Israel Medical Association Journal

Background: The most common and most serious complication of varicella (chickenpox) in adults is pneumonia, which can lead to severe respiratory failure. Varicella pneumonia is associated with considerable morbidity and even death.

Objectives: To summarize our experience with varicella pneumonia in terms of clinical, laboratory and radiological characteristics as well as risk factors, management and outcome.

Methods: We conducted a retrospective cohort survey in our facility from 1995 to 2008.

Results: Our cohort comprised 21 patients with varicella pneumonia, of whom 19 (90%) were men; their mean age was 35 ± 10.5 years. Nineteen patients (90%) were Bedouins and 18 (86%) were smokers. Eleven (52%) were admitted to the Medical Intensive Care Unit; 3 of them required mechanical ventilation and the remaining 10 (48%) were admitted to the general medical ward. Median length of stay was 6 ± 7.7 days. Hypoxemia and elevated lactate dehydrogenase on admission were associated with respiratory failure. Radiological manifestations were variable and nine patients exhibited characteristic findings. All but one patient were treated with acyclovir. All patients fully recovered.

Conclusions: In southern Israel varicella pneumonia is primarily a disease of young male Bedouins who are smokers. Severity ranges from mild disease to severe, resulting at times in respiratory failure requiring mechanical ventilation. Prognosis is favorable with complete recovery.

Background: Peritoneal carcinomatosis is an advanced form of cancer with poor prognosis that in the past was treated mainly palliatively. Today, the definitive approach to peritoneal surface malignancy involves peritonectomy, visceral resection and perioperative intra-abdominal hyperthermic chemotherapy. The anticipated results range from at least palliative to as far as intent to cure. Proper patient selection is mandatory.

Objectives: To determine whether cytoreductive surgery and intraperitoneal hyperthermic chemotherapy can extend survival, and with minor complications only, in patients with peritoneal carcinomatosis.

Methods: Twenty-two IPHP[1] procedures were performed in 17 patients with peritoneal carcinomatosis in our institution between 1998 and 2007: 6 had pseudomyxoma peritonei, 5 had colorectal carcinoma, 3 had ovarian cancer and 3 had mesotheliomas. All patients underwent cytoreductive surgery, leaving only residual metastasis < 1 cm in size. Intraperitoneal chemotherapy was administered through four large catheters (2F) using a closed system of two pumps, a heat exchanger and two filters. After the patient’s abdominal temperature reached 41°C, 30–60 mg mitomycin C was circulated intraperitoneally for 1 hour.

Results: The patients had a variety of anastomoses. None demonstrated anastomotic leak and none experienced major complications. Six patients had minor complications (pleural effusion, leukopenia, fever, prolonged paralytic ileus, sepsis), two of which may be attributed to chemotherapy toxicity (leukopenia). There was no perioperative mortality. Some patients have survived more than 5 years.

Conclusions: IPHP is a safe treatment modality for patients with peritoneal carcinomatosis. It has an acceptable complications rate and ensures a marked improvement in survival and in the quality of life in selected patients.

Background: Unconscious adults with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32–34ºC (ILCOR recommendations, 2003) when the initial rhythm is ventricular fibrillation.

Objectives: To assess the technique, safety and efficacy of mild induced hypothermia in patients after OHCA[1] due to VF[2].

Methods: Patients were cooled using the MTRE CritiCoolÔ external cooling system. Cold intravenous fluids were added to achieve faster cooling in 17 patients. Data were collected prospectively and patients were analyzed according to their neurological outcome on discharge, defined by their cerebral performance category.

Results: From February 2002 to September 2006, 51 comatose VF patients with OHCA underwent MIH[3]. Treatment was discontinued early in five because of hemodynamic instability; goal temperature was reached in 98% and maintained for an average of 19.5 hours; 61% had a favorable outcome (CPC[4] 1–2) and 37% died. Improved outcome was observed with longer hypothermia time and possibly when time from collapse to return of spontaneous circulation was < 25 minutes.

Conclusions: MIH, using an external cooling system, is simple and feasible, reduces mortality and protects neurological function. Four major factors seem to influence outcome: age, co-morbidities, duration of hypothermia, and possibly the length of time from collapse to ROSC[5].

Background: Corneal erosions, a common and very painful ailment, are traditionally treated with pressure patches and antibiotic ointment but the healing is slow.

Objectives: To report our experience with the use of therapeutic contact lenses for the primary treatment of traumatic corneal erosions.

Methods: During the last 5 years in a single community clinic 65 consecutive patients with traumatic corneal erosions were treated with a corneal contact lens and antibiotic drops as a routine measure. The charts were reviewed for outcome, side effects and complications.

Results: Healing of the corneal erosions occurred within 1 to 3 days in all patients, with minimal or no pain. No corneal infection occurred. One patient had a recurrence that was successfully treated by lens placement.

Conclusions: The therapeutic contact lens with antibiotic drops is a safe and effective method to treat traumatic corneal erosions, and patients can immediately resume their regular activities.

Background: Due to multiple chronic illness and disability, the elderly consume a disproportionately large share of medications.

Objectives: To assess the patterns and determinants of drug use among the community dwelling old-old population.

Methods: The study population included 1,369 old-old persons from the baseline data of the Cross-Sectional and Longitudinal Aging Study (CALAS), which is based on a national random stratified sample of the Israeli Jewish population aged 75–94 years.

Results: The mean number of drugs used by the study population was 3.3, and only 12.5% did not consume any drugs. Multivariate linear regression analysis showed that women used significantly more drugs than men, and that those born in Europe took significantly more drugs than those born in Israel and Asia-Africa. The number of medical conditions was the strongest predictor of drug use. Hospitalizations during the last year and frequent visits to family physician were also significant factors related to drug use. All variables combined explained 40% of the variance in drug use by the old-old. The most commonly used therapeutic groups were cardiovascular drugs (53%), psychotropic drugs (31%), analgesics (30%), and gastrointestinal drugs (28%).

Conclusions: Our data indicate that in addition to the association of drug use with health status and healthcare utilization, the number and type of drugs taken vary with gender and place of birth.

Background: Current clinical guidelines restrict catheterization laboratory activity without on-site surgical backup. Recent improvements in technical equipment and pharmacologic adjunctive therapy increase the safety margins of diagnostic and therapeutic cardiac catheterization.

Objective: To analyze the reasons for urgent cardiac surgery and mortality in the different phases of our laboratory’s activity in the last 11 years, and examine the impact of the new interventional and therapeutic modalities on the current need for on-site cardiac surgical backup.

Methods: We retrospectively reviewed the mortality and need for urgent cardiac surgery (up to 12 hours post-catheterization) through five phases of our laboratory’s activity: a) diagnostic (years 1989–2000), b) valvuloplasties and other non-coronary interventions (1990–2000), c) percutaneous-only balloon angioplasty (1992–1994), d) coronary stenting (1994–2000), and e) use of IIb/IIIa antagonists and thienopiridine drugs (1996–2000).

Results: Forty-eight patients (0.45%) required urgent cardiac surgery during phase 1, of whom 40 (83%) had acute coronary syndromes with left main coronary artery stenosis or the equivalent, and 8 (17%) had mechanical complications of acute myocardial infarction. Two patients died (0.02%) during diagnostic procedures. In phase 2, eight patients (2.9%) were referred for urgent cardiac surgery due to either cardiac tamponade or severe mitral regurgitation, and two patients (0.7%) died. The combined need for urgent surgery and mortality was significantly lower in phase 4 plus 5 as compared to phase 3 (3% vs. 0.85%, P = 0.006).

Conclusion: In the current era using coronary stents and potent antithrombotic drugs, after gaining experience and crossing the learning curve limits, complex cardiac therapeutic interventions can safely be performed without on-site surgical backup.
 

Background: Acarbose has become an important adjuvant therapy for diabetic patients. Many of these patients are also treated with digoxin for congestive heart failure or chronic atrial fibrillation

Objective: To evaluate a possible drug interaction between acarbose and digoxin.

Methods: An open-label, analyst-blind, randomized, crossover, two-period study was conducted in 11 healthy subjects. In period I, each subject received one single oral dose of 0.75 mg digoxin. In period ll, they were given acarbose tablets., 60 mg-3 times a day for 12 days. On day 8, one hour after acarbose administration, a single oral dose of 0.75 mg digoxin was administered. The study periods were separated by a 3 week washout interval: Serum. digoxin levels., over. time, in the two periods were compared by standard techniques;

Results: There were no differences in the pharmacokinetic parameters of digoxin in the two periods, apart from a significant increase in the mean maximum serum concentration (Cmax) when digoxin was given with acarbose (5.97 compared to 4.67 g/L, P = 0.02). Simulated steady-state peak levels of digoxin (Cmax,ss) achieved with a daily dose of 0.25 mg digoxin, in the presence.and absence of acarbose, were 2.89 and 2.40 g/L respectively (P =0.05); Simulated steady-state trough (Cmin,ss) and average (Cave,ss) concentrations were similar and within the therapeutic window.

Conclusion: There was no significant pharmacokinetic interaction between digoxin and acarbose at current therapeutic doses in the healthy volunteers. This interaction should be further studied with higher doses of acarbose and at steady-state conditions.