pleurodesis. Treatment of postoperative pain with nonsteroidal antiinflammatory drugs (NSAIDs) is controversial as many surgeons believe that it reduces the efficacy of pleurodesis and increases the pneumothorax recurrence rate.
In this retrospective study, we reviewed the hospital records for patients following VATS pleurodesis for recurrent spontaneous pneumothorax. The patients were divided into two groups: (1) NSAID group: patients were treated with NSAIDs for more than a week following surgery and (2) control group: patients did not receive NSAIDs. Data regarding short- and long-term outcomes were compared.
The study cohort included 105 patients: 48 in the NSAID group and 57 in the control group. During the early postoperative period the average daily requirement of narcotic analgesia and the incidence of narcotic-related side effects were lower in the NSAIDs group. No difference was found in the long-term recurrence rate: two of 48 (4%) in the NSAID group and three of 57 (5%) in the control group. There was one case of early recurrence in the NSAID group. Both groups had similar length of stay with no cases of mortality or major morbidity.
NSAIDs for postsurgical pleurodesis pain obviates the need for narcotics without increasing the pneumothorax recurrence rate. Prospective randomized controlled studies are needed to further investigate this issue.
World Journal of Surgery 09/2011; 35(11):2563-7. · 2.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Since its onset in the spring of 2009, the H1N1 pandemic has kept health-care professionals busy worldwide. Even though it often causes respiratory tract illness, reports describing the radiological manifestations in infected children are few. The purpose of this study was twofold: to review the chest radiograph findings in children with laboratory-confirmed pandemic (H1N1) 2009 influenza virus and compare them with the chest radiographic findings in children with the same symptoms but laboratory negative.
Informed consent was not required by the institutional review board for this retrospective study. We identified 151 children who were tested for pandemic H1N1 virus and had chest radiographs. Chest radiographs were evaluated for the presence of airway disease including hyperinflation, subsegmental atelectasis and peribronchial cuffing, airspace disease, pleural effusion or any combination of these, and compared for H1N1-positive and H1N1-negative children, for healthy and non-healthy children separately.
No statistically significant difference between H1N1-tested positive children and H1N1-tested negative children was found for the proportion of abnormal chest rays (P=1 for healthy children, P=0.08 for children with chronic disease). For individual findings, there was no difference between H1N1-tested positive healthy children and H1N1-tested negative healthy children (P>0.083 for each finding) In children with chronic disease, there was significantly more subsegmental atelectasis (P=0.037) in the radiographs of H1N1-tested negative children.
Chest radiographs have non-specific findings in cases of suspected swine flu in children and have limited value in distinguishing H1N1 from non-H1N1 viral infections for both healthy children and children with chronic disease.
Journal of Medical Imaging and Radiation Oncology 06/2011; 55(3):275-8. · 0.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the clinical presentation, diagnosis, management and complications of children with retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs).
A retrospective chart review was conducted at two tertiary care, pediatric hospitals in Israel. The medical records of all children <18 years who had been admitted with a diagnosis of RPA or PPA during an 11-year period (January 1997 to February 2008) were reviewed. Data on demographics, presenting symptoms, physical examination findings, imaging studies and interpretation, laboratory results, hospital course, medical treatment and surgical interventions were retrieved.
A total of 39 children were diagnosed as having RPA (n=26, 67%) or PPA (n=13, 33%). There was a predominance of boys (61.5%). The mean age of all the children at diagnosis was 4 years. The annual incidence increased over the 11-year period. The most common symptoms at presentation included fever (n=27, 70%) and neck pain (n=24, 62%). The physical examination revealed cervical lymphadenopathy in 30 children (77%), limitation of neck movements in 25 (64%), torticollis in 21 (54%), drooling in three (8%), and stridor in two (5%). Computerized tomographic (CT) scanning with contrast was performed in 37 patients (95%), of whom 17 underwent surgical drainage. Thirteen children were positively diagnosed as having an abscess by the finding of pus at surgery, of whom 12 had been found to have an abscess on their CT scan. All the patients received intravenous antibiotics. There was no significant difference in the duration of hospital stay between those who underwent surgery and those who were treated with antibiotics alone. There were no treatment failures and no complications in either of the two groups.
Children with RPA most commonly present with restricted neck movements, fever and cervical lymphadenopathy, and rarely with respiratory distress or stridor. Many patients with RPA and PPA can be treated successfully without surgery. CT scans are helpful in diagnosing and assessing the extent of the infection, but they are not always accurate.
International journal of pediatric otorhinolaryngology 09/2010; 74(9):1016-20. · 0.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We evaluated the feasibility of a using urine sensor for voiding cystourethrography (VCUG) and its implications for fluoroscopy time reduction.
Institutional Review Board approved the study protocol. Study population included children less than 5 years old referred to our institution for VCUG. Patients with known vesicoureteral reflux or any pacing device were excluded from the study. The urine sensor consists of an electrode that senses the fluid, an electrical circuit and an indicator to provide visual signal. The urine sensor electrode was placed on the medial thigh in the proximity of the catheter close to the urethral opening, but without direct contact to it. A standard VCUG examination was performed with retrograde filling of the urinary bladder. Once the bladder was full, fluoroscopy of the voiding stage was initiated when the indicator blinked. Peak kV and fluoroscopy time were recorded.
Seven patients underwent VCUG with urine sensor and 22 patients without urine sensor. The urine sensor provided a reliable indication of voiding onset. The fluoroscopy time was significantly shorter with urine sensor use (1.99 min) than without urine sensor use (4.33 min) (p=0.001). In patients with normal VCUG, fluoroscopy time was also significantly shorter with urine sensor use (2.13 min) than without urine sensor use (4.39 min) (p<0.001).
VCUG studies with the help of the urine sensor are feasible and its use may result in significant reduction in fluoroscopy time.
European journal of radiology 02/2010; 78(3):394-7. · 2.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: PURPOSE
We evaluated the feasibility of a urine sensor for Voiding Cysto-Urethrography (VCUG) and its implications for fluoroscopy time reduction.
METHOD AND MATERIALS
Institutional Review Board approved the study protocol. Study population included children less than five years old referred to our institution for VCUG. Patients with known vesicoureteral reflux or any pacing device were excluded from the study. The urine sensor consists of an electrode that senses the fluid, an electrical circuit and an indicator to provide visual signal. The device was determined to be safe for patients by the Hospital Review Committee. The urine sensor electrode was placed on the medial thigh in the proximity of the catheter close to the urethral opening, but without direct contact to it. A standard VCUG examination was performed with retrograde filling of the urinary bladder. Once the bladder was full, fluoroscopy of the voiding stage was initiated when the indicator blinked. Peak kV and total fluoroscopy time for examination were recorded.
Seven patients underwent VCUG with urine sensor and twenty-two patients without urine sensor. The urine sensor provided a reliable indication of voiding onset. For the whole study population, the fluoroscopy time was significantly shorter with urine sensor use (1.99 min) than without urine sensor use (4.33 min) (p=0.001). In the subset of patients with normal VCUG, fluoroscopy time was also significantly shorter with urine sensor use (2.13 min) than without urine sensor use (4.39 min) (p<0.001).
VCUG studies with aid of the urine sensor are feasible. The urine sensor allowed two-fold reduction in fluoroscopy time of the VCUG examination.
Application of urine sensor halved the fluoroscopy time needed to perform diagnostic VCUG in patients under 5 years old.
Radiological Society of North America 2009 Scientific Assembly and Annual Meeting; 12/2009
[Show abstract][Hide abstract] ABSTRACT: PURPOSE
To determine whether the Greulich and Pyle Atlas, first published in 1950, is relevant for the Israeli pediatric population today, and estimate the correction needed for Israeli children when determining bone age from the Atlas.
METHOD AND MATERIALS
All left hand radiographs of children obtained for trauma since 2001 were identified through the hospital's computerized archives. 254 radiographs of boys and 184 radiographs of girls aged 3 months to 19 years old were included. Patients with known underlying disease were excluded. All radiographs were scored for bone age according to the atlas by five experienced Pediatric and Musculoskeletal Radiologists, blinded to the patient's calendar age. The individual bone ages were smoothed using LOESS (Local Estimated Surface) procedure to obtain the dependence between the calendar age and bone age from the Atlas. In addition the 95% confidence region was defined.
In average, the agreement between bone age according to the Atlas and the calendar age was almost perfect. The difference for boys was 0.075 year (28 days), and 0.207 years (75 days) for girls. However the range was large (from -3.8 year to 3.5 year for boys and from -2.5 year to 3 years for girls). For ages beyond 15 years the Atlas systematically overestimates the calendar age. In average, this difference reaches approximately 1 year for both boys and girls.
The definition of bone age is practically correct up to age 15 years. For children older than 15 years the Atlas overestimates the correct age. This should be considered when using the Atlas in this age group.
Since the publication of the Atlas changes have occurred in nutrition, healthcare and lifestyle of Israeli Children. Therefore, it is clinically justified to evaluate its relevance today.
Radiological Society of North America 2009 Scientific Assembly and Annual Meeting; 12/2009
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: We report the role of the imaging department at a level 1 trauma center during the Second Lebanon War (summer 2006). Our institution received 849 military and civilian casualties, an average of 25 war-injured patients per day, 338 with acute traumatic stress disorders and 511 physically injured, coming in waves after a rocket attack or a battle confrontation. About 12 potentially critical physically injured patients per day were referred to the imaging department for sometimes complex imaging procedures. The unpredictable waves of casualties and nature of the injuries forced us to reorganize our routine workflow to provide adequate care to casualties and to nonemergent patients. Our nurses' station was transformed into a small emergency department. The radiology staff was distributed into 12 diagnostic stations, providing 24-hour service. Communication was improved by means of walkie-talkies. Three ultrasound units were placed at the emergency department for immediate focused assessment with sonography for trauma performance enabling initial triage of patients. The site and extent of injuries were accurately diagnosed on CT and CT angiography. Digital angiography allowed definitive vascular diagnosis and interventional procedures. CONCLUSION: Adequate communication, strict workflow, and correct use of imaging protocols ensured optimal triage, diagnosis, and therapy of casualties while maintaining care for nonwar patients.
American Journal of Roentgenology 11/2009; 193(5):1212-21. · 2.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine the diagnostic accuracy of sonographically guided biopsy of [(18)F]fluorodeoxyglucose (FDG)-avid foci on positron emission tomography (PET)/computed tomography (CT) in patients with lymphoma.
We retrospectively reviewed the medical records of 56 patients with lymphoma (25 male and 31 female; mean age, 48.5 years; range, 22-80 years) who underwent sonographically guided biopsy of hypermetabolic FDG-avid foci precisely localized by PET/CT. Biopsies were performed up to 3 months after PET/CT. The accuracy of core biopsy was calculated and compared with clinical follow-up and histopathologic results of open biopsy.
Sixty-six sonographically guided biopsies were performed in the 56 patients. Histopathologic results were conclusive in 53 (80%) of 66. No complications occurred during or after the procedure. The overall sensitivity, specificity, positive predictive value, and accuracy for diagnosis of lymphoma were 100%, 95%, 97%, and 98%, respectively.
Sonographically guided biopsy is a safe and effective means for investigating metabolically active lesions on FDG-PET/CT in patients with known lymphoma.
Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 03/2008; 27(2):225-31. · 1.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this presentation is to highlight the color Doppler duplex sonographic features of procedure-related and blunt or penetrating trauma-related vascular injuries.
Different kinds of vascular complications such as pseudoaneurysms, arteriovenous fistulas, dissection, and thrombosis are discussed. Cases of vascular injuries in the extremities, neck, and abdomen are presented to illustrate the spectrum of sonographic appearances.
Color Doppler duplex sonography is valuable in the diagnosis and monitoring of most vessel injuries and in the treatment of pseudoaneurysms. It is useful for flow analysis and for follow-up after treatment. However, because of limitations inherent to sonography, such as bones, air, casts, skin burns, and relatively slow performance of the test, magnetic resonance imaging, computed tomography, and angiography are necessary for further evaluation in selected cases.
Color Doppler duplex sonography is a widely available, noninvasive, and accurate technique for evaluating vascular injuries and should be the first-line imaging modality in most patients.
Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 02/2008; 27(1):95-107. · 1.40 Impact Factor