Aviva Fattal-Valevski, MD, Jacques Bernheim, MD, Yael Leitner, MD, Bela Redianu, RN, Haim Bassan, MD and Shaul Harel, MD
Background: Low birth weight has been shown to be strongly related to hypertension in adult life.
Objective: To determine whether blood pressure is higher in children with intruterine growth retardation than in control subjects.
Methods: Blood pressure was measured in 58 children aged 4-6 years with IUGR and in 58 age-matched controls. The control children, whose birth weight was appropriate for gestational age, were also matched for gestational age.
Results: The children with IUGR had significantly higher mean values of systolic (p<0.05) and diastolic blood pressures (p<0.05) and mean arterial pressure (p<0.05). Significant differences in blood pressure values were found between preterm IUGR (n=21) and preterm controls (p<0.05).
Conclusion: These data indicate that children with IUGR may be at higher risk of hypertension already in childhood.
Edna Katz, MD, Luis Gaitini, MD, Mostafa Samri, MD, Nachum Egoz, MD, PhD, Dean Fergusson, MHA and Andreas Laupacis, MD, MSc
Background: Concern about the side effects of allogeneic blood transfusion has led to an increased interest in methods of minimizing peri-operative transfusion. Technologies to minimize allogeneic transfusion include drugs such as aprotinin, desmopressin, tranexamic acid and erythropoietin, and techniques such as acute normovolemic hemodilution, cell salvage and autologous pre-donation.
Objective: To survey the current use in Israel of these seven technologies used to minimize allogeneic blood transfusion.
Methods: Our survey was conducted in 1996–97 in all hospitals in Israel with more than 50 beds and at least one of the following departments: cardiac or vascular surgery, orthopedics, or urology. All departments surveyed were asked: a) whether the technologies were currently being used or not, b) the degree of use, and c) the factors influencing their use and non-use. The survey was targeted at the heads of these departments.
Results: Pharmaceuticals to reduce allogeneic blood transfusion were used in a much higher proportion in cardiac surgery departments than in the other three departments. Pre-operative blood donation was used in few of the cardiac, urologic and vascular surgery departments compared to its moderate use in orthopedic departments. The use of acute normovolemic hemodilution was reported in a majority of the cardiac departments only. Moderate use of cell salvage was reported in all departments except urology where it was not used at all.
Conclusion: There is considerable practice variation in the use of technologies to minimize exposure to peri-operative allogeneic blood transfusion in Israel.
Moshe Shabtai, MD, Patricia Saavedra-Malinger, MD, Esther L. Shabtai, MSc, Dan Rosin, MD, Josef Kuriansky, MD, Michal Ravid-Megido, MD, MSc, Menachem Ben Haim, MD and Amram H. Ayalon, MD
Background: Fibroadema, one of the most common benign breast lesions, has a characteristic age-specific incidence and is associated with other pathological entities in 50% of cases. The clinical or imaging diagnosis of fibroadenoma may be erroneous, and in some cases is found to be invasive cancer. The clustering of such entities, their correlation with age, and the risk of synchronous breast malignancy are uncertain.
Objective: To explore the possibility of any sigficant clustering of fibroadenoma-associated benign breast disease and to assess the possible risk of concomitant breast cancer.
Method: We analyzed the pathological results of 147 women undergoing excisional biopsies for fibroadenoma diagnosed pre-operatively either by clinical examination and imaging (n=117) or by radiology alone (n=30). The inter-relationships among all entities associated with fibroadenoma were studies by hierarchial cluster analysis. The correlation of the various pathologies with the risk of invasive breast cancer in relation to the patient’s age was also evaluated.
Results: Fibroadema-associated pathologies were found in 48% of the cases: sclerosing adenosis (23%), duct ectasia (17/7%), apocrine metaplasia (15.6%), florid fibrocystic disease (12.9%), duct papillomatosis (11.6%), infiltrating duct carcinoma (5.4%), duct carcinoma in situ (3.4%), and 1 case of lobular carcinoma in situ (0.6%). An orderly internal hierarchy and three significant clusters emerged: a) epithelial apocrine metaplasia, duct ectasia and sclerosing adenosis (similarity coefficients 16.0, 11.0 and 8.0 respectively); b) papillomatosis, florid fibrocystic disease and calcifications (similarity coefficients of 6.0, 4.0 and 2.0 respectively); and c) infiltrating duct carcinoma in situ (similarity coefficients of 1.8 and 1.6 respectively). Seven of the eight patients with breast cancer were older than 40 years.
Conclusions: In about half of the cases fibroadema was associated with other pathological entities clustered in an orderly hierarchy. The rarity of synchronous breast cancer in the younger age group and its more common association with fibroadema in the older age groups dictate a different approach to each. The finding of fibroadema in women older than 40 indicates the need for surgical excision.
Haim Ashkenazi, MD, Bernard Rudensky, PhD, Esther Paz, MA, David Raveh, MD, Jonathan A. Balkin, MBBCh, Dan Tzivoni, MD and Amos M. Yinnon, MD
Background: Recent studies have suggested a possible association between Chlamydia pneumoniae infection and coronary heart disease.
Objectives: To determine titers of antibodies to Chlamydia pneumoniae in patients with acute myocardial infraction compared with titers in several control groups.
Methods: This prospective case-control study investigated 209 individuals. We assessed the serum IgG antibody titers to Chlamydia pneumoniae in 57 consecutive patients admitted with AMI to our intensive coronary care unit during a 4 month period. A serum sample was drawn upon admission after 6 weeks. Results were compared with those of four control groups: a) patients admitted with community-acquired pneumonia (n=18), b) patients with community-acquired urinary tract infection (n=42), c) patients with angiographically normal coronary artery disease (n=44), and d) patients with stable coronary artery disease (n=48). Serum immunoglobin G antibody titers to C. pneumoniae were determined using standard micro-immunofluorescene technology.
Results: Of 57 patients with AMI, 32 (56%) had a high lgG titer to C. pneumoniae (>=1:256) on the initial test, which remained unchanged (62%) after 6 weeks. The percentage of patients with high titers was significantly lower in the control groups: 5 of 18 patients (28%) in the pneumonia group (P<0.01), 11 of 42 (26%) in the urinary tract infection group (P<0.01), 11 of 44 (25%) with normal coronary arteries (P<0.01), and 17 of 48 (35%) with stable chronic ischemic heart disease (P<0.05).
Conclusion: The detection of high titers of lgG antibodies to C. pneumoniae in many patients with AMI, compared to control groups, suggest that chronic Chlamydia pneumoniae infection plays a role in the pathogenesis of atherosclerosis and acute ischemic events.
Avital Hershkovitz, MD, Bruce M. Rothschild, MD, Julia H. Rose, PhD, Thomas Hornick, MD and Elizabeth E. O'Toole, MD
Background: Musculoskeletal complaints represent the second most common reason for visits to a physician, second only to the common cold. The limited capability of medical treatment for musculoskeletal disease requires modification of communication with patients by attending to their perception of the disease.
Objectives: To assess patients’ satisfaction with care provided by their primary physicians, and the relationship of patients' satisfaction to their expectations of that care, perceptions of physician performance, and perceived severity of musculoskeletal disease.
Methods: Questionnaires were administered to 90 community-dwelling elderly patients (mean age 76+-8 years) presenting for follow-up appointments with their primary care physicians. Patients were asked to report on their satisfaction with the medical care provided by the primary physicians for musculoskeletal symptoms, their expectations of that care, their perceptions of their primary physicians' interaction (regarding competence, performance, and communication), and their perceptions of disease severity (based on the number of areas involved, pain frequency and intensity, and impact on daily activity). The effects on the degree of satisfaction were assessed with regard to demographic variables, co-morbidity, site involved, and response to recommended treatment.
Results: Most patients (> 85%) expressed overall satisfaction with their doctor's interpersonal skills. Fewer (76.9%) were satisfied with the amount of effort their doctors spend evaluating their musculoskeletal symptoms, the information received regarding their musculoskeletal symptoms (75%), the degree of pain relief (75%), and the degree of functional improvement (61.8%). Level of education and response to recommended treatment for musculoskeletal disease were the only parameters associated with degree of satisfaction (higher education P = 0.005, lower education P = 0.059, medication P = 0.008, rehabilitation P = 0.076). A high level of expectations (regarding physician's care and musculoskeletal disease treatment) was noted.
Conclusions: The high level of patient satisfaction with their primary physicians' care for musculoskeletal symptoms may reflect the overall tendency of the elderly population to be satisfied with its primary care physicians. However, their high level of expectations (related to perceived efficacy of medical treatment) and their unrealistic perceptions of disease may lead to disappointment and non-compliance with their doctor's recommendations. Management of musculoskeletal disease in the elderly should address the patients’ disease perceptions, as well as their therapeutic and functional needs.
Yodphat Krausz, MD, Beatrice Uziely, MD, Rafael Nesher, PhD, Roland Chisin, MD and Benjamin Glaser, MD
Rabin Gerrah, MD, Yehuda Abramovitch, MD and Amir Elami, MD
Mariana Munichor, MD, Daniel Gold, PhD, Jacob Lengy, PhD, Ran Linn, MD and David Merzbach, PhD
Jan Dequeker, MD, PhD, FRCP Edin, Guy Fabry, MD, PhD and Ludo Vanopdenbosch, MD
Background: At the start of the Bone and Joint Decade 2000-2010, a paleopathologic study of the physically disabled may yield information and insight on the prevalence of crippling disorders and attitudes towards the afflicted in the past compared to today.
Objective: To analyze “The procession of the Cripples,” a representative drawing of 31 disabled individuals by Hieronymus Bosch in 1500.
Method: Three specialists - a rhumatologist, an orthopedic surgeon and neurologist - analyzed each case by problem-solving means and clinical reasoning in order to formulate a consensus on the most likely diagnosis.
Result: This iconographic study of cripples in the sixteenth century reveals that the most common crippling disorder was not a neural form of leprosy, but rather that other disorders were also prevalent, such as congenital malformation, dry gangrene due to ergotism, post-traumatic amputations, infectious diseases (Pott’s, syphilis), and even simulators. The drawings show characteristic coping patterns and different kinds of crutches and aids.
Conclusion: A correct clinical diagnosis can be reached through the collaboration of a rheumatologist, an orthopedist and neurologist. The Bone and Joint Decade Project, calling for attention and education with respect to musculoskeletal disorders, should reduce the impact and burden of crippling disease worldwide through early clinical diagnosis and appropriate treatment.