Israel Medical Association Journal

Background: Lipoid pneumonia is a pneumonitis resulting from the aspiration of lipids, and is commonly associated with the use of mineral oil as a laxative. LP[1] is relatively unfamiliar to clinicians and is probably underdiagnosed.

Objectives: To increase physicians' awareness of LP, its diagnosis and prevention.

Methods: We present two illustrative cases of LP and review the literature.

Results: Two cases of LP were diagnosed within half a year in an internal medicine ward. Both cases were elderly patients, and LP was associated with the use of mineral oil as a laxative agent. Computerized tomography revealed bilateral low attenuation infiltrates, associated with a "crazy paving" pattern in one case. Sudan Black staining was diagnostic in both cases – in one on a transbronchial biopsy specimen, and in the other on sputum cytologic examination. Both patients suffered from neurologic diseases and were at risk of aspiration. In both cases clinical symptoms and signs continued for several months prior to diagnosis but resolved after the mineral oil was discontinued.

Conclusions: LP often occurs in elderly patients who are at risk of aspiration. The condition may be underdiagnosed. Since in most cases mineral oil cathartics are the causative agent, an effort at primary prevention is indicated. It is suggested that the licensing of mineral oil for internal use be changed.

Background: Sentinel lymph node mapping is the standard of care for patients with malignant melanoma and breast cancer. Recently, SLN[1] mapping was introduced to the field of gastric cancer.

Objectives: To evaluate SLN mapping in patients with gastric cancer.

Methods: In 43 patients with gastric cancer, open intraoperative subserosal dye injection in four opposing peritumoral points was used. Ten minutes following dye injection, stained LNs were located, marked and examined postoperatively from the surgical specimen.

Results: SLN mapping was performed in 43 with gastric cancer; 782 lymph nodes were harvested and evaluated. SLNs were stained in 34 of the patients (79.1%) with a mean of 2.85 SLNs per patient. The false negative rate was 20.9%, the positive predictive value 100%, the negative predictive value 78.6% and the sensitivity 86.9%.

Conclusions: SLN mapping in patients with gastric cancer is feasible and easy to perform. SLN mapping may mainly affect the extent of lymph node dissection, and to a lesser degree gastric resection. However, more data are needed.

Background: There are no national data on the burden and management of acute cerebrovascular disease in Israel.

Objectives: To delineate the burden, characteristics, management and outcomes of hospitalized patients with acute cerebrovascular disease in Israel, and to examine adherence to current guidelines.

Methods: We prospectively performed a national survey in all 28 hospitals in Israel admitting patients with acute cerebrovascular events (stroke or transient ischemic attacks) during February and March 2004.

Results: During the survey period 2,174 patients were admitted with acute cerebrovascular disease (mean age 71 ± 13 years, 47% women; 89% ischemic stroke or TIA[1], 7% intracerebral hemorrhage and 4% undetermined stroke). Sixty-two percent of patients were admitted to departments of Medicine and a third to Neurology, of which only 7% were admitted to departments with a designated stroke unit. Head computed tomography was performed during hospitalization in 93% of patients. The overall rate of urgent thrombolytic therapy for acute ischemic stroke was 0.5%. Among patients with ischemic stroke or TIA, 94% were prescribed an antithrombotic medication at hospital discharge, and among those with atrial fibrillation about half were prescribed warfarin. Carotid duplex was performed in 30% and any vascular imaging study in 36% of patients with ischemic events. The mean length of hospital stay was 12 ± 27 days for ICH[2] and 8 ± 11 days for ischemic stroke. Among patients with ICH, 28% died and 66% died or had severe disability at hospital discharge, and for ischemic stroke the corresponding rates were 7% and 41% respectively. Mortality rates within 3 months were 34% for ICH and 14% for ischemic stroke.

Conclusions: This national survey demonstrates the high burden of acute stroke in Israel and reveals discordance between existing guidelines and current practice. The findings highlight important areas for which reorganization is imperative for patients afflicted with acute stroke.

Background: In Japan, helicopters have rarely been used for emergency medical services. The use of helicopters not only ensures rapid evacuation but may also serve to provide emergency management to patients with life-threatening injuries in the prehospital setting.

Objectives: To evaluate a Japanese helicopter-based emergency medical system including an onboard physician, particularly in terms of probability of survival.

Methods: We conducted a retrospective review of trauma victims, and calculated two estimates of PS[1] – at the scene and on arrival at the emergency department – based on patient age, Injury Severity Score, and Revised Trauma Score.

Results: We identified trauma victims who had an ISS[2] above 15 and were transported from the scene by helicopter. Excluding cardiopulmonary arrest at the scene, 151 cases were studied. Thirty-two patients had hemodynamic instability with systolic blood pressures below 90 mmHg, caused by hemorrhagic shock (29 cases) or obstructive shock (3 cases). Their PS values were 0.56 ± 0.38 in the prehospital setting and 0.65 ± 0.38 on arrival at the ED[3], representing a significant difference (P = 0.0003). Twenty-four of these patients survived, reflecting successful resuscitation during prehospital and ED management.

Conclusions: A doctor-helicopter system was shown to improve probability of survival for life-threatening trauma in the Japanese emergency medical system.

Although the airway granulomata in Wegener's granulomatosis were stressed initially by Friedrich Wegener himself, in the last few decades systemic lesions mainly caused by acute vasculitis have received the most attention. However, recently, the implication of granulomatous manifestations in WG[1] has raised much interest. The present data suggest that an aberrant Th1-type response might play a role in the initiation of WG, clinico-pathologically characterized by granulomatous inflammation rather than vasculitis. Disease progression to generalized WG with the predominance of vasculitic manifestations is associated with a “switch” or further complexity of the collective T cell response with the appearance of another subset of Th2-type cells and a less prominent Th1-type cytokine production in the granulomatous lesions of the upper respiratory tract. However, the clinical significance of the granulomatous inflammation is not yet completely understood. Further research will also have to focus on the role of the granulomata during relapsing disease. We review present knowledge of granulomatous inflammation in WG. Morphologic aspects, the scale of cytokine alterations as well as the variety of clinical manifestations are discussed.

Background: In the last decade there has been an increase in asthma morbidity. Hospital admission rates for childhood asthma are influenced by the prevalence of asthma and the quality of asthma care.

Objective: To assess trends in hospital admission and readmission rates for childhood asthma in the Jezreel Valley in Israel in the last decade, and to evaluate the possible effect of changes in asthma treatment upon hospitalization for acute asthma during this period.

Methods: All records from pediatric patients from the central hospital in the Jezreel Valley in northeastern Israel over a 10 year period from 1990 through 1999 who were diagnosed as having asthma were thoroughly reviewed and analyzed for admissions, re-admissions, and treatment before and during admissions

Results: There were 1584 admissions, 1208 were first-time admissions and 374 were re-admissions. The number of first-time admissions increased significantly over time (P < 0.0001), with a significant decrease of re-admissions (P < 0.005); this finding was more significant in children under the age of 8 years (P < 0.005). The length of hospital stay decreased significantly from 3.3 days to 2.7 days (P < 0.002). Significant changes in the use of medications included an increase in inhalant glucocorticoids and a decrease in the use of sodium cromoglycate and theophylline. Controller medication use was concomitant with a significant decrease in the re-admission rates.

Conclusions: The increase in the admission rate and the decrease in the rate of re-admissions and the length of hospital stay probably reflect the increase in the prevalence of asthma and changes in its treatment, respectively. It is essential that asthma be recognized as a significant cause of morbidity and that controller medications be administered to decrease the asthma's severity, morbidity, and resultant hospital admissions.
 

Non-steroidal anti-inflammatory drugs, mainly ibuprofen, are extensively used in children as analgesics and antipyretics.

Background: Analysis of the trends in psychiatric admissions and discharges is necessary to correctly plan and distribute resources, especially given the current international climate of “deinstitutionalization." Israel, too, is implementing “reform” in the national psychiatric system – to transfer psychiatric treatment from a hospital to a community setting

Objectives: To analyze admission and discharge patterns, explore trends in psychiatric hospital length of stay, and compare these characteristics between first-episode and chronic patients, between children, youth and adults, and between hospitals.

Methods: All admissions and discharges from inpatient psychiatric wards between the years 2000 and 2004 were analyzed and characterized according to age, length of hospitalization, legal status, and nature of admitting institution (state hospital, health fund, general hospital).

Results: Mean length of stay in adults decreased during the 5 year study period, from 37.6 days in 2000 to 36.4 days in 2004. In years with higher admissions, hospital stay was shorter (P < 0.05). Length of stay in psychiatric wards in general hospitals was shorter than in state hospitals (P < 0.001). In contrast to adults and children, length of stay among adolescents showed a gradual increase (P < 0.05). Involuntary hospitalization comprised 25.3% of all admissions, and 16.8% of discharged patients were readmitted within 30 days. A dramatic decrease (24.3%) in the number of chronic hospitalizations was noted.

Conclusions: Various factors may account for these developments. Protracted hospitalizations may be reduced through changes in various aspects of treatment planning and psychiatric care continuum. The decrease in number of admissions, length of stay and number of chronically admitted patients remains in line with international practices. Particular attention needs to be devoted to planning and funding so that availability of community services matches reduction in psychiatric hospitalization.
 

In the last few decades there has been a tendency towards reinstitutionalization.

Objective: To assess the effect of establishing a new dedicated acute stroke unit within a department of neurology on indicators of process of care and outcome of acute stroke in a routine clinical setting in Israel.

Methods: Stroke patients admitted to the Sheba Medical Center during the period March 2001 to June 2002 were included in a prospective study according to selection criteria. Data on demographics, risk factors, co-morbidities and stroke severity were collected. Indicators of process of care and outcome were assessed at hospital discharge and 30 days follow-up. Comparison between outcome variables by hospitalization ward was conducted using logistic regression analysis adjusting for confounders.

Results: Of 616 acute stroke patients (mean age 70 years, 61% men, 84% ischemic stroke), 353 (57%) were admitted to general wards and 263 (43%) to the stroke unit. Diagnostic procedures were performed more often, and infection rate was lower in the setting of the stroke unit. Poor outcome (modified Rankin scale ≥3 or death) was present less often in patients managed in the stroke unit both at hospital discharge (adjusted odds ratio 0.5, 95% confidence interval 0.3–0.8) and at 30 day follow-up (adjusted OR[1] 0.6, 95%CI[2] 0.3–0.9). A Functional Independence Measure score ≤90 or death at 30 day follow-up was less frequent among patients managed in the stroke unit than in general wards (adjusted OR 0.5, 95%CI 0.2–0.8).

Conclusions: Improved outcomes and higher adherence to guidelines were observed in patients treated in a stroke unit within a department of neurology. The results suggest that patients with acute stroke should have access to treatment in a dedicated stroke unit.

Objectives: To establish the impact of breast MRI on women undergoing testing in our institution.

Methods: We analyzed 82 cases that underwent MRI between January 2001 and April 2003. Analysis appraised the clinical impact of MRI testing in cases where medical summaries were available.

Results: Studies were categorized into five indications: a) screening in high risk women (n=7), b) search for primary disease in the presence of disease (n=5), c) monitoring of chemotherapy (n=2), d) postoperative assessment of tumor bed (n=9), and e) diagnostic/characterization of primary or recurrent breast cancer (n=59). Results were defined as negative, positive or no impact on clinical management. MRI testing had a positive impact in 62 cases, affecting measurable change in 9 cases. Benefit was seen in screening, diagnosis and postoperative cases. In 15 cases, MRI stimulated investigations.

Conclusion: MRI is a valuable tool in breast imaging and affects management. Further trials are necessary to define clearly the role of MRI and to ascertain whether in cases where beneficial impact on management is noted, there is ultimate impact on outcome. 

Objectives: To estimate self-medication with antibiotics by a population in northern Israel.

Methods: We sent by post a questionnaire on antibiotic usage to 2,615 adults, both Jewish and Arab, living in northern Israel.

Results: The overall response rate was low (17.9%), particularly among the Arab population (9.4% of respondents). Among the 467 respondents, 169 (36.2%) reported 215 antibiotic courses within the last year. Amoxicillin was the antibiotic most commonly used (32.7% of courses); 89.4% of antibiotics were obtained via a physician’s prescription; 114 respondents (24.4%) stored leftover antibiotics at home and 81 (18.7%) would consider self-medication with antibiotics without a medical consultation.

Conclusions: Our results show that over-the counter acquisition of antibiotics is rare in Israel. However, the storage of leftover antibiotics in the home constitutes an alternative potential source of self-medication that can have untoward consequences, not only for the individual patient but also for the general population since inappropriate antibiotic usage contributes to the increasing rates of antimicrobial resistance.

Adjustment disorder is a common diagnosis in psychiatric settings and carries a significant rate of morbidity and mortality. However, both current and previous diagnostic criteria are vague and lead to many difficulties in terms of validity and reliability. This review is based on a thorough literature search and a systematic evaluation of the empiric and theoretic data. The various pitfalls inherent in the process of diagnosing this disorder are discussed in light of the diagnostic criteria for the disorder.