Nurith Hiller, MD, Daniel Berelowitz, MD and Irith Hadas-Halpern, MD
Background: Primary epiploic appendagitis is a relatively rare condition in which torsion and inflammation of an epiploic appendix result in localized abdominal pain. This is a non-surgical situation that clinically mimics other conditions requiring surgery such as acute diverticulitis or appendicitis.
Objective: To investigate the clinical, laboratory and radiological findings of the disease.
Methods: During the years 1995-88 five patients with primary epiploic appendigitis were diagnosed at our institution. The clinical, laboratory and imaging results were summarized and compared to previously reported series. Emphasis was placed on the computed tomography findings, which are the gold standard for diagnosis.
Results: All our patients (two males and three females, mean age 47 years) presented with left lower quadrant abdominal pain. CT proved to be the imaging modality of choice in all patients by showing a pericolic fatty mass with an increased attenuation as compared to normal abdominal fat. In all cases the mass was surrounded by a high attenuation rim, and focal stranding of the fat was observed. In no case was there thickening of the adjacent bowel wall. This serves as an important, and previously unreported, clue for diagnosis.
Conclusion: Primary epiploic appendagitis is a relatively rare condition that may be clinically misdiagnosed, resulting in unnecessary surgical intervention. Judicious interpretation of CT may lead to early diagnosis and ensure proper conservative treatment.
Sonia Habib, MD, MPH, Shmuel Rishpon, MD, MPH and Lisa Rubin, MD, MPH
Objective: To determine the vaccination rates among healthcare workers in the Haifa subdistrict and to assess factors associated with vaccination uptake among them.
Methods: The study was conducted in the three general hospitals in Haifa City, and in five nursing homes in the Haifa subdistrict. Self-administered questionnaires were distributed to 1,014 employees of whom 71% were females, 34% were nurses, 27% were physicians and 28% were non-professional workers.
Results: The crude response rate was 66%. Response rates were higher in females (71%) than in males (49%), in nurses (70%) than in physicians (43%), and in staff of internal and pediatric departments than in workers of surgery departments and emergency rooms. The overall vaccination rate among the respondents was 11%, which was higher among males (15%) than among females (10%). No significant relationship between vaccination rate and age, occupation and department was found. The vaccination rate among employees with chronic illness was very low (7%). Influenza vaccine was actively recommended to 29% of the employees. The main reasons for non-compliance were low awareness of the severity of the disease and of the vaccine's efficacy and safety, and unavailability of the vaccine within the workplace.
Conclusions: Educational efforts and offering the vaccine at the workplace at no cost are the most important measures for raising influenza vaccination rates.
Zvi H. Abramson, MD, MPH and Vered Cohen-Naor, MD
Background: Influenza is a major cause of morbidity and mortality in the elderly. While immunization has been shown to reduce these complications, many of the elderly are not immunized.
Objective: To identify correlates for under-utilization of influenza immunization among the elderly.
Methods: A telephone survey was conducted among a random sample of patients aged 65 and over registered at a Jerusalem primary care community clinic. The 626 questionnaires were analyzed for associations of immunization receipt for the latest influenza season. Multivariate logistic regression was performed to identify independent correlates. Respondents were also asked what factors had influenced their decision about immunization.
Results: The most frequently reported influence on getting immunized was a physician's recommendation. Immunization was independently associated with the identity of the primary care physician (P0.0001) and with having visited the physician during the previous 3 months (P=0.0006). Immunization was more likely among persons who believed that it provides complete protection from influenza (P0.0001) and less likely among those who believed immunization can cause influenza (P0.0001). Higher immunization rates were also associated with being married (P=0.0031).
Conclusion: Through their influence on patient knowledge and the effect of their recommendation, primary care physicians play a pivotal role in determining immunization rates. Physicians should routinely discuss the effects of immunization and recommend it to the elderly.
Aliza Noy, MD, Ruth Orni-Wasserlauf, MD, Patrick Sorkine, MD and Yardena Siegman-Igra, MD, MPH.
Background: An increase in multiple drug-resistant Klebsiella pneumoniae due to extended spectrum -lactamase production has recently been reported from many centers around the world. There is no information in the literature regarding this problem in Israel. A high prevalence of ceftazidime-resistant K. pneumoniae was noted in our Intensive Care Unit in the first few months of 1995.
Objective: To describe the epidemiology of ceftazidime-resistant K. pneumoniae in our medical center, as representing the situation in tertiary care hospitals in Israel.
Methods: We vigorously restricted the use of ceftazidime in the ICU and enforced barrier precautions. The susceptibility rate of K. pneumoniae was surveyed in the ICU and throughout the hospital before and after the intervention in the ICU.
Results: Following the intervention, the susceptibility rate of K. pneumoniae increased from 11% (3/28) to 47% (14/30) (P0.01) among ICU isolates, from 55% (154/280) to 62% (175/281) (P=0.08) among total hospital isolates, and from 61% (50/82) to 74% (84/113) (P0.05) among total hospital blood isolates, although no additional control measures were employed outside the ICU.
Conclusions: The epidemiology of ceftazidime-resistant K. pneumoniae in our medical center is similar to that reported from other centers around the world. Early awareness to the emergence of this resistance, identification of the source of the epidemic, and prompt action at the putative source site may reduce the rate of acquisition and spread of such resistance inside and outside of the source unit.
Manfred S. Green, MD, PhD
Donald S. Berns, PhD and Bracha Rager, PhD
As the twenty-first century begins it becomes increasingly apparent that the twentieth century, which opened with the promise of the eradication of most infectious diseases, closed with the specter of the reemergence of many deadly infectious diseases that have a rapidly increasing incidence and geographic range. Equally if not more alarming is the appearance of new infectious diseases that have become major sources of morbidity and mortality. Among recent examples are HIV/AIDS, hantavirus pulmonary syndrome, Lyme disease, hemolytic uremic syndrome (caused by a strain of Escherichia coli), Rift Valley fever, Dengue hemorrhagic fever, malaria, cryptosporidiosis, and schistosomiasis. The reasons for this situation are easily identified in some cases as associated with treatment modalities (permissive use of antibiotics), the industrial use of antibiotics, demographic changes, societal behavior patterns, changes in ecology, global warming, the inability to deliver minimal health care and the neglect of well-established public health priorities. In addition is the emergence of diseases of another type. We have begun to characterize the potential microbial etiology of what has historically been referred to as chronic diseases.
Maya Koren Michowitz, MD, Yoav Michowitz, MD, Ronit Zaidenstien, MD and Ahuva Golik, MD
Eli Magen, MD and Reuven J. Viskoper, MD
Renin-angiotensin-aldosterone systems play a critical role in the development and progression of cardiovascular diseases, and inhibitors of angiotensin-converting enzyme have proven effective for the treatment of these diseases. Since angiotensin II receptor antagonists can inhibit the effects of angiotensin II via ACE-independent pathways, e.g., chymase, they were considered to be more effective than ACEIs. On the other hand, ACE inhibitors can increase bradykinin, and thus, nitric oxide, which may cause potent cardioprotection, inhibition of smooth muscle proliferation and attenuation of inflammation mechanisms. It appears that angiotensin II receptor antagonists and ACEIs may mediate cardioprotection in different ways. This is the rationale to explore the possibility of a combined administration of both drugs for the treatment of chronic heart failure and other cardiovascular pathology. In this review we try to analyze the role of ACE, kinins and chymase inhibition in the pathophysiology and treatment of cardiovascular diseases.
Daniel E. Furst, MD and Alan Tyndall, MD
Rita Rachmani, MD, Zohar Levi, MD, Rika Zissin, MD, Merav Lidar, MD and Mordechai Ravid, MD, FACP
Jayson Rapoport, MB, BS, MRCP
Atzmon Tsur, MD and Gershon Volpin, MD