G. Izbicki, G. Fink, A. Algom, R. Hirsch, L. Blieden, E. Klainman, E. Picard, S. Goldberg and M. R. Kramer
Background: Since surgical repair of tetralogy of Fallot was introduced, follow-up studies have shown that the majority of patients lead actives lives and have no subjective exercise limitation.
Objectives: To examine lung function, cardiopulmonary functional capacity and echo-Doppler assessment of pulmonary pressure in adult patients 20 years after repair of TOF.
Methods: Unselected consecutive patients performed full lung function testing, progressive cardiopulmonary exercise, and echo-Doppler assessments of pulmonary pressure.
Results: Fifty consecutive patients (33 men, 17 women) aged 29 ± 11 years who underwent surgical repair of TOF at age 10.1 ± 10.9 years were enrolled in this study. Patients after TOF showed no restriction (forced expiratory vital capacity 80%, total lung capacity 91%) and had normal oxygen saturation (97%) and 6 minute walking distance (600 meters). Echocardiography showed normal pulmonary pressure and left ventricular ejection function (62%). Cardiopulmonary exercise testing showed mild limitation of exercise capacity with oxygen uptake at maximal effort of 75–78% predicted.
Conclusions: After corrections of TOF the study patients had normal lung function and pulmonary arterial pressure but mild limitation in their exercise capacity.
D. Starobin, L. Bolotinsky, J. Or, G. Fink and Z. Shtoeger
Background: Locally delivered steroids by inhalers or nebulizers have been shown in small trials to be effective in acute asthma attack, but evidence-based data are insufficient to establish their place as routine management of adult asthma attacks.
Objectives: To determine the efficacy of nebulized compared to systemic steroids in adult asthmatics admitted to the emergency department following an acute attack.
Methods: Adult asthmatics admitted to the ED were assigned in random consecutive case fashion to one of three protocol groups: group 1 – nebulized steroid fluticasone (Flixotide Nebules®), group 2 – intravenous methylprednisolone, group 3 – combined treatment by both routes. Objective and subjective parameters, such as peak expiratory flow, oxygen saturation, heart rate, and dyspnea score, were registered before and 2 hours after ED treatment was initiated. Steroids were continued for 1 week following the ED visit according to the protocol arm. Data on hospital admission/discharge rate, ED readmissions in the week after enrollment and other major events related to asthma were registered.
Results: Altogether, 73 adult asthmatics were assigned to receive treatment: 24 patients in group 1, 23 in group 2 and 26 in group 3. Mean age was 44.4 ± 16.8 years (range 17–75 years). Peak expiratory flow and dyspnea score significantly improved in group 1 patients compared with patients in the other groups after 2 hours of ED treatment (P = 0.021 and 0.009, respectively). The discharge rate after ED treatment was significantly higher in groups 1 and 3 than in group 2 (P = 0.05). All 73 patients were alive a week after enrollment. Five patients (20.8%) in the Flixotide treatment arm were hospitalized and required additional systemic steroids. Multivariate analysis of factors affecting hospitalization rate demonstrated that severity of asthma (odds ratio 8.11) and group 2 (OD 4.17) had a negative effect, whereas adherence to chronic anti-asthma therapy (OD 0.49) reduced the hospitalization rate.
Conclusions: Our study cohort showed the advantage of nebulized steroid fluticasone versus systemic corticosteroids in adult asthmatics managed in the ED following an acute attack. Both these and previous results suggest that nebulized steroids should be used, either alone or in combination with systemic steroids, to treat adults with an acute asthma attack.
M. Avital, I. Hadas-Halpern, M. Deeb and G. Izbicki
Background: Sarcoidosis is a multisystemic disorder of unknown cause that primarily affects the lungs. The diagnosis is made by the clinical manifestations, radiological findings and histological examination.
Objectives: To review and illustrate the typical and atypical radiological findings of sarcoidosis in the chest.
Methods: We analyzed the radiographic thoracic findings of all patients who had biopsy-proven sarcoidosis over the last 10 years.
Results: There were 100 consecutive patients (36 men and 64 women, age 20–84 years) with an established diagnosis of sarcoidosis. Thoracic lymphadenopathy was detected in 89 patients (89%). Lung parenchyma involvement was found in 60 patients. These changes were variable and included: ground glass attenuation (n=39), multiple small nodules (n= 44) and irregular thickening of the interlobular septa (n=16). Larger nodules (1–3 cm) were identified in 12 patients and frank consolidations were seen in 12 patients. Pleural thickening with subpleural nodules was identified in 17 patients.
Conclusions: Sarcoidosis has a wide variety of radiological manifestations in the chest. Familiarity with the various radiographic findings is important for diagnosis and management.
I. Ben-Dov, N. Kaminski, N. Reichert, J. Rosenman and T. Shulimzon
Diaphragmatic paralysis has a predictable effect on lung function. However, the symptoms depend on the preexisting heart-lung diseases and may mimic various cardiorespiratory processes. We describe the presentation in six patients. In a fit man, unilateral diaphragmatic paralysis caused dyspnea only at strenuous exercise. In a patient with emphysema it caused dyspnea mainly when carrying light weights. In another patient with emphysema it caused life-threatening hypoxemia simulating parenchymal lung disease. A patient with mild chronic obstructive lung disease and nocturnal wheezing following the onset of ULDP was believed for 15 years to have asthma. A patient with bilateral diaphragmatic weakness had severe choking sensation only in the supine position, simulating upper airway obstruction or heart failure. A female patient suffered nocturnal sweating due to ULDP. The clinical manifestations of diaphragmatic paralysis vary and can mimic a wide range of cardiorespiratory diseases.
H. Maayan, G. Izbicki, J. Heyd, R. Cyter, S. Silberman and M. Deeb
E. Picard, S. Goldberg, G. Izbicki and E. Kerem
I. Abu-Kishk and N. Rosenfeld-Yehoshua
D. Starobin, M. Katz, M. Huszar and Z. Shtoeger
M. Shuvy, J. E. Arbelle, A. Grosbard and A. Katz
Background: Heart rate variability is a sensitive marker of cardiac sympathetic activity.
Objectives: To determine whether long-term hyperthyroidism induced by thyroxine suppressive therapy affects HRV.
Methods: Nineteen patients treated with suppressive doses of thyroxin for thyroid cancer and 19 age-matched controls were enrolled. Thyroid function tests and 1 minute HRV were performed on all subjects and the results were compared between the groups. The 1 minute HRV was analyzed during deep breathing and defined as the difference in beats/minute between the shortest and the longest heart rate interval measured by eletrocardiographic recording during six cycles of deep breathing.
Results: One minute HRV during deep breathing was significantly lower among thyroxine-treated patients compared to healthy controls (25.6 ± 10.5 vs. 34.3 ± 12.6 beats/min, P < 0.05). There were no significant differences in mean, maximal and minimal heart rate between the groups
Conclusions: Thyroxine therapy administered for epithelial thyroid cancer resulted in subclinical hyperthyroidism and significantly decreased HRV due to autonomic dysfunction rather than basic elevated heart rate.
Y. Linhart, Z. Amitai, M. Lewis, S. Katser, A. Sheffer and T. Shohat
Background: Food-borne pharyngitis outbreaks causing substantial morbidity have been documented.
Objectives: To investigate an outbreak of food-borne Streptococcus beta hemolyticus group A pharyngitis among employees of a high-tech company.
Methods: We received a report on an unusually high rate of morbidity among employees of a company in September 2003. The Tel Aviv District Health Office conducted an epidemiological investigation of the outbreak.
Results: Among the 278 people who attended a company party, 83 people became ill. The overall attack rate was 29.8%. Information was available on 174 of 193 employees and family members who attended the party and worked in the Tel Aviv district. Forty-six of them became ill (attack rate 26.4%). The secondary attack rate was 3.8%. Most cases developed symptoms 24–48 hours following the event. Seven cases had throat cultures positive for Streptococcus beta hemolyticus group A. Three items were significantly associated with becoming sick: spring chicken (odds ratio 2.26, 95% confidence interval 1.11–4.63, P = 0.02), vegetable salad (OR 2.88 95%CI 1.40–5.94, P = 0.003) and corn (OR 7.73, 95%CI 3.18–18.80, P < 0.001). Eating corn remained significantly associated with pharyngitis after controlling for other food items consumed.
Conclusions: We describe the epidemiological investigation of a large food-borne outbreak of Streptococcus beta hemolyticus group A pharyngitis most probably transmitted by corn. No previous publication has implicated corn. Food handlers and the public should be aware that they can transmit diseases to others.. Physicians should be aware that streptococcal pharyngitis could be a food-borne disease and that outbreaks in a non-confined setting may be easily missed.