תוצאת חיפוש

Mesalamine-Induced Hyper- Sensitivity Pneumonitis

D. Zamir, J. Weizman, C. Zamir, Z. Fireman, P. Weiner

Dept. of Medicine A and Gastroenterology Unit, Hillel Yaffe Medical Center, Hadera and Hadera Subdistrict Health Office

A 23-year-old woman was admitted with a history of 2 weeks of cough, fever and bilateral lung infiltrates. She had been diagnosed 2 months before as having ulcerative proctitis and was treated with mesalamine, which induced a full remission, but 3 antibiotic regimens failed to improve her lung disease.

Since computerized tomography revealed bilateral peripheral lung infiltrates and her eosinophile count was elevated, the diagnosis of drug-induced eosinophilic pneumonia was suggested. Mesalamine and antibiotics were stopped and oral corticosteroids begun. She became almost asymptomatic a week after mesalamine withdrawal, and the x-ray became normal.

Effect of Specific Inspiratory Muscle Training on Dyspnea and Exercise Tolerance in Congestive Heart Failure

Paltiel Weiner, Joseph Waizman, Rasmi Magadle, Noa Berar-Yanay, Benny Pelled

Depts. of Medicine A and Cardiology, Hillel Yaffe Medical Center, Hadera

It has been shown that the inspiratory muscles of patients with congestive heart failure (CHF) are weaker than normal. This weakness may contribute to dyspnea and limit exercise capacity. But respiratory muscles can be trained for increase in both strength and endurance. This study was designed to evaluate the effect of specific inspiratory muscle training (SIMT) on muscular performance, lung function, dyspnea and exercise capacity in moderate heart failure.

10 patients with CHF (NYHA functional class II-III) received 1/2 hour of SIMT daily, 6 times/week, for 3 months. They started breathing at a resistance 15% of their Pimax for 1 week and the resistance was then increased incrementally to 60%. Spirometry, inspiratory muscle strength and endurance, and the 12-minute walk test were performed before and after the training period. All showed an increase in inspiratory muscle strength and endurance. This was associated with a small but significant increase in FVC, a significant increase in the distance walked (458±29 to 562±32 m, p<0.01), and improvement in the dyspnea index score.

SIMT resulted in increased inspiratory muscle strength and endurance. This increase was associated with decreased dyspnea and an increase in submaximal exercise capacity. SIMT may prove to be useful complementary therapy in CHF.

Knowledge and Practice of Primary Care Physicians Relating to Streptococcal Pharyngitis

S. Leshem, H. Tabenkin, E. Dan, A. Tamir

Family Medicine Dept., Emek Medical Center and Northern District of Kupat Holim; and Northern Branch of Specialization Institute, Faculty of Life Sciences, Ben-Gurion University of the Negev, Beer Sheba

Knowledge and practice of primary care physicians as to diagnosis and treatment of group A, b-hemolytic streptococcal pharyngitis, and the degree to which they agreed with the medical literature and current clinical guidelines were examined. The study was conducted in a group of 195 general physicians, pediatricians, and family medicine specialists and residents. The data were collected using questionnaires which included personal information and questions relating to b-hemolytic streptococcal pharyngitis and were analyzed by chi-square and t-tests, and logistic regression, as appropriate. A new dependent variable, good clinical practice (GCP), was defined as the total number of correct answers to the questions in the questionnaire. 147 of the 195 eligible physicians returned completed questionnaires, a compliance rate of 76%.

96.6% cited pV as the drug of choice at a daily dosage of 1 g (43.7%) or 2 g (25.4%), for 10 days (90%). 133 physicians (90%) stated that the goal of penicillin therapy for beta-hemolytic streptococcal pharyngitis is to prevent late complications. 116 physicians (82%) cited rheumatic fever as a complication of group A beta-hemolytic streptococcal pharyngitis, preventable by appropriate antibiotic therapy. However, only 84 (59%) cited glomerulonephritis as a preventable complication.

When the knowledge and attitudes of the respondents was analyzed in terms of the new variable, GCP, a significant association (p<0.001) was found between physicians’ attitudes and variables such as where they had studied medicine, and work seniority. Those with less seniority and or medical graduates of the Americas demonstrated greater knowledge and better clinical judgment than their more senior colleagues and graduates of European and Asian medical schools. Most primary care physicians in northern Israel treat group A b-hemolytic streptococcal pharyngitis as recommended in the medical literature.

The level of medical studies in Israel and the Americas and the quality of training of residents in family medicine and pediatrics, have a positive influence on the degree of knowledge of as common a subject as b-hemolytic streptococcal pharyngitis. Emphasis should be placed on continuing medical education among primary care physicians, particularly veteran general physicians and those who studied in European or Asian medical schools.

Proper use of Pressurized Hand-Held Inhalers in Patients with Chronic Airway Obstruction 

Shabtai Varsano, Ilana Jacoby, Mila Garenkin

Asthma Care and Education Unit, Dept. of Pulmonary Medicine, and Epidemiology Unit, Meir General Hospital, Sapir Medical Center, Kfar Saba; and Sackler School of Medicine, Tel Aviv University

Inhaling drugs via hand-held inhalers in recommended for those with chronic obstructive airway disease (COPD). Approximately 8%-9% of Israel's population use hand-held inhalers, many of them pressurized. Skill in using them and ability of chronic users to learn their proper use have not been assessed.

During 1993 and 1994 we studied 200 patients with bronchial asthma or COPD who regularly used a pressurized hand-held inhaler (PI), but were not trained to use it in our out-patient pulmonary clinic. Only a third were found to be skilled in its use. About half were completely unable to use it properly, and 17% used it in a suboptimal way. Remarkably, only 40% had been taught anything with regard to its use. About 75% of the suboptimal users significantly improved their skill in its use immediately after receiving a single individual teaching and corrective demonstration session. While 15% failed to learn the proper use of the PI, many of those who improved immediately after a single teaching session retained the learned skills for months.

We conclude that the physician who recommends the use of a PI is responsible for the patient's being taught its proper use in a demonstration session. Skill in its use should be reassessed periodically during the entire treatment period.

Pulmonary Hypertension and Multi-Valvular Damage Caused by Anorectic Drugs

Serge E. Goldstein, Yair Levy, Yehuda Shoenfeld

Medical Dept. B and Institute for Immunological Disease Research, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Marked obesity is an independent risk factor for multisystem morbidity. The use of anorectic drugs is an aggressive strategy for weight reduction. It appears to be an easy way of dealing with the problem, because the patient needn't change his behavior. However, such treatment is not harmless. At the end of the 60's an outbreak of pulmonary hypertension was associated with the drug aminorex, and it was soon withdrawn from the market. 30 years later it became clear that new-generation anorectic drugs (fenfluramine, dexfenfluramine, phentermine), which were being used world-wide, lead to both pulmonary hypertension and valvular damage.

We describe a woman of 70 with both these complications which developed after prolonged anorectic therapy with a fenfluramine-phentermine combination.

Miliary and Reticulo-Nodular Pulmonary Brucellosis

Nasser Gattas, Norman Loberant, David Ri

Medical Dept. B and Radiology Depts., Western Galilee Regional Hospital, Nahariya and Rappaport Faculof Medicine, The Technion, Haifa

Brucellosis is a classical zoonosis caused by a Gram-negative bacillus of the genus Brucella. Human brucellosis can either be acute or chronic and present with a variety of manifestations, mostly with fever and signs of musculo-skeletal involvement. It may be complicated by involvement of the cardiovascular, central nervous or genito-urinary systems. However, pulmonary brucellosis is a rare complication.

We report a case of miliary and reticulo-nodular brucellar pneumonia with positive blood and sputum cultures and positive serological tests. To the best of our knowledge this is the first case to be reported from Israel of miliary pneumonia with sputum positive for brucellosis.

Spontaneous Internal Jugular Vein Thrombosis Complicating Chronic Pulmonary Disease

Nir Hilzenrat, Edit Liberty, Luna Avnon

Depts. of Medicine B and E, and Pulmonary Disease Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba

Spontaneous internal jugular thrombosis is a rare vascular disorder. It usually occurs as a result of external pressure due to a tumor, infection or as a result of damage to the vessel wall after trauma or central venous catheterization. We report a 35-year-old woman who suffered from severe pulmonary hypertension due to chronic cystic lung disease. She was admitted due to sudden, severe, right-sided neck pain. Internal jugular occlusion by a thrombus was demonstrated by ultrasound and CT-scans but no apparent cause was found. We postulated that the important factors in the development of her thrombosis were stasis due to pulmonary hypertension and high blood viscosity.

Nasopharyngeal Colonization with Streptococcus Pneumoniae in Pediatric Respiratory Infections

Isaac Srugo, Irena Chystiakov, Ella Cohen, Yoram Tal, Michael Jaffe

Clinical Microbiology and Pediatric Depts., Bnai Zion Medical Center and Technion Faculty of Medicine, Haifa

During the winter of 1995, nasopharyngeal colonization of Streptococcus pneumoniae was evaluated in 204 children with respiratory infection and 107 normal control children. There was no difference in gender or mean age between the groups, and no difference in carrier rate between sick (24.5%) and normal (22%) children (p=0.6). Carrier rates were 19%, 32%, 31% and 17% at 6, 12, 24 and 48 months, respectively. Penicillin-resistant pneumococci (PRP) were found in 42% of sick and 16.6% of normal children, (p<0.05). Resistance to more than 2 antibiotics was found in 28% of sick and in 12.5% of normal children. PRP were found in 67% and 34% of sick children with and without prior antibiotic treatment (p<0.05). We conclude that there is no difference in the carrier rate of Streptococcus pneumoniae between sick and normal children. However, the high prevalence of PRP in children with respiratory infections is probably due to prior antibiotic treatment.

Massive Pulmonary Embolism

Ron Ben Abraham, Eran Segal, Dov Freimark, Elinor Goshen, Hanoch Hod, Jacob Lavee, Zvi Ziskind, Azriel Perel

Depts. of Anesthesiology and Intensive Care, Cardiology, Nuclear Medicine and Cardiac Surgery, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Pulmonary embolism is a common event in hospitalized patients. In some cases it presents with hemodynamic collapse, indicating massive obliteration of the pulmonary vasculature and has a very grim prognosis; 2/3 of such patients die within 2 hours of onset of symptoms. We describe our experience in 13 patients with massive pulmonary embolism. An aggressive diagnostic and therapeutic approach, utilizing sophisticated imaging techniques, thrombolytic therapy and surgery, led to the survival of 8 of the patients. Our experience supports an aggressive approach in these seriously ill patients.

Community-Acquired Pneumonia in the Elderly: Guidelines for Hospitalization

Jacob Feldman, Abraham Yarezky, Carola Vigder

Geriatric. Dept., Meir Hospital, Kfar Saba and Sakler Faculty of Medicine, Tel Aviv University

A prospective study was carried out among elderly patients with community-acquired pneumonia to determine if there are any specific features that could help in deciding whether to hospitalize, or to treat in the community. We concluded that there is no correlation between clinical presentation of pneumonia and outcome, except for impairment of consciousness. Laboratory data showed a correlation between oxygen saturation in arterial blood, levels of hemoglobin and albumin, and outcome. Sputum culture was not helpful in deciding about diagnosis and treatment, which remain empiric. These patients should be treated at home if conditions permit. Recommendations are made for improving such conditions.

Recurrent Tuberculosis in a Psychiatric Hospital

A. Zeenreich, B. Gochstein, A. Grinshpoon, M. Miron, J. Rosenman, I. Ben-Dov

Pulmonary and Radiology Institutes, Chaim Sheba Medical Center, Tel Hashomer and Tel Aviv University; Israel Ministry of Health; and Gan Meged Hospital

During 1987-1996, 39 of 720 patients hospitalized (most for severe schizophrenia) were diagnosed as having active pulmonary tuberculosis (5.4%, 975 per 105 per year). In 1992-1993, after a cluster of 5 cases was found, all patients were screened by PPD skin test and chest X-ray and 16 more cases were identified. Diagnosis was confirmed bacteriologically in only 10 of them but there were typical radiological findings in the others. 39 were treated with a multi-drug regimen. In addition, 333 exposed patients and 21% who had converted their skin tests were given isoniazid preventive therapy. A small increase in levels of liver enzymes was common, but significant abnormality (over 4 times the upper limit of normal) was found in only 7 patients, in whom therapy was therefor stopped or changed. During a follow-up period of 4 years, 2 more developed tuberculosis and 33 converted their PPD reactivity status. We conclude that an outbreak of tuberculosis in a psychiatric hospital can be controlled with a relatively low rate of side-effects by using systematic diagnostic and therapeutic measures. However, single step screening is not sufficient. Routine screening of all new patients, a high index of suspicion and contact investigation are needed.