Jihad Bishara, MD, Avivit Golan-Cohen, MD, Eyal Robenshtok, MD, Leonard Leibovici, MD and Silvio Pitlik, MD
Background: Erysipelas is a skin infection generally caused by group A streptococci. Although penicillin is the drug of choice, some physicians tend to treat erysipelas with antibiotics other than penicillin.
Objectives: To define the pattern of antibiotic use, factors affecting antibiotic selection, and outcome of patients treated with penicillin versus those treated with other antimicrobial agents.
Methods: A retrospective review of charts of adult patients with discharge diagnosis of erysipelas was conducted for the years 1993-1996.
Results: The study group comprised 365 patients (median age 67 years). In 76% of the cases infection involved the leg/s. Predisposing condition/s were present in 82% of cases. Microorganisms were isolated from blood cultures in only 6 of 176 cases (3%), and Streptococcus spp. was recovered in four of these six patients. Cultures from skin specimens were positive in 3 of 23 cases. Penicillin alone was given to 164 patients (45%). Other antibiotics were more commonly used in the second half of the study period (P < 0.0001) in patients with underlying conditions (P = 0.06) and in those hospitalized in the dermatology ward (P< 0.0001). Hospitalization was significantly shorter in the penicillin group (P= 0.004). There were no in-hospital deaths.
Conclusions: We found no advantage in using antibiotics other than penicillin for treating erysipelas. The low yield of skin and blood cultures and their marginal impact on management, as well as the excellent outcome suggest that this infection can probably be treated empirically on an outpatient basis.
Tuvia Ben-Gal, MD and Nili Zafrir, MD
Background: The evaluation of hospitalized patients with chest pain and non-diagnostic electrocardiogram is problematic and the optimal cost-effective strategy for their management controversial.
Objectives: To determine the utility of myocardial perfusion imaging with thallium-201 for predicting outcome of hospitalized patients with chest pain and a normal or non-diagnostic ECG.
Methods: On pain cessation, 109 hospitalized patients, age 61+14 years (mean+SD), with chest pain and non-diagnostic ECG underwent stress myocardial perfusion SPECT imaging with thallium-201. Costs related to their management were calculated. The occurrence of non-fatal myocardial infarction or cardiac death was recorded at 12+5 months follow-up.
Results: A normal SPECT was found in 84 patients (77%). During one year follow-up, only 1 (1.2%) compared to 7 (28%) cardiac events (6 myocardial infarctions, 1 cardiac death) occurred in patients with normal versus abnormal scans respectively (P < 0.0001). Negative predictive value and accuracy of the method were 99% and 83% respectively. Multivariate regression analysis identified an abnormal SPECT as the only independent predictor of adverse cardiac event (P = 0.0016). Total cost from admission until discharge was 11,193 vs. 31,079 shekels (P < 0.0001) for normal and abnormal scan. Considering its high negative predictive value, shortening the hospital stay from admission until scan performance to 2 days would result in considerably reduced management costs (from NIS 11,193 to 7,243) per patient.
Conclusion: Stress SPECT applied to hospitalized patients with chest pain and a normal or non-diagnostic ECG is safe, highly accurate and potentially cost effective in distinguishing between Iow and high risk patients.
Efraim Aizen, MD, Rachel Swartzman, MD and A. Mark Clarfield, MD, FRCPC
Background: Transfer to an emergency room and hospitalization of nursing home residents is a growing problem that is poorly defined and reported.
Objectives: To assess the clinical effectiveness of a pilot project involving hospitalization of nursing home residents directly to an acute-care geriatric department.
Methods: We retrospectively compared the hospitalization in an acute-care geriatric unit of 126 nursing home residents admitted directly to the unit and 80 residents admitted through the emergency room. The variables measured included length of stay, discharge disposition, mortality, cause of hospitalization, chronic medical condition, cognitive state, functional status at admission, and change of functional status during the hospital stay. Follow-up data were obtained from medical records during the 2 year study.
Results: No significant differences between the groups were found for length of stay, mortality, discharge disposition and most characteristics of the hospital stay. The only significant difference was in patients’ mean age, as emergency room patients were significantly older (86 vs. 82.9 years). The most common condition among nursing home patients admitted via the emergency room was febrile disease (36.9%) ,while functional decline was the most common in those coming directly from the nursing home (32.5%). The prevalence of functional dependence and dementia were similar in both groups. Functional status did not change throughout the hospital stay in most patients.
Conclusions: Treatment of selected nursing home residents admitted directly from the nursing home to an acute- care geriatric unit is feasible, medically effective, results in the safe discharge of almost all such patients and provides an alternative to transfer to an emergency room. This study suggests that quality gains and cost-effective measures may be achieved by such a project, although a randomized controlled trial is necessary to support this hypothesis.
Sigal Ringel, MD, Ernesto Kahan, MD, MPH, Revital Greenberg, Shlomo Arieli, MD, Amihood Blay and Matitiahu Berkovitch, MD
Background: Many women stop smoking before or during pregnancy, or while breast-feeding (nursing).
Objectives: To assess the relation between breast-feeding and smoking habits.
Methods: A survey was conducted among 920 women attending family health clinics (group 1) and a maternity department (group 2) on their breast-feeding and smoking habits.
Results: A total of 156 women (16.95%) smoked during pregnancy. A significant correlation was found between breast-feeding and not smoking after delivery (P=0.009 in group 1, P=0.03 in group 2). A higher tendency to nurse was found among women with an uneventful pregnancy, who vaginally delivered a singleton at term weighing 2,500-4000 g, and who received guidance on breast-feeding.
Conclusion: Professional guidance in favor of breastfeeding is crucial to increase the rate of nursing. Encouraging breast-feeding will probably decrease the rate of cigarette smoking.
Hagit Cohen, PhD, Lily Neumann, PhD, Moshe Kotler, MD and Dan Buskila, MD
Fibromyalgia syndrome is a chronic, painful musculoskeletal disorder of unknown etiology and/or pathophysiology. During the last decade many studies have suggested autonomic nervous system involvement in this syndrome, although contradictory results have been reported. This review focuses on studies of the autonomic nervous system in fibromyalgia syndrome and related disorders, such as chronic fatigue syndrome and irritable bowel syndrome on the one hand and anxiety disorder on the other, and highlights techniques of dynamic assessment of heart rate variability, It raises the potentially important prognostic implications of protracted autonomic dysfunction in patient populations with fibromyalgia and related disorders, especially for cardiovascular morbidity and mortality.
Michalis Voulgarelis, MD and Haralampos M. Moutsopoulos, MD, FACP, FRCP (Edin)
Sjogren’s syndrome is a chronic inflammatory process involving primarily the exocrine glands. Its association with lymphoma is well documented. A low grade marginal-zone lymphoma related to mucosa-associated lymphoid tissue is the commonest lymphoid neoplasia in Sjogren’s syndrome. We review the literature and comment on the molecular, clinical, histopathologic and therapeutic aspects of these tumors in Sjogrens syndrome.
Rivka Zissin, MD and Myra Shapiro-Feinberg, MD