Israel Medical Association Journal

Background: Takayasu arteritis (TA) is a rare chronic granulomatous inflammatory disease of the aorta and/or its major branches and more frequently affects female patients before menopause. Since persistent inflammation may lead to arterial ischemia, hypertension is an important complication of TA. Objectives: To evaluate gestational results and complications in patients with TA arteritis.

Methods: We conducted a retrospective analysis of the medical records of patients with TA admitted to the high risk pregnancy clinic for women with systemic autoimmune diseases at Hospital Universitário Pedro Ernesto.

Results: From 1998 to 2011 we followed 11 pregnancies in 9 patients with TA; the patients’ age ranged from 17 to 42 years and disease duration from 2 to 28 years. In 7 of the 11 pregnancies, uncontrolled blood pressure occurred before labor and preeclampsia was diagnosed in one. Two deliveries were preterm, one newborn was treated for sepsis and four (36%) had intrauterine growth restriction (IUGR).

Conclusions: Close monitoring improves the perinatal outcomes in patients with TA who are more prone to develop hypertension, preeclampsia and IUGR. Disease activity was not observed in our group of patients during pregnancy. Coordinated care between the obstetric, rheumatologic and cardiologic teams is the ideal setting to follow pregnant women with TA.

Background: Multidrug-resistant tuberculosis (MDR-TB) presents a difficult therapeutic problem due to the failure of medical treatment. Pulmonary resection is an important adjunctive therapy for selected patients with MDR-TB.

Objectives: To assess the efficacy of pulmonary resection in the management of MDR-TB patients.

Methods: We retrospectively reviewed the charts of MDR-TB patients referred for major pulmonary resections to the departments of thoracic surgery at Assaf Harofeh and Wolfson Medical Centers. For the period under study, 13 years (from 1998 to 2011), we analyzed patients’ medical history, bacteriological, medical and surgical data, morbidity, mortality, and short-term and long-term outcome.

Results: We identified 19 pulmonary resections (8 pneumonectomies, 4 lobectomies, 1 segmentectomy, 6 wedge resections) from among 17 patients, mostly men, with a mean age of 32.9 years (range 18–61 years). Postoperative complications developed in six patients (35.3%) (broncho-pleural fistula in one, empyema in two, prolonged air leak in two, and acute renal failure in one). Only one patient (5.8%) died during the early postoperative period, three (17.6%) in the late postoperative period, and one within 2 years after the resection. Of 12 survivors, 9 were cured, 2 are still under medical treatment, and 1 is lost from follow-up because of poor compliance.

Conclusions: Pulmonary resection for MDR-TB patients is an effective adjunctive treatment with acceptable morbidity and mortality.
 

Background: The 20%–60% rate of acute anterior myocardial infarction (AAMI) patients with concomitant left ventricular thrombus (LVT) formation dropped to 10–20% when thrombolysis and primary percutaneous coronary intervention (PPCI) were introduced.

Objective: To test our hypothesis that prolonged anticoagulation post-PPCI will lower the LVT incidence even further.

Methods: Included in this study were all 296 inpatients with ST elevation AAMI who were treated with PPCI (from January 2006 to December 2009). Treatment included heparin anticoagulation (48 hours) followed by adjusted doses of low molecular weight heparin (3 more days). All patients underwent cardiac echocardiography on admission and at discharge. LVT and bleeding complications were reviewed and compared.

Results: LVT formation was present on the first echocardiogram in 6/296 patients. Another 8/289 patients displayed LVT only on their second echocardiogram (4.7%, 14/296). LVT patients had significantly lower LV ejection fractions than non-LVT patients at admission (P < 0.003) and at discharge (P < 0.001), and longer time to reperfusion (P = 0.168). All patients were epidemiologically and clinically similar. There were 6 bleeding episodes that required blood transfusion and 11 episodes of minor bleeding.

Conclusions: Five days of continuous anticoagulation therapy post-PPCI in inpatients with AAMI is associated with low LVT occurrence without remarkably increasing bleeding events.
 

Background: Frequent readmissions significantly contribute to health care costs as well as work load in internal medicine wards.

Objective: To develop a simple scoring method that includes basic demographic and medical characteristics of  elderly patients in internal medicine wards, which would allow prediction of readmission within 3 months of discharge.

Methods: We conducted a retrospective observational study of 496 hospitalized patients using data collected from discharge letters in the computerized archives. Univariate and multivariate logistic regression analyses were performed and factors that were significantly associated with readmission were selected to construct a scoring tool. Validity was assessed in a cohort of 200 patients.

Results: During a 2 year follow-up 292 patients were readmitted at least once within 3 months of discharge. Age 80 or older, any degree of impaired cognition, nursing home residence, congestive heart failure, and creatinine level > 1.5 mg/dl were found to be strong predictors of readmission. The presence of each variable was scored as 1. A score of 3 or higher in the derivation and validation cohorts corresponded with a positive predictive value of 80% and 67%, respectively, when evaluating the risk of rehospitalization.

Conclusions: We propose a practical, readily available five-item scoring tool that allows prediction of most unplanned readmissions within 3 months. The strength of this scoring tool, as compared with previously published scores, is its simplicity and straightforwardness.
 

Background: The management of sexual assault victims comprises complex medical, psychological, social and judicial care that was previously provided by various disciplines at several distant locations. This novel concept is the delivery of comprehensive care to victims of sexual assault at one location 24 hours a day.

Objectives: To describe the characteristics of sexual assault victims, their assailants, the assault and the treatment, and provide descriptive data on the evidentiary examination.

Methods: We performed a retrospective analysis of the charts of all sexual assault victims presenting to the Regional Israeli Center for Care of Sexual Assault Victims between October 2000 and July 2010. The center, the first in Israel, provides comprehensive care to victims of sexual assault in one location 24 hours a day using a multidisciplinary approach.

Results: The study group comprised 1992 subjects; 91.5% of the victims were females and 8.5% were males, and the age ranged from 1 to 88 years (mean age 22.3 years). Of the 1992 victims, 1635 were single (82.2%), 195 were divorced (9.8%), 141 were married (7.1%), 18 were widowed (0.9%) and 3 were unspecified. The assailant was a stranger in 794 (39.8%) of the cases, someone familiar to the victim in 786 cases (39.0%), a partner in 127 cases (6.4%), a family member in 117 cases (5.9%), someone met via the internet in 53 cases (2.7%), an authority figure in 39 cases (2.0%), and unspecified in 76 (3.9%). In the majority of cases the attack occurred either in the evening or at night (71.7%).

Conclusions: We identified several risk factors for sexual assault that can be used in prevention programs. The sexual assault victim in our study tended to be a young, single woman who was attacked by a familiar assailant in the evening or at night. Our center provides comprehensive care to victims 24 hours a day at one location and includes a team of forensic, psychological, physical and legal specialists.