L.V. Lage, J.F. de Carvalho, M.T.C. Caleiro, N.H. Yoshinari, L.M.H. da Mota, M.A Khamashta and W. Cossermelli
Background: Antibodies directed against endothelial cell surface antigens have been described in many disorders and have been associated with disease activity. Since the most prominent histopathologic feature in mixed connective tissue disease (MCTD) is the widespread and unique proliferative vascular lesion, our aim was to evaluate the frequency of anti-endothelial cell antibodies (AECA) in this condition.
Objectives: To evaluate the frequency of AECA in this disease and assess its clinical and laboratory associations.
Methods: Seventy-three sera from 35 patients with MCTD (Kasukawa’s criteria), collected during a 7 year period, were tested for immunoglobulins G and M (IgG and IgM) AECA by cellular ELISA, using HUVEC (human umbilical vein endothelial cells). Sera from 37 patients with systemic lupus erythematosus (SLE), 22 with systemic sclerosis (SSc) and 36 sera from normal healthy individuals were used as controls. A cellular ELISA using HeLa cells was also performed as a laboratory control method.
Results: IgG-AECA was detected in 77% of MCTD patients, 54% of SLE patients, 36% of SSc patients and 6% of normal controls. In MCTD, IgG-AECA was associated with vasculitic manifestations, disease activity and lymphopenia, and was also a predictor of constant disease activity. Immunosuppressive drugs were shown to reduce IgG-AECA titers. Since antibodies directed to HeLa cell surface were negative, AECA was apparently unrelated to common epitopes present on epithelial cell lines.
Conclusions: AECA are present in a large proportion of patients with MCTD and these antibodies decrease after immunosuppressive treatment.
R. Haimov-Kochman, C. Adler, E. Ein-Mor, D. Rosenak and A. Hurwitz
Background: ‘Religious (halachic[1]) infertility’ results from precoital ovulation prior to immersion in a ritual bath (mikveh) 7 days after menstruation, as mandated by Jewish religious law. Previous authors recommended treatment with estradiol to postpone ovulation and enhance pregnancy rates.
Objectives: To evaluate the prevalence of halachic infertility in an ultra-Orthodox Jewish community, and assess the efficacy of estradiol treatment in postponing ovulation and increasing pregnancy rates.
Methods: We reviewed 88 cycles, of which 23 were control cycles and 65 estradiol-treated cycles, and analyzed the files of 23 women who were treated with 6 mg estradiol/day from day 1 for 5 days of the cycle.
Results: The prevalence of precoital ovulation in the infertile population was 21%. Most of the patients (94%) ovulated before day 13 of the cycle. A short follicular phase due to low ovarian reserve or thyroid endocrinopathy was noted in 12% of the patients. While 64% of the women reported consultation with a Rabbinate authority, 68% of the patients sought medical therapy. Estradiol postponed ovulation for at least one day in 89% of the treatment cycles. Ovulation post-mikveh occurred in 73% of estradiol-treated cycles. The pregnancy rate was 12.5% per cycle and the cumulative pregnancy rate 35% per woman. Half the patients reported spotting during estradiol-treated cycles, and this postponed coitus.
Conclusions: Precoital ovulation is a major reason for infertility among observant couples attending fertility clinics. Estradiol treatment is effective in delaying ovulation and restoring fecundity however, it causes some adverse effects that may decrease its effectiveness.
[1] Referring to Halacha, the body of Jewish Law
A. Zabari, E. Lubart, F. DeKeyser Ganz and A. Leibovitz
Background: Pain following hip fracture and internal fixation is a major factor during the treatment of elderly patients on rehabilitation programs. A proactive pain management program was instituted in our geriatric rehabilitation ward in 2005.
Objectives: To compare retrospectively two groups of patients, one before and one after implementation of the proactive pain management program.
Methods: The study group comprised 67 patients and the control group 77 patients. Pain in the study group was evaluated daily by the visual analogue scale (VAS) and the outcome of the rehabilitation process by the Functional Independence Measure (FIM). During the study period (2003–2006) no changes were made in the rehabilitation team, methods or facilities other than introduction of the pain control program. We compared the FIM scores between admission and discharge in both groups.
Results: Improvement in FIM scores between admission and discharge was significantly higher in the study group than in the control group (11.07 ± 7.9 vs. 8.4 ± 7.3, P < 0.03). There was no significant difference between the average lengths of stay.
Conclusions: These data support the view that the proactive monitoring of pain in surgical hip fracture patients is associated with a better outcome of the rehabilitation process.
D. Bendayan, A. Hendler, K. Litman and V. Polansky
Background: Interferon-gamma release tests are appealing alternatives to the tuberculin skin test (TST) for latent tuberculosis infection.
Objectives: To determine the yield of the Quantiferon TB Gold test (QFT-G) in the diagnosis of active tuberculosis disease, with a focus on elderly patients, human immunodeficiency virus (HIV) co-infection, and extra-pulmonary tuberculosis (EPTB).
Methods: The QFT-G test was performed in 98 patients suspected of having active tuberculosis. The results were evaluated for each subgroup of patients and compared to the results of the TST.
Results: Active tuberculosis was diagnosed in 92 of the 98 patients. Sixteen (17.3%) were elderly patients (over age 70), 15 (16%) were co-infected with HIV, and 14 (15%) had EPTB. QFT-G was positive in 49 patients (53%) and indeterminate in 4. The results were not significantly affected by HIV co-infection (P = 0.17), old age (P = 0.4), or the presence of EPTB (P = 0.4). There was a good correlation between the TST and the QFT-G test (P < 0.001). In EPTB and in the elderly, the QFT-G test appears to be better than the TST.
Conclusions: The QFT-G test is suboptimal in its ability to detect active tuberculosis and should not be used to exclude it.
M. Vardi, T. Kochavi, Y. Denekamp and H. Bitterman
Background: Extended-spectrum beta-lactamase (ESBL) resistance is a growing concern in and outside hospitals. Physicians often face a true clinical dilemma when initiating empirical antibiotic treatment in patients admitted to internal medicine departments.
Objectives: To determine the prevalence of risk factors for ESBL resistance in patients with urinary tract infection (UTI) admitted to internal medicine departments.
Methods: We conducted a retrospective analysis of the medical records of patients with UTI admitted to an internal medicine division in a community-based academic hospital over a 1 year period. We collected clinical, laboratory and imaging data that were available to the treating physician at admission. Outcome measures included ESBL resistance and death.
Results: Of the 6754 admissions 366 patients were included in the study. Hospitalization during the previous 3 months (odds ratio 3.4, P < 0.0001), residency in a long-term-care facility (OR[1] 2.4, P = 0.004), and the presence of a permanent urinary catheter (OR 2.2, P = 0.015) were correlated to ESBL resistance with statistical significance. These risk factors were extremely prevalent in our patient cohort.
Conclusions: ESBL resistance is becoming prevalent outside hospital settings, and patients admitted to an internal medicine department with UTI frequently carry risk factors for harboring resistant bacteria. In such patients a high index of suspicion and early targeted antibiotic treatment for ESBL-producing Enterobacteriaceae may be justified.
OR = odds ratio
N. Shoenfeld, O. Rosenberg, M. Kotler and P.N. Dannon
The phenomenon of hair pulling has been recognized for centuries, yet the true prevalence of trichotillomania (TTM) is largely unknown and the topic has been sparsely studied. TTM is classified as an impulse-control disorder despite much debate about its etiology. In this review we summarize the different hypotheses, including impulse-control disorders, obsessive-compulsive disorders, behavioral problems and addiction, and the appropriate treatment methods. The combination of selective serotonin reuptake inhibitors and antipsychotic medications are shown to be most effective. Treatment with anti-addiction drugs seems relevant. Further research is needed to increase our knowledge regarding the etiology of TTM.
D. Boltin and Y. Niv
Eradication of Helicobacter pylori is accompanied by an array of metabolic and hormonal changes in the host. Weight gain following H. pylori eradication is a poorly understood phenomenon and probably results from an interaction between multiple factors. Ghrelin, a peptide hormone secreted by the stomach, is involved in the regulation of food intake and appetite and may account for some of these changes. Although several observational studies have demonstrated that H. pylori infection suppresses circulating ghrelin levels, it has yet to be proven that ghrelin levels increase following eradication. On the other hand, gastric expression of ghrelin, also suppressed by H. pylori, clearly increases following eradication. The determinants of plasma ghrelin levels remain elusive, as do the effects of eradication on these levels. Weight gain following H. pylori eradication may be attributable to changes in plasma and gastric ghrelin however, this hypothesis needs to be further investigated.