Israel Medical Association Journal

Background: Non-infectious uveitis (NIU) leads to severe visual impairment, potentially impacting on health-related quality of life (QoL). 

Objectives: To investigate the impact of NIU on QoL.

Methods: Eighty NIU patients and 23 healthy controls completed the 36-item Short-Form Health Survey (SF)-36. The SF-36 values were statistically analyzed to evaluate differences between patients and healthy controls and to identify correlations between SF-36 subscores and clinical/demographic data. 

Results: NIU patients showed a decrease in the physical component summary score (P < 0.0001) compared to healthy controls, while no difference was highlighted in the mental component summary score (P = 0.97). NIU patients showed a decrease in physical functioning (P = 0.008), role-physical (P = 0.003), bodily pain (P = 0.0001), general health (P < 0.0001), and social functioning (P = 0.01). Physical functioning was lower in patients with acute anterior uveitis (AAU) than in those with panuveitis (P = 0.003). No differences were found between patients with bilateral or unilateral NIU, isolated NIU, or NIU associated with systemic diseases and with or without ocular activity. No correlations were identified between best-corrected visual acuity and SF-36 subscores. Physical functioning (P = 0.02), bodily pain (P = 0.004), and social functioning (P = 0.02) were reduced in males versus females. 

Conclusions: QoL is impaired in individuals with NIU, particularly in the physical domains, general health, and social functioning. AAU affects physical functioning more than panuveitis. NIU seems to affect per se QoL disregarding inflammatory activity, visual impairment, and presence of associated systemic diseases.

 

Background: Pulmonary arterial hypertension (PAH) is a significant consequence of congenital heart disease (CHD). Its presence and severity is associated with increased morbidity and mortality. 

Objectives: To evaluate the clinical and demographic characteristics of adults with congenital heart diseases (ADCHD) and PAH at a single center. 

Methods: A prospective registry of all patients with PAH was conducted between 2009 and 2015. 

Results: Thirty-two patients were identified. The mean age at the last visit was 44 years (range 19–77 years). The prevalence of PAH among all ADCHD patients was 6% (95% confidence interval 4.3%–8.4%). A much higher prevalence (53%) was found in patients with Down syndrome. Most patients with PAH had moderate or severe disease. Fifteen patients (47%) were treated with pulmonary vasodilators and 6 (19%) with combination therapy. The average World Health Organization functional class was 2.6. Morbidity included cerebral vascular accident or transient ischemic attack in 22% (mostly in patients with right-to-left shunt) and arrhythmia in 37% of the patients. During a median follow-up of 3.5 years, 5 patients (15.6%) died. Of 13 women with no mental retardation, 11 were or had been married and all had children (between 1 and 13, mean 3.3). 

Conclusions: Patients with congenital heart disease and PAH have significant morbidity and mortality. PAH is more prevalent in patients with Down syndrome. While pulmonary pressure during the reproductive years was not always known, 27% of women with PAH at the time of the study were multiparous.

 

Background: The evidence on the use of dexamethasone implants in the treatment of Behçet’s disease (BD)-related uveitis is limited to a few cases. 

Objectives: To evaluate the efficacy of dexamethasone implants on ocular functional, morphological, and clinical parameters in BD patients with severe refractory uveitis. 

Methods: Five eyes from five BD patients were enrolled. A single intravitreal dexamethasone injection was applied to each eye. Best corrected visual acuity (BCVA), central macular thickness (CMT) assessed with optical coherence tomography, retinal vasculitis assessed by fluorescein angiography, vitreous haze score (Nussenblatt scale), intraocular pressure (IOP), and lens status (LOCS III, Lens Opacities Classification System III) were recorded at baseline and at 1, 3, and 6 month follow-up visits.

Results: At baseline, all eyes showed marked macular edema and 4/5 had concomitant active retinal vasculitis. Mean BCVA was increased from baseline at each control visit with a mean improvement of 0.26 ± 0.18 lines at 6 months follow-up. Mean CMT decreased from baseline at each control visit with a mean improvement at 6 months follow-up of 198.80 ± 80.08 µm. At the end of the study, none of the eyes showed macular edema and the mean CMT was 276.80 ± 24.94 µm. Retinal vasculitis resolved in all eyes. One eye experienced an IOP spike during treatment that resolved spontaneously, and one eye developed a clinically significant lens opacity at 6 months follow-up. 

Conclusions: Treatment with a dexamethasone implant in BD-uveitis and inflammatory macular edema was safe and effective as an additional treatment combined with systemic immunomodulatory drugs.

 

Background: The debate continues regarding the best way to manage partial anterior cruciate ligament (ACL) tears.

Objectives: To prospectively compare the clinical outcomes of remnant-preserving augmentation (RPA) and double-bundle reconstruction (DBR) in patients with ACL tears.

Methods: In this prospective study, we included 13 cases of RPA and 30 cases of DBR with a follow-up period of 6 months, 12 months and 24 months. We clinically compared the preoperative and postoperative range of motion, Knee Society Score (KSS), Visual Analog Scale (VAS), Lysholm score, Tegner activity score, Short Form Health Survey (SF-36), thigh and calf circumference and anterior translation (Using the KT-1000 knee arthrometer). 

Results: There were no significant differences in Lysholm score, Tegner score, VAS or KSS within the two groups at any time. The KT-1000 arthrometer results were higher in the RPA group at 6 months than in the DBR group; however, it did not reach statistical significance. 

Conclusions: We found no significant differences between the two specific groups leading us to believe that RPA may play a role in reconstruction when only a single bundle is injured.

 

Background: Pulmonary infiltrates (PIs) detected in patients with non-Hodgkin lymphoma (NHL) may present a diagnostic challenge due to their wide differential diagnosis, including infection, pulmonary lymphoma and immunochemotherapy-associated pulmonary toxicity.

Objectives: To characterize therapy-associated PIs by positron emission tomography/computed tomography (PET/CT) imaging.

Methods: We conducted a historical analysis of fluorodeoxyglucose-PET/CT (¹⁸F-FDG-PET/CT) PIs in NHL patients treated with combined immunochemotherapy including rituximab. Incidence of PIs, radiological features, patients’ characteristics, underlying NHL type, rituximab/chemotherapy dosing schedules, and symptoms were recorded. Therapy-associated PIs were defined as new or worsening PIs appearing after treatment onset, without evidence of active pulmonary lymphoma or infection.

Results: Among 80 patients who met the pre-specified criteria, therapy-associated PIs were identified in 17 (21%), 6 of whom had accompanying symptoms. Increased FDG uptake was observed in nine, and PI resolution in six. The incidence of PIs was higher in females and in patients with aggressive lymphoma, at advanced stages, and in those who had received treatment consisting of a combination of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone every 14 days (R-CHOP-14).

Conclusions: This characterization of therapy-associated PIs may support the clinician managing NHL patients. Further prospective studies are needed to establish the role of each therapeutic component and the natural history of this phenomenon.

Background: Thyroid-associated ophthalmopathy (TAO) is an inflammatory disease that affects the thyroid gland and the eye orbit. Of patients with TAO, 3%–5% have severe sight-threatening disease due to optic neuropathy Optical coherence tomography (OCT), the non-invasive imaging technology that yields high-resolution cross-sectional images of the retina, provides qualitative and quantitative data on the retina.

Objectives: To apply this technique to quantitatively assess retinal nerve fiber layer (RNFL) and macular ring thicknesses in healthy subjects and in patients with TAO to determine their relationship to the severity of the orbital disease.

Methods: All patients in the ophthalmology clinic who were diagnosed with TAO and underwent OCT imaging as part of their ocular examination comprised the study group, and healthy patients who volunteered to undergo OCT examination served as controls. Results of the complete ophthalmologic examination and OCT findings were collected from medical files, including the thickness of the RNFL and the macula.

Results: The study comprised 21 patients and 41 healthy controls. TAO patients exhibited RNFL thickening and inner macula thinning compared to healthy subjects. Mean RNFL thickness was correlated with the severity of the orbital disease.

Conclusion: The OCT findings suggest that the retina is involved in TAO, probably as early as the subclinical stage. This highlights the ability of OCT to identify retinal changes earlier and far more accurately than is detected today, enabling earlier diagnosis and more timely treatment to prevent severe visual sequelae.

Background: It is a challenge to diagnosis Clostridium difficile colitis.

Objectives: To determine, among patients who developed nosocomial diarrhea, whether serum procalcitonin (PCT) can distinguish between C. difficile toxin (CDT)-positive and CDT-negative patients.

Methods: This prospective study included 50 adults (>18 years) who developed diarrhea during hospitalization, 25 with a positive fecal test for CDT (study group) and 25 CDT negative (control group).

Results: Baseline demographic and underlying illnesses were similar in both groups. Duration of diarrhea was 6 ± 4 days and 3 ± 1 in the study and control groups, respectively (P = 0.001). Mean blood count was 20 ± 15 and 9.9 ± 4, respectively (P = 0.04). CRP level was higher in the study than in the control group (10.9 ± 7.4 and 6.6 ± 4.8, P = 0.028). PCT level was higher in the study group (4.4 ± 4.9) than the control group (0.3 ± 0.5, P = 0.102). A PCT level > 2 ng/ml was found in 7/25 patients (28%) and 1/25 (4%), respectively [odds ratio 9.33, 95% confidence interval (0.98 to 220), P = 0.049]. Multivariate analysis showed that only duration of diarrhea and left shift of peripheral leucocytes were significant indicators of CDT (P = 0.014 and P = 0.019, respectively). The mortality rate was 12/25 (48%) vs. 5/25 (20%), respectively (P = 0.04).

Conclusions: We found a non-significant tendency to higher PCT levels in patients with CDT-positive vs. CDT-negative nosocomial diarrhea. However, a PCT level > 2 ng/ml may help distinguish between these patients.

Background: The optimal approach to the evaluation of asymptomatic bacteruria in stroke patients is uncertain. 

Objectives: To compare elderly patients after an acute stroke with and without asymptomatic bacteriuria for the development of symptomatic urinary tract infections (UTI).

Methods: We prospectively monitored patients over 65 years of age admitted to our rehabilitation hospital after an acute stroke, with and without asymptomatic bacteriuria, for the development of symptomatic UTIs. The prevalence of bacteriuria was determined by urine cultures obtained 2 and 4 weeks after admission. Patients with and without persistent bacteriuria were compared to identify variables associated with bacteriuria.

Results: Fifty-five patients were included in the study. The prevalence of asymptomatic bacteriuria at baseline was 20%. Of all 55 stroke patients, 13 (23.6%) developed a symptomatic UTI during the 30 day follow-up. Patients with stroke and asymptomatic bacteriuria at baseline had an increased risk of developing a symptomatic UTI (54.5% with asymptomatic bacteriuria vs. 15.9% without, P = 0.011). To exclude the effects of several confounders, we performed multivariate Cox regression analysis, which showed that bacteruria remained a significant covariate for symptomatic UTI (hazard ratio 2.86, 95% confidence interval 0.71–10.46, P = 0.051). When subjects who experienced symptomatic urinary infection were included, the prevalence of bacteriuria in the study cohort declined to about 45.5% by 30 days. 

Conclusion: Elderly patients with stroke and asymptomatic bacteriuria have an increased risk of developing a symptomatic UTI compared to those without asymptomatic bacteriuria during a 30 day post-stroke follow-up.