A. Balbir-Gurman and Y. Braun-Moscovici
Background: Overlap syndrome is an entity that satisfies the criteria of at least two connective tissue diseases. These conditions include systemic sclerosis, dermatomyositis or polymyositis, Sjogren's syndrome, rheumatoid arthritis and systemic lupus erythematosus. A combined pathology has impact on the clinical features, diagnosis and treatment.
Objectives: To analyze the features of SSc[1] patients with overlap syndrome registered in the European (EUSTAR) database at our center and to review the literature focusing on clinical and diagnostic issues and new treatments.
Methods: We studied the medical records of 165 consecutive SSc patients and reviewed cases with scleroderma overlap syndrome. Using the key words “overlap syndrome," "systemic sclerosis," “connective tissue disease” and “biological agents” we conducted a PubMed search for the period 1977 to 2009.
Results: Forty patients satisfied the criteria for scleroderma overlap syndrome. The incidence of additional connective tissue diseases in the whole group and in the overlap syndrome group respectively was: dermatomyositis or polymyositis 11.5% and 47.5%, Sjogren's syndrome 10.3% and 42.5%, rheumatoid arthritis 3.6% and 15.4%, and systemic lupus erythematosus 1.2% and 5.0%. Coexistence of SSc and another CTD[2] aggravated the clinical course, especially lung, kidney, digestive, vascular and articular involvement. Non-rheumatic complications mimicked SSc complications. An additional rheumatic or non-rheumatic disease affected treatment choice.
Conclusions: The definition of scleroderma overlap syndrome is important, especially in patients who need high-dose corticosteroids for complications of a CTD. The use of novel biological therapies may be advocated in these patients to avoid the hazardous influences of high-dose steroids, especially renal crisis. In some overlap syndrome cases, biological agents serve both conditions; in others one of the conditions may limit their use. In the absence of formal clinical trials in these patients a cautious approach is preferred.
E. Davidi, A. Paz, H. Duchman, M. Luntz and I. Potasman
Background: Perichondritis of the auricle is a serious disease that may lead to residual deformity.
Objectives: To assess our experience with perichondritis in a large group of patients hospitalized with this entity.
Methods: We retrospectively studied 114 patients who were admitted with perichondritis during 1987–2004, including their demographic details, medical history, current illness, etiology, pathogens and treatments.
Results: The patients’ mean age was 41.8 ± 20.7 years. In more than half of the patients the etiology could not be determined. Forty-seven patients (41%) were treated prior to hospitalization for an average of 2.5 ± 1.9 days. Eight patients (7%) required surgical intervention. Pseudomonas aeruginosa was found to be the predominant organism (69% of available isolates) and was associated with a more advanced clinical presentation and longer hospitalization (P = 0.008).
Conclusions: Perichondritis develops in many cases after apparent minor trauma. Since P. aeruginosa is probably the predominant pathogen, initial treatment should include anti-pseudomonal antibiotics.
A. Gover, D. Bader, M. Weinger-Abend, I. Chystiakov, E. Miller, A. Riskin, O. Hochwald, L. Beni-Adani, E. Tirosh and A. Kugelman
Background: The rate of brain abnormalities in asymptomatic term neonates varies substantially in previous studies. Some of these rates may justify general screening of healthy newborns by head ultrasound.
Objectives: To assess the incidence of intracranial abnormalities among asymptomatic term newborns with HUS and to detect high-risk populations that might need such screening.
Methods: This was a prospective study in 493 term newborns who underwent HUS and a neurological evaluation during the first 3 days of life. The neurological examination results were unknown to the sonographist and the examiner was blinded to the HUS findings. The abnormal HUS findings were classified as significant or non-significant according to the current literature.
Results: Abnormal HUS was found in 11.2% of the neonates. Significant findings were noted in 3.8% of the infants. There was no association between non-structural HUS findings (hemorrhage or echogenicity) and mode of delivery. There was no relationship between any HUS abnormality and birth weight, head circumference and maternal age, ethnicity, education or morbidity. The rate of abnormal neurological, hearing or vision evaluation in infants with a significant abnormal HUS (5.2%) was comparable to the rate in infants with normal or non-significant findings on HUS (3.1%).
Conclusions: There is no indication for routine HUS screening in apparently healthy term neonates due to the relatively low incidence of significant brain abnormalities in these infants in our population.
R. Gingold-Belfer and Y. Niv
J. Farhi and A. Ben-Haroush
Background: Infertility is one of the most prevalent health disorders in young adults.
Objectives: To study the distribution of causes of infertility in couples referred to primary infertility clinics in Israel.
Methods: Data for a 9 year period were derived from two clinics of major women's hospitals run by the country's largest health insurance funds. All patients were treated by one physician. Laparoscopy was not performed to rule out endometriosis.
Results: Of the 2515 couples identified, 1991 (79.2%) had a definitive diagnosis following complete workup (including hysterosalpingography). Mean age was 29.6 ± 6.0 years; mean duration of infertility was 1.7 ± 1.8 years. Primary infertility accounted for 65% of cases. Causes of infertility were male factor (45%), oligo-ovulation disorders (37%), and tubal damage (18%). Infertility factors were identified in the woman alone in 30.6% of cases and the man alone in 29.2%. Two combined infertility factors were found in 18% of patients, and three combined factors in 0.5%. The rate of unexplained infertility (which probably includes non-tubal endometriosis) was 20.7%.
Conclusions: As male factor accounts for almost half of all cases of infertility in couples, sperm analysis is mandatory before any treatment.
L. Leibenson, S. Banani, A. Borer, M. Meirovitz, Y. Shemer Avni, D. Singer, F. Schlaeffer, M. Leibenson, T. Silberstein, A. Wiznitzer and K. Riesenberg
Background: Concomitant human immunodeficiency virus and human papillomavirus infection increases both HPVpersistence and the risk of invasive cervical cancer. An estimation of HPV prevalence among HIV-positive women in Israel would contribute to improving care for this population and preventing morbidity and mortality related to cervical cancer.
Objectives: To determine the prevalence of HPV infection and cervical cytology abnormalities, and to assess the possible influence of HIV infection on HPV carriage in HIV-positive women attending the Infectious Disease Clinic at Soroka University Medical Center.
Methods: The study population included 84 HIV-seropositive women. They were examined by a gynecologist and screened for HPV genotyping, and Pap smears were obtained for cervical cytology. Demographic, behavioral, and HIV infection variables were also recorded and analyzed.
Results: Forty-nine (58.3%) of the study participants were HPV-positive; 34 of them had oncogenic genotypes. Young age (< 16 years) at first sexual intercourse was the only variable significantly associated with HPV infection (P < 0.05). Abnormal cervical cytology was present in 17 women (20.3%); 21 women were referred to colposcopy, which was abnormal in 9 (10.7%).
Conclusions: The prevalence of HPV carriage among HIV-positive woman in our study was slightly higher than published elsewhere. The prevalence of pathological cervical cytology was much higher than in the general population. An extremely high prevalence of pathological colposcopies requiring further treatment was found. Screening for HPV and premalignant changes in the uterine cervix is highly recommended in the HIV-seropositive population. We suggest that colposcopy be considered part of the routine workup in HIV-seropositive woman.
E. Dagan, A. Yakirevich, L. Migirov, and M. Wolf
Background: The fish-eating habits of Israelis who present with impacted fish bones in the aerodigestive tract are unknown.
Objectives: To retrospectively investigate the relation between an impacted fish bone in the aerodigestive tract, the species of fish, and the place of occurrence in an Israeli population.
Methods: The current prospective observational study included all patients with aerodigestive impacted fish bones who were treated in our emergency department from 1 September 2008 to 30 September 2009. The data retrieved from their medical records included age, gender, place of event (at home or elsewhere), species of fish, and method of removing the bone.
Results: A total of 108 patients aged 1.5–87 years (median 48 years), 52.8% female, met the study criteria. Most (87%) of the events occurred at home, and 50.9% occurred during the weekend (Friday- Saturday). The bones were from low-priced fish (e.g., carp, hake) in 62% of the cases, high-priced fish (e.g., salmon, red snapper) in 30.5%, and of unknown species in 10.2%. The proportion of cases in which the fish bone belonged to a high-priced fish eaten out of the home was significantly higher than the cases in which a low-priced fish was eaten at home (64.3% vs. 22.3%, P = 0.04). One hundred bones were removed during direct oral inspection and 8 bones were removed under general anesthesia by endoscopy.
Conclusions: Most fish bone impactions in the aerodigestive tract in central Israel involve low-priced fish and take place at home over the weekend.
E. Bar-Yishay, A. Avital, C. Springer and I. Amirav
Background: In infants, small volume nebulizers with a face mask are commonly used to facilitate aerosol therapy. However, infants may be disturbed by mask application, causing poor mask-to-face seal and thus reducing the dose delivered.
Objectives: To compare lung function response to bronchodilator nebulization via two delivery devices: hood versus mask.
Methods: We studied 26 recurrently wheezy infants aged 45.8 weeks (95% confidence interval 39.6–52.0). Inhalations of 0.30 mg/kg salbutamol were administered in two alliqots 30 minutes apart using mask and hood in alternating order (M+H or H+M). Response to inhalations was measured by maximal expiratory flows at functional residual capacity at 5 minute intervals after each dose, and area under the VmaxFRC curve was documented.
Results: A small but significant response to salbutamol was observed following the second inhalation with VmaxFRC, improving by 31.7% (7.2–56.2, P < 0.02) and AUC by 425 %•min (-154, 1004; P < 0.02). The improvement following salbutamol was similar by both delivery modalities but with a small but significantly better response when H was used after M (P < 0.01).
Conclusions: Nebulized salbutamol induced a variable but positive response in wheezy infants. Salbutamol via hood was as effective as conventional face mask delivery. Since it is simple and patient-friendly, it could replace the face mask method particularly with uncooperative infants.
S. Badarny, H. Rawashdeh, J. Meer, S. Abed and G. Habib
Background: Local corticosteroid injection for the treatment of carpal tunnel syndrome, using the classic method, is usually associated with improvement in different electrophysiologic parameters of the median nerve. However, there was no correlation between the clinical response and these electrophysiological parameters.
Objectives: To evaluate the effect of our novel approach of LCI[1] for the treatment of CTS[2] on repeated electrophysiologic studies of the median nerve.
Methods: Patients with symptomatic CTS with duration of symptoms of less than 1 year were offered a LCI of 12 mg methylprednisolone acetate using a novel approach and asked to repeat the EP study one month later. Pearson correlation test was used to correlate between the difference of similar electrophysiological parameters and duration of favorable clinical response and also between the differences among themselves.
Results: Thirteen patients completed the study and 25 hands were injected. Improvement in median distal sensory and motor latency was noted in 61% and 75% of the hands respectively. There was no correlation between duration of clinical response and the differences of either the distal latency (sensory or motor) or the amplitude. There was also no correlation between the differences of motor median distal latency and sensory median distal latency.
Conclusions: LCI at the carpal tunnel using our approach is also associated with favorable electrophysiologic results similar to what had been reported using the classic approach.
Y. Landau, I. Berger, R. Marom, D. Mandel, L. Ben Sira, A. Fattal-Valevski, T. Peylan, L. Levi, S. Dolberg and H. Bassan
Background: Major advances in the treatment of perinatal asphyxial–hypoxic ischemic encephalopathy followed the translation of hypothermia animal studies into successful randomized controlled clinical trials that substantially influenced the current standard of care.
Objectives: To present our preliminary experience with the first cases of clinical application of therapeutic hypothermia for PA-HIE in what we believe is the first report on non-experimental hypothermia for PA-HIE from Israel.
Methods: We reviewed the medical records, imaging scans, electroencephalograms and outcome data of the six identified asphyxiated newborns who were managed with hypothermia in our services in 2008–2009.
Results: All asphyxiated newborns required resuscitation and were encephalopathic. Systemic hypothermia (33.5ºC) was begun at a median age of 4.2 hours of life (range 2.5–6 hours) and continued for 3 days. All six infants showed a significantly depressed amplitude integrated electroencephalography background, and five had electrographic seizures. One infant died (16%) after 3.5 days. Major complications included fat necrosis and hypercalcemia (n=1), pneumothorax (n=1), and meconium aspiration syndrome (n=2). None of the infants developed major bleeding. Neurodevelopmental follow-up of the five surviving infants at median age 7.2 months (4.1–18.5 months) revealed developmental delays (Battelle screening), with their motor scores ranging from -1 to +1 standard deviation (Bayley scale). None developed feeding problems, oculomotor abnormalities, spasticity or seizures.
Conclusions: Our preliminary experience with this novel modality in a large Tel Aviv neonatal service is consistent with the clinical findings of published trials.
Z. Shapira, R. Lavy, A. Altshuler, A. Peer, L. Copel and A. Halevy