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.
Y. Esayag, V. Furer and G. Izbicki
Background: Spontaneous pneumomediastinum is a rare entity that usually occurs in young males without any apparent precipitating factor. Several case series have been published focusing on clinical features, workup and prognosis. Due to the rarity of this entity, there is no consensus on the most appropriate treatment.
Objectives: To describe the clinical characteristics and course of patients with spontaneous pneumomediastinum in our institution.
Methods: This is a retrospective descriptive study based on a review of the charts of all patients discharged from our hospital with a diagnosis of SPM during the period 2000 to 2007. Thirteen patients were identified and information on their clinical presentation, course, hospital stay, investigations and outcome was gathered.
Results: In 70% of patients the presenting complaint of SPM was pleuritic chest pain, while 30% of patients developed SPM in the course of another respiratory illness. Subcutaneous emphysema was the most common clinical finding (46%). Chest X-ray was diagnostic in 12 of 13 patients, and additional tests such as esophagogram and echocardiogram were unrevealing. Leukocytosis and electrocardiographic changes in inferior leads were seen in 30% of patients. Mean hospital stay was 48 hours, treatment was supportive, and symptomatic improvement was usually noted within 24 hours. No recurrences occurred.
Conclusions: SPM is a rare entity that should be considered in patients with pleuritic chest pain. Treatment is supportive, and if no clues for esophageal rupture are present investigations other than chest X-ray are probably not warranted. It is safe to discharge the patient within 24 hours provided that symptomatic improvement is achieved.
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
I. Grotto, S. Zarka, R. D. Balicer, M. Sherf, and J. Meyerovitch
Background: In view of the rising prevalence of obesity, the identification of young adult populations at risk is important for the formulation of intervention and prevention programs.
Objectives: To assess demographic and behavioral factors associated with an increase in body mass index in young healthy adults and to identify the incidence of overweight/obesity in this population.
Methods: Data on anthropometric measures, demographic characteristics, and health behaviors were collected retrospectively for a representative sample of young Israeli adults (11,391 men, 11,280 women) on their release from military service (age 20–22 years) between 1989 and 2003. The incidence of overweight (BMI < 25-< 30 kg/m2), incidence of obesity (BMI ≥ 30 kg/m2), and increase in BMI during military service were calculated.
Results: The average increase in BMI during military service was 1.11 kg/m2 in males and 1.08 kg/m2 in females. A greater increase was positively associated with low paternal education and smoking cessation, and negatively associated with high physical activity. Twelve percent of subjects with a normal BMI on recruitment became overweight, and 21.7% of overweight subjects became obese. On multivariate logistic regression analysis, a higher incidence of overweight was associated with low education level (in both the subject and his or her father) in both genders, and non-use of oral contraceptives and low level of physical activity in females.
Conclusions: BMI appears to increase significantly during early adulthood. Intervention programs should be targeted specifically at subjects with low education or who started smoking before age 18, and physical activity (especially among females) should be encouraged.
A. Shalom, H. Eran, M. Westreich and T. Friedman
Background: Negative-pressure therapy for the closure of wounds, a technique to accelerate secondary wound healing, is clinically available as the V.A.C.™ system (KCI Inc, San Antonio, TX, USA). Budgetary considerations in our institution precluded widespread use of the expensive V.A.C.™ system in routine cases.
Objectives: To develop a less expensive comparably effective dressing, based on the same principles.
Methods: We used our “homemade” system to treat 15 patients with appropriate complex wounds. Their hospital charts were reviewed and assessed retrospectively. Cost analysis was performed comparing our dressing with the V.A.C.™ system.
Results: Our homemade negative-pressure wound treatment system obtained results similar to what one could expect with the V.A.C.™ System in all parameters. Complications encountered were few and minor. Cost per day using our negative-pressure system for a 10 cm² wound is about US$1, as compared to US$22, utilizing the V.A.C.™ System.
Conclusions: Our homemade negative-pressure system proved to be a good cost-effective treatment for wound closure in hospitalized patients, yielding results comparable to those of the more expensive V.A.C.™ system.