תוצאת חיפוש

Therapeutic and Toxic Theophylline Levels in Asthma Attacks

Aliza Zeidman, Joseph Gardyn, Zinaida Fradin, Gershon Fink, Moshe Mittelman

Dept. of Medicine B, Rabin Medical Center, Golda (Hasharon) Campus and Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva; and Sackler Faculty of Medicine, Tel Aviv University

Although first-line therapy for bronchial asthma has changed over the past decade to anti-inflammatory medication such as inhaled corticosteroids and cromolyn with possible addition of beta-agonists, theophylline is still useful and therefor widely used. However, several studies have raised serious questions regarding its efficacy in acute asthmatic exacerbations. These studies, the narrow therapeutic range of the drug, the frequency of side effects and interactions with common drugs, and individual variation in clearance and metabolism, have prompted its reevaluation in the management of asthma. Therapeutic serum levels of theophylline are between 10 to 20 mcg/ml. Most adults achieve these concentrations with daily slow-release oral theophylline preparations, 200-400 mg (approximately 10 mg/Kg) twice a day. However, when such a patient presents to the emergency room (ER) in an asthmatic attack, immediate intravenous theophylline is often given, regardless of maintenance treatment. Since the rationale for this common therapeutic approach has been challenged, the current study was undertaken. Serum theophylline levels were measured in 23 consecutive asthmatics presenting to the ER in an acute attack. 15 (68%) had therapeutic levels (above 10 mcg/ml) and 2 had toxic levels (above 20 mcg/ml), prior to receiving the standard intravenous theophylline dose given for an attack. These data indicate that most patients with bronchial asthma on oral maintenance theophylline do not require additional intravenous theophylline when in an attack. It probably will not benefit them and may even induce serious theophylline toxicity.

Bacterial Culture of Chip Tissue of Enucleated Prostates

I.Z. Ben-Zion, P.M. Dagtyar, J. Kaneti

Urology Dept., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

To assess the prevalence of infection and colonization of the prostate by bacteria, chip tissue samples from 166 patients undergoing retropubic prostatectomy were submitted for bacterial tissue culture. In 28 patients with an indwelling catheter before surgery, E. coli, Klebsiella, Pseudomonas and Enterobacter were the commonest species encountered, the first the most common. In only 7 patients (20%) who didn't have an indwelling catheter before operation was the culture positive. We confirmed that the longer the time the catheter was indwelling before surgery, the greater the likelihood of positive cultures. However, postoperative outcome and morbidity were not related to culture results. We conclude that even though it is worth trying to sterilize the urine and prostate before prostatectomy, the effect on the postoperative outcome is minimal when proper antimicrobial therapy is given perioperatively.

Embolic Splenic Infarction: A Rare Complication of Atrial Fibrillation

Doron Merims, Doron Zilberman, Liliana Lupu, Emanuel Sikuler

Depts. of Medicine B and Radiology, Soroka Medical Center and Ben-Gurion University of the Negev, Beer Sheba

Splenic infarction is a rare disorder. The typical clinical presentation is sudden pain in the left upper quadrant of the abdomen, and awareness to this possibility is the major clue for diagnosis. We describe a 49-year-old man with chronic atrial fibrillation and splenomegaly who was treated with anticoagulants. Because of hematuria, the regular dose of anticoagulant therapy was reduced. The hematuria stopped but he complained of sudden onset of pain in the left upper quadrant. Computerized tomography and isotope scan of the spleen confirmed the clinical suspicion of splenic infarction. Treatment with anticoagulants and analgesics was followed by clinical improvement.

Traumatic Common Carotid-Internal Jugular Fistula: Positive Aspect

R. Avrahami, M. Liverson, M. Haddad, A. Zelikovsky

Dept. of Vascular Surgery and Anesthesia, Rabin Medical Center, Beilinson Campus, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University

A 42-year-old man presented with a penetrating neck injury from a pellet gun. Physical examination showed an open 1 cm wound on the right side of the neck, hematoma of the right sternocleidomastoid muscle, and carotid artery injury. He was hemodynamically stable and there was no neurological deficit. Arteriogram of the neck disclosed a pseudoaneurysm with an arteriovenous fistula between the common carotid artery and internal jugular vein. At surgery, the tears in the carotid artery and jugular vein were sutured and a vacuum drain was introduced. The postoperative course was uneventful, and the patient was discharged 5 days later. Instead of the expected results of a penetrating carotid artery injury, such as blood loss, airway obstruction or neurological deficit, the arteriovenous fistula caused by the pellet actually saved the patient's life. Blood flow from the artery via the pseudoaneurysm to the jugular vein kept the patient in stable condition.

Effect of Chlorocresol VS Caffeine on Muscle Contracture in Malignant Hyperthermia Susceptible Patients

R. Ben-Abraham, R.M. Krivosic-Horber, G. Haudcoeur, A. Perel, P.J. Adnet

Dept. of Anesthesiology and Intensive Care, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University; and Dept. d'Anesthesie-Reanimation Chirurgicale, Laboratoire de Pharmacologie Hospitaliere, et Service des Urgence, Centre Hospitalier Universitaire, Lille Cedex, France

The phenotype of susceptibility to malignant hyperthermia (MHS); can only be detected reliably by the in vitro caffeine-halothane contracture test (CHCT). Enhanced sensitivity of the calcium-induced calcium release mechanism is responsible for the exaggerated contracture response of skeletal muscle fibers from MHS patients to halothane and caffeine. Chlorocresol was demonstrated to be a potent activator of Ca++release from skeletal muscle sarcoplasmic reticulum. This effect is probably mediated through action on a ryanodine sensitive Ca++ release channel known to be more sensitive in MH. We studied the effect of chloroscresol on the mechanical contracture response of skeletal muscle from patients presenting for the in vitro CHCT. Chlorocresol induces contracture response in a concentration 1/200 of that of caffeine in muscle strips from MH patients. By adding chlorocresol to the protocol of the CHCT, there is clearer discrimination between the responses of MH patients and normal subjects can be achieved. 

Hyponatremia due to Prolonged Excessive Ingestion of Water

I. Shavit, J. Diment, S. Ravid, N. Shehadeh

Dept. of Pediatrics A, Rambam Medical Center and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

We report a 1.5-year-old boy admitted for restlessness and constipation. He was found to have hyponatremia caused by voluntary drinking of excessive amounts of water. Although unusual in children, intoxication by oral water is a recognized clinical syndrome in infants, 3-6 months old, fed with dilute formula. Water intoxication in older children is rare. The diagnosis was established by the water deprivation test.

Distraction Osteogenesis for Hypoplastic Facial Bones

Adi Rachmiel, Dina Lewinson, Dror Eizenbud, Daren Rosen, Dov Laufer

Dept. of Oral and Maxillofacial Surgery, and Orthodontics and Cleft Palate Unit, Rambam Medical Center; and Division of Morphological Sciences, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

Distraction osteogenesis is a well-known method for bone lengthening which stretches callus to generate new bone in the distracted area. The method was developed by Ilizarov for the lengthening of long enchondral bones. In recent years the method has also been applied to the facial bones and to the jaw.

Habitual Dependence on Modern Imaging Modalities: The New Golem

Samuel Argov

Elisha Hospital, Haifa

Modern imaging techniques have been taking over our medical life, but none denies the progress that has followed introduction of modern imaging modalities. For the generation of younger physicians who entered the profession after the introduction of these techniques, use of US, CT, MRI and the like is natural and often applied. But the patient is not computerized and medicine is far from being a pure science. 3 cases of common surgical problems are presented in which excessive use of diagnostic modalities resulted in unnecessary operations, thus leading to unnecessary morbidity.

In these days of soaring medical expenses, many unnecessary imaging and laboratory studies are done for reasons of "defensive" medicine. It is important to fortify the position of clinical diagnosis, but making clinical decisions without requiring expensive and sometimes misleading imaging studies significantly reduces costs. Admittedly, courage and firm professional backbone are required to face a lawyer or a judge and say: "This CT or US study would not have changed my clinical decision; it would have made no positive contribution to it, and might even have mislead me." This paper comes to remind physicians of the importance of clinical diagnosis and the need to develop and rely on primary medical skills. Machines and laboratory tests are aids to diagnosis, they do not make the diagnosis.

International Quality Assurance Standards (ISO 9002) in an Israeli Hospital

Shaul M. Shasha, Noam Goldstein, Abraham Ofek

Western Galilee Hospital, Nahariya and Ofek Institute, Ramat Hasharon

This hospital has been certified by the Israel Standards Institute as having a quality assurance system fulfilling the requirements of the international standard, ISO 9002. This is the first hospital in this part of the world to be certified as fulfilling this standard. Its adoption is one of several accepted approaches to quality assurance in medicine. World-wide, very few health organizations, including hospitals, have implemented this system successfully. Opinions regarding its importance are divided, mostly because of lack of experience in its application. We describe its features, goals and structure, and its implementation in various sectors, including health organizations. The process of its adoption, application and implementation is described, and the problems which arose are discussed.

Immediate Orthopedic Surgery in Multiple Trauma

R. Mosheiff, D. Segal, M. Liebergall

Orthopedic Dept., Hadassah Medical Center, Jerusalem

The increase in mortality and morbidity from multiple trauma due to road accidents, industrial trauma and combat injuries obligates treatment based on emergency systems and trauma centers. Follow-up of the frequency of different types of injury calls attention to increasing involvement of the orthopedic surgeon in primary treatment. This situation calls for appropriate deployment of immediate surgical treatment which will rapidly enable mobility. We present several methods for immediate orthopedic treatment of multiple-trauma patients.

Chronic Tophaceous Gout

Rita Toker, Daniel Flusser, Yanku Hertzanu, Shaul Sukenik

Medical Dept., Rheumatology Unit and Radiology Dept., Soroka Medical Center; and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

A 51-year-old immigrant from the Caucasus had had chronic tophaceous gout for over 20 years, but had never been treated with anti-hyperuricemic drugs. He had developed large, multiple tophi in many locations, including both ankles and feet. The enormous size and unique location of the tophi caused considerable pain, and difficulty in standing and on walking. Since surgical removal of the tophi was refused by the patient, a course of allopurinol, 300 mg/day, was begun.

Inhaled Budesonide for Chronic Obstructive Pulmonary Disease

Paltiel Weiner, Doron Zamir, Marinella Beckerman

Medical Dept A, Hillel Yaffe Medical Center, Hadera

A significant, large minority of patients with chronic obstructive pulmonary disease (COPD) respond favorably to corticosteroid treatment; but the benefit may be outweighed by its side effects. Long-term administration of inhaled steroids is a safe means of treatment. We hypothesized that treatment with inhaled budesonide would improve clinical symptoms and pulmonary function in subjects with COPD, and that the response to an inhaled B2-agonist would individualize steroid responders. In 44 patients with stable COPD in a double- blind crossover trial, we compared a 6-week course of inhalations of 800 mg/d budesonide with a placebo, separated by a 4-week interval when no medication was taken. In 33 out of 42 responders to the B2-agonist who remained in the study, there was a significant improvement in FEV1 of greater than 20% following budesonide inhalation, as compared to placebo. There was also a significant difference between the 2 periods of treatment as to the mean number of B2-agonist inhalations. We conclude that about 1/4 of patients with stable COPD respond to bronchodilators, and treatment with inhaled steroids improves spirometry data and inhaled B2-agonist consumption in about 3/4.

Oral Anticoagulation Therapy in the Primary Care Setting

Shlomo Vinker, Sasson Nakar, Sergei Finkel, Emanuel Nir, Eitan Hyam

Family Medicine Dept., Sackler Faculty of Medicine, Tel Aviv University; and Shaaraim Clinic, General Sick Fund, Rehovot; Central Cinical Laboratories, and District Medical Director, Central District of the General Sick Fund

The use of oral anticoagulant therapy (OAT) to prevent thromboembolism has been widespread in recent years. The concept of high- and low-intensity regimens has facilitated treatment for many, and has lowered the hazards of overly intense anticoagulation. However, a significant proportion of patients suited to the low intensity regimen are not being treated. It is not clear whether its wider use is limited by continued debate, lack of resources, lack of expertise, or other causes. We retrospectively reviewed the medical records of 32 patients treated with OAT administered in the primary care setting. The average age was 66±11 years (range 34-84). 9 were treated with high-intensity OAT: 8 due to artificial heart valves, and 1 due to a hypercoagulable syndrome with recurrent thromboembolism. 23 were treated with low-intensity OAT, 17 of whom had atrial fibrillation. 11 were also being treated continuously with other medication which interacted with OAT or interfered with other coagulation pathways. Such medication included: aspirin, dipyridamole, amiodarone, bezafibrate and allopurinol. Of 414 coagulation tests, 57% and 65% were in the therapeutic range in the high- and low-intensity OAT groups, respectively. There was no major bleeding event, but in 2 of 8 who bled, gastrointestinal bleeding led to hospitalization. Treatment was discontinued in 1 patient because of difficulties in achieving target INR, and in the 2 hospitalized for bleeding. The percentages of test results in, above and below the therapeutic range were similar to those in other large series, for both intensity regimens. We found that a significant proportion of patients were under chronic treatment with other medication which interacted with OAT. To estimate the rate of complications in primary care OAT, larger series are needed. We conclude that OAT can be given and monitored by the family physician, and that awareness of long and short term drug interactions with OAT is mandatory.

Laser photorefractive surgery

Y. Domniz, L. Hefetz, D. Haviv, U. Kibersky, D. Karkovski, P. Nemet

Dept. of Ophthalmology, Assaf Harofeh Medical Center, Zerifin and Sackler Faculty of Medicine, Tel Aviv University

As photorefractive keratectomy (PRK) with excimer laser gains world-wide acceptance, more patients are able to discard their spectacles. Our study comprised 611 eyes which underwent PRK and were followed for at least a year. Those with myopia up to -6.00D had better post-operative visual acuity and refraction, than patients with higher grades of myopia. They had less corneal haze and a greater proportion were satisfied with their results. Complaints of halos and glare were similar at all degrees of myopia up to -10.00D.

Pulmonary Alveolar Micro-Lithiasis Presenting With Prolonged Cough

I. Barshack, M. Krupsky, M. Perelman, J. Kopolovic

Institute of Pathology and Dept. of Pulmonary Diseases, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

A 40-year-old man had been followed in the pulmonary clinic for prolonged cough. Chest X-ray showed bilateral diffuse interstitial infiltrates with accentuation toward the bases. CT-scan demonstrated a fine diffuse reticulonodular pattern. Transbronchial lung biopsy showed pulmonary alveolar microlithiasis, a rare disease characterized by the presence of concentric calcifications within the pulmonary alveoli. This is the second case of the disease reported in Israel.