Alexander Blankstein, MD, Ilan Cohen, MD, Zehava Heiman, MD, Moshe Salai, MD, Lydia Diamant, RT, Michael Heim, MD and Aharon Chechick, MD
Background: Foreign bodies are sometimes overlooked in the initial evaluation of soft tissue wounds in the emergency room setting. The physical examination identifies foreign bodies that are superficial enough to be seen or palpated, while radiographs reveal those that are radio-opaque. If these two criteria are not met, however, the foreign body may remain undetected. These patients present later with long-standing pain in the area of penetration sometimes associated with localized tenderness.
Objectives: To assess the role of ultrasonography in the diagnosis and management of patients with a suspected retained foreign body.
Methods: Ultrasound was used in 21 patients with suspected retained foreign bodies and the diagnosis was positive in 19. Fifteen underwent a surgical exploration in which the ultrasound was used as an adjunctive modality either pre- or intraoperatively to assist in the localization of the foreign body.
Results: All procedures were successful. No postoperative complications were recorded at an average follow-up of 2 years. Three patients gradually became asymptomatic and were left untreated. One patient was lost to follow-up.
Conclusion: Sonography is an extremely effective tool for the late diagnosis of retained foreign bodies in the soft tissues. We suggest that its availability in the emergency room may decrease the rate of misdiagnosis and avoid these unfortunate cases, although this remains tc be proven.
Rivka Zissin, MD, Gabriela Gayer, MD, Michal Chowers, MD, Myra Shapiro-Feinberg, MD, Eugen Kots, MD and Marjorie Hertz, MD
Background: Abdominal tuberculosis usually presents with general symptoms and obscure abdominal complaints for which computerized tomography is often the first imaging study.
Objective: To evaluate the CT findings of abdominal tuberculosis.
Methods: The CT scans of 19 patients (10 men and 9 women aged 20-85 years) with proven abdominal tuberculosis were retrospectively reviewed to define the location and extent of the disease. The patients were referred for the study mainly with general systemic symptoms. Additional abdominal complaints were present in four, including acute abdomen in one. Two had symptoms deriving from the urinary tract. Nine patients had recently arrived from high prevalence countries five of them and two others were positive for human immunodeficiency virus. Three patients had a family history of tuberculosis one had previously been treated for tuberculosis and four others had an underlying chronic disease. The diagnosis of tuberculosis was established by standard microbiological and histological techniques.
Results: We divided the disease manifestations into intraperitoneal (n-13) and genitourinary involvement (n- 6). Peritoneal tuberculosis was fairly common, characterized by ascites, omental and mesenteric infiltration, and smooth thickening of the parietal peritoneum. One oncology patient had a false positive Tc-99m CEA isotope scanning, suggesting tumor recurrence. Genitourinary disease manifested mainly as hydronephrosis and calcifications. Three patients had pulmonary tuberculosis as well.
Conclusion: The CT findings of abdominal tuberculosis may mimic various diseases, mainly diffuse peritoneal malignancy. We emphasize the need to consider tuberculosis in the differential diagnosis in patients with obscure abdominal symptoms, especially with multi-organ involvement. A high degree of clinical suspicion and familiarity with the abdominal CT manifestations allow early diagnosis of this treatable disease.
Menashe N. Mukamel, MD, Yosef Weisman, MD, Raz Somech, MD, Zipora Eisenberg, MSc, Jacob Lanman, MD, Itzhak Shapira, MD, Zvi Spirer, MD and Uri Jurgenson, MD
Background: The modest clothing that Orthodox Jewish women wear exposes very little of their skin to sunlight. Under these conditions they may develop vitamin D deficiency, even in sunny Israel.
Objectives: To determine and compare the vitamin D nutritional status in Jewish orthodox mothers to that of non-orthodox mothers who live in the same metropolitan area in Israel.
Methods: 25-Hydroxyvitamin D was measured by competitive protein-binding radioassay in the sera of 341 Jewish Israeli mothers (156 orthodox and 185 non-orthodox). The sera were obtained 48-72 hours after childbirth during the late summer of 1998 and the spring of 1999.
Results: The mean (SD) serum concentration of 25-OHD was significantly (P<0.002) lower (13.5 ± 7.5 ng/ml) in the orthodox than in the non-orthodox mothers (18.6 + 9.6 ng/ml). Vitamin D deficiency (<5 ng/ml) and insufficiency (<10 ng/ml) were more common in the orthodox mothers (5.1% and 32.7% respectively) than in the non-orthodox mothers (2.7% and 13%, respectively). In subgroups of mothers supplemented with 400 units of vitamin D daily during pregnancy, vitamin D deficiency and insufficiency were less common (2.2% and 13%, respectively) in orthodox and non-orthodox mothers (0% and 8.1%, respectively). Vitamin D insufficiency was more common in the winter than in the summer only among nonorthodox mothers.
Conclusions: The high prevalence of vitamin D deficiency and insufficiency in Israeli mothers raises the question whether vitamin D supplements should be given to pregnant women in Israel, at least to orthodox mothers.
Haim Reuveni, MD, Shifra Shvarts, PhD, Joachim Meyer, PhD, Asher Elhayany, MD, MPA and Dan Greenberg, MSc
Background: On 1 January 1995 a new mandatory National Health Insurance Law was enacted in Israel, The new law fostered competition among the four major Israeli healthcare providers (HMO5 or sick funds) already operating in the market due to the possibility that an unlimited number of patients and the relative budget share would shift among the HMOs. This led them to launch advertising campaigns to attract new members.
Objectives: To examine newspaper advertising activities during the early stages of healthcare market reform in Israel.
Methods: Advertising efforts were reviewed during a study period of 24 months (July 1994 to June 1996). Advertisements were analyzed in terms of marketing strategy, costs and quality of information.
Results: During the study period 412 newspaper advertisements were collected. The total advertising costs by all HMOs was approximately US$4 million in 1996 prices. Differences were found in marketing strategy, relative advertising costs, contents and priorities among the HMOs.
Conclusions: The content of HMO5 newspaper advertising was consistent with their marketing strategy. The messages met the criteria of persuasive advertising in that they cultivated interest in the HMOs but did not provide meaningful information about them. Future developments in this area should include consensus guidelines for advertising activities of HMOs in Israel, instruction concerning the content of messages, and standardization of criteria to report on HMO performance.
Alessandra Della Rossa, MD, Antonio Tavoni, MD, Chiara Baldini, MD and Stefano Bombardieri, MD
Mixed cryoglobulinemia is a systemic vasculitis described as a triad characterized by purpura, weakness and arthralgias. Since the first description of the disease in 1964 by Meltzer and Franklin our understanding of its pathogenesis has increased considerably. The striking association of the disease with hepatitis C virus infection was initially noted in 1990. Since then, the disease has gained growing attention among investigators involved in the study of autoimmune systemic disorders because it represents one of the most intriguing models of autoimmunity triggered by a virus. Nonetheless, a number of answered questions still remain to be resolved and are reviewed in this article.
Hanna J. Garzozi, MD, Nur Shoham, MD, Hak Sung Chung, MD, PhD, Larry Kagemann, MS and Alon Harris, PhD
Carmi Bartal, MD, Maximo Maislos, MD, Doron Zilberman, MD and Emanuel Sikuler, MD
Jacob Gilad, MD, Abraham Borer, MD, Dafna Hallel-Halevy, MD, Klaris Riesenberg, MD, Michael Alkan, MD and Francisc Schlaeffer, MD