Edward G. Abinader, MD FRCPI, Dawod Sharif, MD, Arie Shefer, MD and Johanan Naschitz, MD
Background: Long-term follow-up in apical hypertrophic cardiomyopathy is rare.
Objective: To study the natural history of the disease.
Methods: We followed 11 patients, 5 women and 6 men, for 5-20 years.
Results: At presentation all 11 patients had typical features of apical hypertrophic cardiomyopathy, with dyspnea in 3 and chest pains in 8, of whom 5 were typical of angina and 3 had myocardial infarction. R-wave voltage and T-wave negativity progressively decreased in magnitude at serial electrocardiograms in four patients. Perfusion defects were detected on thallium myocardial scintigraphy in three, increased apical uptake in two, and normal in one patient. Apical aneurysm with normal coronary arteries developed in a patient who had sustained ventricular tachycardia. All of the 10 catheterized patients had normal coronaries except for one with significant left anterior descending artery stenosis and another with a minor lesion. Symptomatic sustained ventricular tachycardia was found in two patients, one of whom required the implantation of an internal cardioverter-defibrillator.
Conclusions: Apical hypertrophic cardiomyopathy may develop morphologic and electrocardiographic changes with life-threatening arrhythmias necessitating close follow-up and treatment.
Zeev Rotstein, MD, MHA, Rachel Wilf-Miron, MD, MPH, Bruno Lavi BA, Daniel S. Seidman, MD, MMSc, Poriah Shahaf, MD, MBA, Amir Shahar, MD, MPH, Uri Gabay, MD, MPH and Shlomo Noy, MD, MBA
Background: The emergency department is one of the hospital’s busiest facilities and is frequently described as a bottleneck. Management by constraint is a managerial methodology that helps to focus on the most critical issues by identifying such bottlenecks. Based on this theory, the benefit of adding medical staff may depend on whether or not physician availability is the bottleneck in the system.
Objective: To formulate a dynamic statistical model to forecast the need for allocating additional medical staff to improve the efficacy of work in the emergency department, taking into account patient volume.
Methods: The daily number of non-trauma admissions to the general ED was assessed for the period 1 January 1992 to 1 December 1995 using the hospital computerized database. The marginal benefit to shortening patient length of stay in the ED by adding a physician during the evening shift was examined for different patient volumes. Data were analyzed with the SAS software package using a Gross Linear Model.
Results: The addition of a physician to the ED staff from noon to midnight significantly shortened patient LOS: an average decrease of 6.61 minutes for 80–119 admissions (P<0.001). However, for less than 80 or more than 120 admissions, adding a physician did not have a significant effect on LOS in the ED.
Conclusions: The dynamic model formulated in this study shows that patient volume determines the effectiveness of investing manpower in the ED. Identifying bottleneck critical factors, as suggested by the theory of constraints, may be useful for planning and coordinating emergency services that operate under stressful and unpredictable conditions. Consideration of patient volume may also provide ED managers with a logical basis for staffing and resource allocation.
Moshe Wald, MD, Sarel Halachmi, MD, Gilad Amiel, MD, Shahar Madjar, MD, Michael Mullerad, MD, Ines Miselevitz, MD, Boaz Moskovitz, MD and Ofer Nativ, MD
Background: The bladder tumor antigen stat is a simple and fast one-step immunochromatographic assay for the detection of bladder tumor-associated antigen in urine.
Objectives: To evaluate the BTA stat in non-bladder cancer patients in order to identify the categories contributing to its low specificity.
Methods: A single voided urine sample was collected from 45 patients treated in the urology clinic for conditions not related to bladder cancer. Each urine sample was examined by BTA stat test and cytology.
Results: The overall specificity of the BTA stat test was 44%, which was significantly lower than that of urine cytology, 90%. The false positive rates for BTA stat test vary among the different clinical categories, being highest in cases of urinary tract calculi (90%), and benign prostatic hypertrophy (73%). Exclusion of these categories from data analysis improved BTA stat specificity to 66%.
Conclusions: Clinical categories contributing to low BTA stat specificity can be identified, and their exclusion improves the specificity of this test.
Konstantin Lavrenkov, MD, PhD, Sofia Man, MD, David B. Geffen, MD and Yoram Cohen, MD
Background: Recent years have brought significant progress to the development of hormonal therapies for the treatment of breast cancer. Several new agents have been approved for the treatment of breast cancer in the metastatic setting, among which is the new non-steroidal aromatase inhibitor, anastrozole, introduced for clinical use in Israel in March 1997.
Objectives: To evaluate the response rate and survival duration of patients treated with anastrozole for metastatic breast cancer, who had previously received at least one line of hormonal therapy.
Methods: Anastrozole was administered to 37 patients with metastatic breast cancer. The median age was 64 years. Estrogen receptor was positive in 20 patients, negative in 10 and unknown in 7. All patients were previously treated with tamoxifen in the adjuvant setting or as first-line hormonal therapy for metastatic disease. Anastrozole was given orally, 1 mg/day. Response was evaluated 2 months after the initiation of treatment and reevaluated every 2 months. Therapy was given until disease progression. Ten ER-negative patients were excluded from the final analysis.
Results: Twenty-seven patients were eligible for response and toxicity analysis. The median follow-up was 20 months. One patient (3.7%) achieved complete response and remains free of disease 28 months after start of therapy. No partial responses were seen. Twenty patients (74%) had stable disease. Two year actuarial survival was 57%. Median survival was 26.5 months after starting therapy and median progression free survival was 11 months. The toxicity was mild: one patient (3.7%) complained of weight gain and one patient (3.7%) had mild fatigue.
Conclusion: Although the response rate was low, hormonal therapy with anastrozole seems to be beneficial in terms of disease stabilization, freedom from progression, and overall survival without serious toxicity.
Ido Solt, MD, Sohair Ganadry, MD and Zeev Weiner, MD
Background: Visual interpretation of fetal heart rare monitoring is subject to intra and inter observer variability.
Objective: To examine the effect of intrapartum administration of meperidine and promethazine on fetal heart activity measured by a computerized system.
Methods: Fourteen healthy women with normal pregnancies at term were studied during the active phase of labor. Fetal heart rate was recorded with the Oxford Sonicaid system 8000. Recordings were performed for 40 minutes prior to and after maternal intravenous administration of meperidine 50 mg with promethazine 25 mg.
Results: The combination of meperidine and promethazine caused a significant decrease in the number of accelerations of 10 beats per minute (9.7 versus 2.6, P = 0.002) and 15 beats per minute (5.2 vs. l.4, P = 0.003), time spent in episodes of high variation (14.8 vs. 2.0, P = 0.005) and short-term variation (7.8 vs. 5.0, P = 0.003). On the other hand there was an increase in the time spent in episodes of low variation (5.3 vs. 19.7, P = 0.009).
Conclusions: Maternal administration of meperidine with promethazine has a significant effect on FHR indices during the active phase of normal labor.
Alp Aydinalp, MD, Alice Wishniak, MD, Lily van den Akker-Berman, MD, Tsafrir Or and Nathan Roguin, MD
Background: Myocardial infarction-associated pericarditis is a common cause of chest pain following MI, its frequency depending on how it is defined.
Objectives: To investigate the incidence of acute pericarditis and pericardial effusion in the acute phase of ST-elevation MI treated with thrombolytic therapy.
Methods: The study group comprised 159 consecutive patients fulfilling the criteria for acute MI who were admitted to our department during 18 months. Infarct-associated pericarditis was defined as the finding of a pericardial friction rub, a typical pleuropericardial pain, or both. All patients underwent physical examination of the cardiovascular system four times daily for 7 days, as well as daily electrocardiogram and echo Doppler examinations.
Results: Fourteen patients (8.8%) developed a friction rub and 11 patients (6.9%) had a mild pericardial effusion. Six patients (4.0%) had both a friction rub and pericardial effusion. Two patients had a friction rub for more than 7 days. Pleuropericardial chest pain was present in 31 patients (19.5%) but only 7 of them had a friction rub. The in-hospital mortality rate was 1.3% and no mortality was observed in the acute pericarditis group.
Conclusion: The incidence of signs associated with acute pericarditis was lower in MI patients treated with thrombolysis, compared with historical controls, when a friction rub and/or pericardial effusion was present. There was no significant reduction in the incidence of pleuropericardial chest pain.
Guy Amit, MD, Patrizia Cohen, MD and Zvi Ackerman, MD
Background: Nitrofurantoin is a commonly prescribed urinary antiseptic. Hepatic injury has been associated with its use.
Objectives: To present three patients in whom long-term exposure to the drug resulted in chronic active hepatitis, and review the epidemiology, clinical immunology, histopathology, pathogenetic features and treatment of previously reported cases.
Findings: Withdrawing nitrofurantoin once the diagnosis was suspected did not lead to remission of the liver disease and glucocorticoids had to be administered. One patient died of liver failure.
Conclusions: Awareness of this unusual side effect of nitrofurantoin is important and caution should be exerted before prescribing it. Over the past years new insight into the immune nature of this drug has emerged.