Israel Medical Association Journal

Background: Persistent creatine kinase elevation is occasionally encountered in subjects without any clinical manifestation of a neuromuscular disorder or any condition known to be associated with increased serum CK[1] levels. It is still unresolved whether extensive investigations and specifically a muscle biopsy should be performed in clinically normal individuals with elevated CK levels.

Objective: To study the muscle pathology of patients with asymptomatic or minimally symptomatic hyperCKemia.

Methods: The clinical and laboratory data of patients with persistent hyperCKemia and normal neurologic examination were reviewed and their muscle biopsies evaluated.

Results: The study group included 40 patients aged 7–67 years; the male to female ratio was 3:1. Nineteen patients were completely asymptomatic, 20 had mild non-specific myalgia, and 1 had muscle cramps. Electromyography was performed in 27 patients and showed myopathic changes in 7 (26%). Abnormal muscle biopsy findings (e.g., increased variation in fiber size, increased number of central nuclei and occasional degenerating fibers) were detected in 22 of the 40 patients (55%). No fat or glycogen accumulation was detected. Immunohistochemistry demonstrated abnormal dystrophin staining in 3 patients (8%), resembling the pathologic changes of Becker muscular dystrophy. No abnormal findings were detected on immunohistochemical staining for merosin, dysferlin, caveolin 3, or alpha and gamma sarcoglycans. The EMG[2] findings did not correlate with the pathologic findings.

Conclusions: Abnormal muscle biopsies were found in 55% of patients with asymptomatic or minimally symptomatic hyperCKemia. Specific diagnosis of muscular dystrophy, however, was possible in only 8% of the patients.

Three decades have elapsed since the inception of Level I trauma centers as the final link in the trauma system "chain of survival".

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

Background: Since 1984, several waves of Ethiopian immigrants have settled in Israel. On arrival they were found to be highly infected with intestinal parasites and to have increased serum immunoglobulin E and eosinophilia. 

Objectives: To study serum IgE [1] levels in Ethiopian children growing up in the environment of Israel . 

Methods: We assessed four groups of children of Ethiopian origin: a) adolescents examined on their arrival to Israel (group 1, n=11); b) adolescents born in Ethiopia and living in Israel for more than 7 years (group 2, n=10); c) children of Ethiopian origin born in Israel, without a history of allergy or asthma (group 3, n=15); and d) asthmatic children of Ethiopian origin born in Israel (group 4, n=8). A thorough clinical interview and examination as well as serum IgE levels, stool parasites and absolute eosinophil count were performed. 

Results: Group 1 (11 newly arrived Ethiopian adolescents) had a mean eosinophil count of 688 cells/ml (0–1739) and a mean serum IgE of 1043 IU/ml (253–2932), P < 0.0009 as compared to group 2. Helminthic parasites were observed in 8/11 individuals; after 1 year of follow-up and anti-parasitic treatment, serum IgE levels did not change significantly. Group 2 (10 Ethiopian born adolescents living in Israel for on average 10 years, 7–15 years) had a normal leukocyte count, MEC [2] 192 cells/ml (range 54–289), serum IgE 142 IU/ml (range 14–399 IU/ml) and no parasites in stool. Group 3 (15 Ethiopian children born in Israel) had a normal leukocyte count, MEC 128 cells/ml (0–324), serum IgE 55 IU/ml (7–189 IU/ml), similar to age-matched Israeli controls. In group 4 (8 Israeli born children of Ethiopian descent diagnosed with asthma), serum IgE showed significant elevation compared to Israeli age-matched asthmatic children (P < 0.005).  

Conclusions: High levels of IgE found in Ethiopian children on arrival to Israel declined to Israeli control levels after several years of living in the new environment. Ethiopian children born in Israel had normal levels of IgE, suggesting that environment is the main factor affecting IgE levels in this population. Israeli born Ethiopian children with asthma had significantly increased serum IgE levels compared to asthmatics of Israeli origin. These findings suggest that both environmental and genetic factors determine the level of serum IgE in these children. 

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 [1] Ig = immunoglobulin

 [2] MEC = mean eosinophil count
 

Background: Chlorpromazine is a dopamine-receptor antagonist antipsychotic agent. Because of its strong alpha-blocking and sedative actions, it has also been used as emergency therapy for extreme arterial hypertension. Published reports to date have included very small numbers of patients (i.e., 5–30).

Objectives: To analyze data on almost 500 patients who received intravenous chlorpromazine for the emergency treatment of uncontrolled symptomatic hypertension in the pre-hospital setting.

Methods: We reviewed data from 496 consecutive patients who received intravenous chlorpromazine as emergency therapy for uncontrolled symptomatic hypertension. Chlorpromazine was injected intravenously. The dose was 1 mg every 2–5 minutes until the systolic pressure was -<140 mmHg and the diastolic pressure -<100 mmHg with alleviation of symptoms.

Results: The mean dose of chlorpromazine administered was 4.5 +- 5 mg (range 1–50 mg). Only 33 patients (7%) required >10 mg. Chlorpromazine reduced the systolic blood pressure from 222.82 +- 26.31 to 164.93 +- 22.66 mmHg (P < 0.001) and the diastolic blood pressure from 113.5 +- 16.63 to 85.83 +- 11.61 mmHg (P < 0.001). The sinus rate decreased from 97.9 +- 23.5 to 92.2 +- 19.7 beats per minute (P < 0.001). These results were achieved within the first 37 +- 11 minutes.

Conclusions: Intravenous chlorpromazine is safe and effective when used as emergency treatment for uncontrolled symptomatic hypertension.

Objectives: To use pelvic fractures as a test case for the efficiency of the Israeli trauma system, as reflected in the experience of our medical center.

Methods: Data were obtained from the medical charts of all cases of pelvic fractures admitted to our medical center between 1987 and 1999. We obtained demographic data, information on the cause of injury, fracture classification, co-injuries and Injury Severity Score, treatment strategies, and mortality rate.

Results: Altogether, 808 patients with pelvic injuries were treated in our medical center. The most common cause of injury was motor vehicle accidents (51%). Pelvic fractures without acetabular involvement were diagnosed in 58% of patients and isolated acetabular fractures in 32%, while 10% sustained combined injuries to the pelvic ring and the acetabulum. The overall rate of operative stabilization was 34%. The majority of patients had associated injuries, mostly additional musculoskeletal injuries. Altogether, 13% were referred from Level II/III trauma centers. We observed an increase in the total number of local admissions, in the percentage of referred patients and in the percentage of operated patients during the study period. The observed mortality rate was 5%.

Conclusions: Our results show a more than twofold increase in the percentage of referred patients following the designation of a Level I trauma center. These referrals result not only from the designation as a Level I trauma center, but also from the presence of a dedicated team of pelvic fracture specialists, available 24 hours a day. In addition, a larger percentage of patients undergo surgery for internal fixation of pelvic fractures, in accordance with current worldwide trends.

Objectives: To review the current status of MAS[1] in a pediatric tertiary care center in Israel, in terms of feasibility, safety, and effect on standard practices.

Methods: We reviewed the files of all children who underwent a MAS procedure in our department during the period April 2002 to July 2004, and compared the findings with those of children treated by standard practices.

Results: A total of 301 procedures were performed in 271 patients: 107 thoracoscopic and 194 laparoscopic. There were no major intraoperative complications. The total conversion rate was 3.65%: 0 for thoracoscopy and 5.6% for laparoscopy (11/194). Twenty-four types of procedures were performed during the study period. The thoracoscopies accounted for 92.24% of all thoracic procedures in the department (107/116), and routine abdominal laparoscopic procedures replaced open surgery in 30–100% of cases (total 44.8%, 194/433).

Conclusions: MAS procedures appear to be safe for a wide range of indications in children. In our center they currently account for a significant percentage of pediatric surgeries. We suggest that the integration of MAS training in the residency programs of pediatric surgeons be made a major long-term goal. The creation of a pediatric MAS study group, which would allow for multi-institutional studies, is especially important in Israel where a relatively large number of pediatric surgery departments handle a small annual number of patients.

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[1] MAS = minimal access surgery

Objectives: To present a variety of radiologic findings on high resolution computerized tomography in eight sequential patients with COP[1], together with clinical and pathologic correlation.

Methods: Sequential HRCT[2] examinations of eight patients (four males) aged 53–80 years (mean 65.5 years) with pathologically proven COP were retrospectively analyzed by a consensus of two experienced chest radiologists for the existence and distribution of airspace consolidation, ground-glass opacities, nodular thickening along bronchovascular bundles, small (<1 cm) and large (>1 cm) nodules. The distribution of radiologic findings was classified as unilateral or bilateral, located in the upper, lower or middle lobe, and central or peripheral. Also recorded was the presence or absence of mediastinal lymphadenopathy and pleural effusion. Correlation with clinical symptoms was analyzed.

Results: All eight patients had bilateral airspace consolidations: in two cases consolidations were limited to central fields, in four they were peripheral, and in the remaining two cases they were both central and peripheral. Small nodules were noted in six cases and large nodules in three. Ground-glass opacities were found in four cases. All patients had enlarged lymph nodes (1–1.5 cm) in the mediastinum. Radiologic abnormalities resolved or improved after steroid treatment in all patients.

Conclusions: HRCT findings of bilateral multiple heterogenic lung infiltrates and nodules associated with mild mediastinal lymphadenopathy in a patient with non-specific clinical symptoms are suggestive of COP; in such cases, lung biopsy is indicated. Radiologic resolution of abnormalities correlates well with clinical improvement under adequate steroid treatment.

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[1] COP = cryptogenic organizing pneumonia

[2] HRCT = high resolution computerized tomography

Objectives: To compare the subjective visibility of normal anatomic landmarks in the chest on storage phosphor-based digital radiographs versus conventional screen-film radiographs.

Methods: Digital phosphor-based and screen-film posteroanterior chest radiographs were obtained during 1 year in 140 asymptomatic patients without any known pulmonary disease (119 men, 21 women; mean age 52.1 years, range 23–86). Both sets of films were independently compared by two experienced radiologists in different sessions. The visibility of each of the following anatomic landmarks was graded from 1 to 3: pulmonary fissures, carina, bronchi to left upper lobe, right upper lobe and left lower lobe, bronchus intermedius, anterior and posterior junctional lines, and vessels behind the heart and diaphragm. Additionally, subjective general quality impression of each radiograph was graded similarly. Statistical analyses were performed using the chi-square test. A P value less than 0.05 was considered significant.

Results: Visibility with the digital images was statistically significantly higher for the carina, left lower lobe bronchus, bronchus intermedius, and vessels behind the heart and diaphragm. Subjective general quality impression of digital radiographs was also higher (P < 0.001). No significant visibility differences were found for pulmonary fissures or junctional lines.

Conclusion: Subjective visibility of anatomic structures behind the heart and diaphragm and at the hilae is significantly improved with phosphor-based digital radiography compared with conventional screen-film radiography. This suggests that pathologic processes such as pulmonary nodules, masses or consolidations projected over those structures may be more easily and reliably depicted on digital than conventional chest X-rays.

Objectives: To describe an alternative de-loading method using a fiberglass removable walking cast.

Methods: This prospective uncontrolled study comprised 24 diabetic and non-diabetic patients with a single planter neuropathic ulcer. Exclusion criteria included the presence of osteomyelitis or cellulites, peripheral vascular disease, severe foot or leg edema, more than one ulcer on the treated foot, ulcers on the other foot, visual problems, gait instability, and personality or psychiatric problems. All patients were treated with the removable fiberglass de-loading cast. At each weekly follow-up visit the cast was removed. Data were collected using a clinical report form.

Results: The ulcer healed completely in 21 of the 24 patients treated (87.5%). The mean time for healing was 6.8 weeks (range 3–20 weeks, SD = 4.2). New ulcers developed in six patients (25% of the group).

Conclusions: The effectiveness and safety of the method is comparable to that of the total contact cast, but is less labor intensive because the cast is manufactured only once and serves for the whole length of treatment. Improving the technique is expected to lower the complication rate.

Objective: To determine breast-feeding patterns and the association between sociodemographic characteristics and breast-feeding in the Tel Aviv district.

Methods: The mothers of infants aged 2, 4, 6 and 12 months, attending 59 well-baby clinics in the Tel Aviv district, were interviewed by telephone. Singleton infants who weighed less than 2,000 g and multiple-gestation infants were excluded from the study. The questions covered background data, sociodemographic characteristics of the family, and breast-feeding practices. Stepwise logistic regression was used to analyze the association between breast-feeding and various sociodemographic characteristics.

Results: Altogether, 78.5% of the mothers (1,307/1,665) initiated breast-feeding. The rate of breast-feeding at 2, 4, 6 and 12 months was 55.8, 36.8, 29.9 and 11.8%, respectively. Only 35.8% of the infants at 2 months and 11.2% at 6 months were exclusively breast-fed. The mean duration of breast-feeding was 5.2 ± 0.2 months. Grand multiparas (≥5 children) had a significantly higher rate of breast-feeding than women with one to four children (P < 0.001). More likely to breast-feed for 2 weeks or longer were women married to Yeshiva students (odds ratio = 5.3), women with ≥13 years education (OR[1] = 2.1), and women on maternity leave (OR = 1.6). The predictors for breast-feeding for 6 months or longer were similar.

Conclusions: Although the rate of breast-feeding initiation in central Israel was 78.5%, only 29.9% of the mothers continue to breast-feed for 6 months. Already at a young age, an appreciable number of breast-fed infants receive infant formula. Breast-feeding promotion should focus on less educated women, homemakers, and families with one to four children.

Objectives: To investigate the time relation between the insertion of a new NGT and formation of the biofilm.

Methods: We examined sequential samples on NGTs that were forcibly pulled out by the patients themselves during any of the 7 days after insertion. Scanning electron micrography and confocal laser scanning microscopy were used for biofilm detection.

Results: Biofilm was identified on 60% of the 35 samples of day 1 and on all the samples of the following days, by both microscopic methods.

Conclusions: Biofilms form within a single day on most NGTs inserted for the feeding of elderly patients with dysphagia. Further research should be devoted to prevention of biofilm formation on NGTs.

Objectives: To assess the relative efficacy of clinical and laboratory methods in the diagnosis of Bordetella pertussis by patient age and immunization status.

Methods: We compared the clinical and laboratory diagnosis of B. pertussis in 87 pre-vaccinated, 78 recently vaccinated, and 75 post-vaccinated children with suspected pertussis. Serum and nasopharyngeal swabs were obtained for serology, culture and polymerase chain reaction.

Results: PCR[1] and culture identified 41% and 7% of patients with B. pertussis, respectively (P < 0.001). All positive cultures were PCR-positive. Positive PCR was less common among those recently vaccinated than among those in the pre- (P < 0.001) and post-vaccinated groups (P < 0.05). Positive culture was more common among those pre-vaccinated than among those recently vaccinated (P < 0.01). Positive tests for immunoglobulin M and A were more common among the post-vaccinated than the pre- and recently vaccinated (P < 0.001), respectively. Logistic regression analyses revealed that clinical criteria have no significant association with infection in recently and post-vaccinated children. Among the pre-vaccinated children, whoop and cough duration were associated with a positive PCR (odds ratio 7.66 and 0.5, P < 0.001). Seventy-six percent of pre-vaccinated, 39% of recently vaccinated and 40% of post-vaccinated children with positive PCR did not meet the U.S. Centers for Disease Control diagnostic criteria for B. pertussis.

Conclusions: PCR is a useful tool for pertussis diagnosis, particularly in pre-vaccinated infants. The yield of culture and serology is limited, especially among pre- and recently vaccinated children. In pre-vaccinated infants with whoop and less than 2 weeks of cough, PCR testing should be implemented promptly.