Israel Medical Association Journal

Objective: To investigate hemodynamic variables, including small and large artery compliance, in cirrhotic patients during total paracentesis.

Methods: The study included 15 cirrhotic patients admitted for an episode of tense diuretic-resistant ascites. Hemodynamic variables including vascular compliance were measured using an HDI pulse wave cardiovascular profiling instrument CR-2000. The variables were measured in these patients before, immediately after and 24 hours following large volume (mean 5.6 L) paracentesis.

Results: Cardiac output increased immediately after paracentesis due to increment in stroke volume, with no change in heart rate. However, 24 hours later the cardiac output decreased to below the basal level. The fluctuation was statistically significant (P < 0.05). There was no change in large artery compliance, but small artery compliance increased after paracentesis (P < 0.05) and partially returned to the basal level after 24 hours. Systemic vascular resistance measurement showed the same pattern of change: vasodilatation occurred during paracentesis and was attenuated 24 hours later.

Conclusions: Large volume paracentesis with albumin replacement caused an accentuation of the vasodilatation (small but not large artery) already present in these patients. This may be the first sign of enhanced vasodilatation due to large volume paracentesis before the clinical expression of impaired hemodynamics and deterioration of renal function.

Objectives: To define the incidence of congenital CMV infection in two different subpopulations, as a model for the entire population of Israel.

Methods: Urine specimens were randomly collected from 2,000 newborns in Shaare Zedek Medical Center, Jerusalem, and HaEmek Medical Center, Afula (1,000 specimens each). These hospitals have many characteristic differences, presumably representing the diverse population of Israel. Urine specimens were subjected to a CMV PCR[2] reaction and positive specimens were validated by urine viral culture. Maternal seroprevalence was determined in a representative sample of the mothers in each hospital. Epidemiologic characteristics of the mothers were extracted from hospital records and compared.

Results: The population in Shaare Zedek Medical Center was mostly Jewish (95.8%) and urban (87.0%), as compared to that of HaEmek Medical Center (49.2% and 61.0%, respectively, P < 0.01). Nevertheless, CMV seroprevalence was similar: 81.5% and 85%, respectively. Ten (1.0%) and 4 (0.4%) newborns, respectively, were found to have congenital CMV infection (not significant).

Conclusions: The combined incidence of congenital CMV infection in the study population was 0.7% (95% confidence interval 0.3–1.0%). If this rate is extrapolated to the entire population of Israel, then a total of 945 cases of congenital CMV can be expected among the 135,000 annual deliveries. A nationwide screening program for congenital CMV should be considered.

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[1] CMV = cytomegalovirus

[2] PCR = polymerase chain reaction

Objective: To establish the frequency of A. haemolyticum in throat cultures in a northern Israeli population and to estimate the clinical significance of this pathogen in patients with sore throat.

Methods: We examined suspected colonies for A. haemolyticum by gram stain, catalase test and reverse CAMP test in 518 throat cultures sent to the microbiologic laboratory of HaEmek Medical Center.

Results: Of the throat cultures tested, A. haemolyticum was recovered from one patient (0.2%). In contrast, group A Streptococcus (Streptococcus pyogenes) was recovered from 135 patients (26%).

Conclusion: A. hemolyticum is an uncommon pathogen implicated in acute pharyngitis, therefore routine screening in throat swabs is not required.

Objectives: To evaluate the extent and characteristics of CAM[1] use among cancer patients in northern Israel.

Methods: Telephone interviews were conducted with 2,176 newly registered cancer patients or their family members, at least 1 year following referral.

Results: The rates of CAM use varied significantly according to demographic characteristics and chemotherapy treatment, from 3% in the basically educated elderly group up to 69% of educated Israeli-born Jews younger than 70 years receiving chemotherapy. The overall rate of CAM use was 17%. The most influential factors determining CAM use were academic or high school education, chemotherapy treatment, Israel as country of birth, and age 41–50 years. All patients used CAM in addition to conventional therapies. Less than half of them reported it to their physicians. The most frequently used treatments were various chemical, biological, botanic and homeopathy remedies. Friends and relatives were the main recommenders of CAM. Most CAM users reported that they used CAM because they believed it “strengthens the immune system,” alleviates side effects of chemotherapy, improves quality of life and helps to overcome pain and stress, and 62% of them reported subjective beneficial effects.

Conclusions: A predicting module of CAM user patients was built, which may help physicians initiate conversations with their patients on CAM use. Expanding physicians' knowledge on CAM methods will encourage them to provide additional advice, promote the use of beneficial therapies, and inform patients about potentially harmful methods.

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[1] CAM = complementary and alternative medicine

Objectives: To assess the prevalence of metabolic syndrome and different glucose intolerance states in healthy, overweight Arab individuals attending a primary healthcare clinic in Israel.

Methods: We randomly recruited 95 subjects attending a primary healthcare clinic who were healthy, overweight (body mass index >27) and above the age of 40. Medical and family history was obtained and anthropometric parameters measured. Blood chemistry and oral glucose tolerance test were performed after overnight fasting.

Results: Twenty-seven percent of the subjects tested had undiagnosed type 2 diabetes according to WHO criteria, 42% had impaired fasting glucose and/or impaired glucose tolerance and only 31% had a normal OGTT[1]. Metabolic syndrome was found in 48% according to criteria of the U.S. National Cholesterol Education Program, with direct correlation of this condition with BMI[2] and insulin resistance calculated by homeostasis model assessment. Subjects with metabolic syndrome had a higher risk for abnormality in glucose metabolism, and the more metabolic syndrome components the subject had the higher was the risk for abnormal glucose metabolism. Metabolic syndrome predicted the result of OGTT with 0.67 sensitivity and 0.78 specificity. When combined with IFG[3], sensitivity was 0.83 and specificity 0.86 for predicting the OGTT result.

Conclusions: According to our initial evaluation approximately 70% of the overweight Arab population in Israel has either metabolic syndrome or abnormal glucose metabolism, indicating that they are at high risk to develop type 2 diabetes and cardiovascular morbidity and mortality. This population is likely to benefit from an intervention program.

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[1] OGTT = oral glucose tolerance test

[2] BMI = body mass index

[3] IFG = impaired fasting glucose
 

Objectives: To test the in vitro activity of linezolid (oxazolidinone) and other antimicrobial agents against MRSA[1] isolates recovered from hospitalized patients.

Methods: We tested 150 MRSA isolates recovered from hospitalized patients. The minimal inhibitory concentration of vancomycin, teicoplanin, pristinamycin (quinupristin-dalforistin), and linezolid was determined by the Etest method. Susceptibility to other antibiotics was tested by the disk diffusion method.

Results: All isolates were sensitive to vancomycin, teicoplanin, pristinamycin, and linezolid. The MIC₉₀ was 2.0 mg/ml for vancomycin and teicoplanin (range 0.5–2.0 mg/ml and 0.125–2.0 mg/ml, respectively), and 0.5 mg/ml for pristinamycin and linezolid (range 0.125–0.75 mg/ml and 0.125–0.5 mg/m, respectively). Of the other antibiotics, fusidic acid showed the best in vitro activity, with 96.7% susceptibility, associated with trimethoprim/sulfamethoxazole (85.8%) and minocycline (84%). Penicillin was associated with the lowest susceptibility (1.3%), associated with ofloxacin (3%) and erythromycin (14%). An increase in the minimal inhibitory concentration value of vancomycin was associated with a significant decrease in resistance to TMP-SMZ[2] (P < 0.01) and an apparent increase in resistance to other antibiotics.

Conclusion: The excellent in vitro activity of linezolid and its reported in vivo effectiveness renders it an important therapeutic alternative to vancomycin in the treatment of MRSA infection.

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[1] MRSA = methicillin-resistant Staphylococcus aureus

[2] TMP-SMX = trimethoprim/sulfamethoxazole

Objectives: To minimize ventilatory limitation during training of patients with severe COPD[1] by applying bi-level positive pressure ventilation during training in order to augment training intensity (and effect).

Methods: The study group comprised 19 patients (18 males, 1 female) with a mean age of 64 ± 9 years. Mean forced expiratory volume in 1 second was 32 ± 4% of predicted, and all were ventilatory-limited (exercise breathing reserve 3 ± 9 L/min, normal >15 L/min). The patients were randomized: 9 were assigned to training with BiPAP[2] and 10 to standard training. All were trained on a treadmill for 2 months, twice a week, 45 minutes each time, at maximal tolerated load. Incremental maximal unsupported exercise test was performed before and at the end of the training period.

Results: BiPAP resulted in an increment of 94 ± 53% in training speed during these 2 months, as compared to 41 ± 19% increment in the control group (P < 0.005). Training with BiPAP yielded an average increase in maximal oxygen uptake of 23 ± 16% (P < 0.005), anaerobic threshold of 11 ± 12% (P < 0.05) and peak O₂ pulse of 20 ± 19% (P < 0.05), while peak exercise lactate concentration was not higher after training. Interestingly, in the BiPAP group, peak exercise ventilation was also 17 ± 20% higher after training (P < 0.05). Furthermore, contrary to our expectation, at any given work rate, ventilation (and tidal volume) in the BiPAP group was higher in the post-training test as compared to the pre-training test, and the end tidal partial pressure of CO₂ at 55 watts was lower, 40 ± 4 and 38 ± 4 mmHg respectively (P < 0.05). No improvement in exercise capacity was observed after this short training period in the control group.

Conclusion: Pressure-supported ventilation during training is feasible in patients with severe COPD and it augments the training effect. The improved exercise tolerance was associated with higher ventilatory response and therefore lower P_ETCO₂[3] at equal work rates after training.

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[1] COPD = chronic obstructive pulmonary disease

[2] BiPAP = bi-level positive pressure ventilation

[3] P_ETCO₂ = end tidal partial pressure of CO₂
 

Objectives: To determine to what extent the current Centers for Disease Control guidelines are practiced in Israel, the reasons for their adoption or rejection, and the need for local official guidelines.

Methods: A telephone questionnaire was conducted of all 27 delivery units in Israel. Answers were obtained from 26, either from the clinical director or the senior obstetrician in charge at the time of the interview.

Results: Only in 2 of the 26 delivery units (8%) are the CDC[1] guidelines adhered to exactly; in 6 units they are deliberately rejected, and in 8 units they are not practiced, although they are allegedly implemented. Thus, the CDC guidelines are not practiced in 14 delivery units (54%). Medico-legal consideration is the sole or major reason for adopting these guidelines in 80% (16/20) of the delivery units where they are seemingly implemented. In the majority of these units (18/20) there is readiness to abandon current practice, should local guidelines differ from those of the CDC, provided that local guidelines are issued by an authoritative source.

Conclusion: CDC guidelines are either deliberately rejected or incorrectly practiced in most Israeli delivery units. The medico-legal argument is one of the main reasons for practicing these guidelines. Since the CDC guidelines probably do not apply in Israel, official local guidelines are urgently needed.

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[1] CDC = Centers for  Disease Control

Objectives: To evaluate the diagnostic accuracy and outcome of coccygectomy.

Methods: We retrospectively reviewed the operative results in nine patients (seven females and two males) who underwent coccygectomy for coccygodynia in the last 5 years following conservative treatment failure.

Results: The outcome of the procedure was excellent in five patients, good in one patient and poor in two patients.

Conclusions: It is mandatory to perform bone scanning in every patient with coccygodynia and before coccygectomy in order to rule out the presence of malignancy. Coccygectomy is recommended for patients with isolated coccygodynia.

Objective: To identify risk factors and associated conditions that may cause TdP[1] in patients on chronic amiodarone treatment.

Methods: We reviewed the data of six consecutive patients on chronic amiodarone treatment who were admitted to the intensive cardiac care unit due to syncope and TdP.

Results: The patients’ median age was 73.5 years, and five were women. Concomitantly, loratadine was given to two patients and trazodone to one patient. Associated and attributing conditions to the development of TdP were hypokalemia in three patients, drug-induced bradycardia in one and reduced left ventricular function in four.

Conclusions: TdP associated with chronic amiodarone treatment may occur when amiodarone is co-administered with drugs that may potentially prolong QT interval. Additional risk factors for amiodarone-associated TdP include female gender, hypokalemia, reduced left ventricular function and bradycardia.

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[1] TdP = torsade de pointes