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עמוד בית
Fri, 14.06.24

October 2001

Original Articles
Alexander Belenky, MD, PhD, Maya Cohen, MD and Gil N. Bachar, MD

Background: Leiomyoma is the common benign tumor of the female genital tract. The traditional treatment is hysterectomy, myomectomy or medical therapy by hormonal manipulation. Uterine arterial embolization, a recognized treatment for acute pelvic hemorrhage, has recently been applied to the management of non-acute uterine hemorrhage due to leiomyoma.

Objective: To describe our experience with uterine arterial embolization for the management of uterine fibroid.

Methods: Uterine arterial embolization was performed in nine patients with leiomyomas in whom medical therapy failed and who sought to avoid surgery.

Results: Follow-up ultrasound examination after 2 months revealed an average reduction in fibroid volume of 38%. There were no early or long-term complications.

Cunclusions: Uterine arterial embolization appears to be effective and safe in the management of symptomatic leiomyomas. It is a promising alternative to myomectomy or hysterectomy and warrants further investigation in this setting.

Jihad Bishara, MD, Avivit Golan-Cohen, MD, Eyal Robenshtok, MD, Leonard Leibovici, MD and Silvio Pitlik, MD

Background: Erysipelas is a skin infection generally caused by group A streptococci. Although penicillin is the drug of choice, some physicians tend to treat erysipelas with antibiotics other than penicillin.

Objectives: To define the pattern of antibiotic use, factors affecting antibiotic selection, and outcome of patients treated with penicillin versus those treated with other antimicrobial agents.

Methods: A retrospective review of charts of adult patients with discharge diagnosis of erysipelas was conducted for the years 1993-1996.

Results: The study group comprised 365 patients (median age 67 years). In 76% of the cases infection involved the leg/s. Predisposing condition/s were present in 82% of cases. Microorganisms were isolated from blood cultures in only 6 of 176 cases (3%), and Streptococcus spp. was recovered in four of these six patients. Cultures from skin specimens were positive in 3 of 23 cases. Penicillin alone was given to 164 patients (45%). Other antibiotics were more commonly used in the second half of the study period (P < 0.0001) in patients with underlying conditions (P = 0.06) and in those hospitalized in the dermatology ward (P< 0.0001). Hospitalization was significantly shorter in the penicillin group (P= 0.004). There were no in-hospital deaths.

Conclusions: We found no advantage in using antibiotics other than penicillin for treating erysipelas. The low yield of skin and blood cultures and their marginal impact on manage­ment, as well as the excellent outcome suggest that this infection can probably be treated empirically on an outpatient basis.

Tuvia Ben-Gal, MD and Nili Zafrir, MD

Background: The evaluation of hospitalized patients with chest pain and non-diagnostic electrocardiogram is problematic and the optimal cost-effective strategy for their management controversial.

Objectives: To determine the utility of myocardial perfusion imaging with thallium-201 for predicting outcome of hospitalized patients with chest pain and a normal or non-diagnostic ECG.

Methods: On pain cessation, 109 hospitalized patients, age 61+14 years (mean+SD), with chest pain and non-diagnostic ECG underwent stress myocardial perfusion SPECT imaging with thallium-201. Costs related to their management were calculated. The occurrence of non-fatal myocardial infarction or cardiac death was recorded at 12+5 months follow-up.

Results: A normal SPECT was found in 84 patients (77%). During one year follow-up, only 1 (1.2%) compared to 7 (28%) cardiac events (6 myocardial infarctions, 1 cardiac death) occurred in patients with normal versus abnormal scans respectively (P < 0.0001). Negative predictive value and accuracy of the method were 99% and 83% respectively. Multivariate regression analysis identified an abnormal SPECT as the only independent predictor of adverse cardiac event (P = 0.0016). Total cost from admission until discharge was 11,193 vs. 31,079 shekels (P < 0.0001) for normal and abnormal scan. Considering its high negative predictive value, shortening the hospital stay from admission until scan performance to 2 days would result in considerably reduced management costs (from NIS 11,193 to 7,243) per patient.

Conclusion: Stress SPECT applied to hospitalized patients with chest pain and a normal or non-diagnostic ECG is safe, highly accurate and potentially cost effective in distinguishing between Iow and high risk patients.

Sergey Lyass, MD, Tamar Sela, MD, Pinchas D. Lebensart, MD and Michael Muggia-Sullam

Background: The exact value of follow-up ultrasonogra­phy and computed tomography in the non-operative manage­ment of blunt splenic injuries is not yet defined. Although follow-up studies have been recommended to detect possible complications of the initial injury, evidence shows that routine follow-up CT scans usually do not affect management of these patients.

Objective: To determine whether follow-up imaging influences the management of patients with blunt splenic injury.

Methods: Between 1995 and 1999, 155 trauma patients were admitted with splenic trauma to a major trauma center. Excluded from the study were trauma patients with penetrating injuries, children, and those who underwent immediate laparotomy due to hemodynamic instability or associated injuries. The remaining trauma patients were managed conservatively. Splenic injury was suspected by focused abdominal sonography for trauma, upon admission, and confirmed by CT scan. The severity of splenic injury was graded from I to V. The clinical outcome was obtained from medical records.

Results: We identified 32 adult patients (27 males and 5 females) with blunt splenic injuries who were managed non-operatively. In two patients it was not successful, and splenectomy was performed because of hemodynamic dete­rioration. The remaining 30 stable patients were divided into two groups: those who had only the initial ultrasound and CT scan with no follow-up studies (n= 8), and those who under­went repeat follow-up ultrasound or CT scan studies (n = 22). The severity of injury was similar in both groups. In the second group follow-up studies showed normal spleens in 2 patients, improvement in 11, no change in 8, and deterioration in one. All patients in both groups were managed successfully with good clinical outcome.

Conclusion: In the present series the follow-up radiologi­cal studies did not affect patient management. Follow-up imaging can be omitted in clinically stable patients with blunt splenic trauma grade I-III.

Efraim Aizen, MD, Rachel Swartzman, MD and A. Mark Clarfield, MD, FRCPC

Background: Transfer to an emergency room and hospitalization of nursing home residents is a growing problem that is poorly defined and reported.

Objectives: To assess the clinical effectiveness of a pilot project involving hospitalization of nursing home residents directly to an acute-care geriatric department.

Methods: We retrospectively compared the hospitalization in an acute-care geriatric unit of 126 nursing home residents admitted directly to the unit and 80 residents admitted through the emergency room. The variables measured included length of stay, discharge disposition, mortality, cause of hospitalization, chronic medical condition, cognitive state, functional status at admission, and change of functional status during the hospital stay. Follow-up data were obtained from medical records during the 2 year study.

Results: No significant differences between the groups were found for length of stay, mortality, discharge disposition and most characteristics of the hospital stay. The only significant difference was in patients’ mean age, as emergency room patients were significantly older (86 vs. 82.9 years). The most common condition among nursing home patients admitted via the emergency room was febrile disease (36.9%) ,while functional decline was the most common in those coming directly from the nursing home (32.5%). The prevalence of functional dependence and dementia were similar in both groups. Functional status did not change throughout the hospital stay in most patients.

Conclusions: Treatment of selected nursing home residents admitted directly from the nursing home to an acute- care geriatric unit is feasible, medically effective, results in the safe discharge of almost all such patients and provides an alternative to transfer to an emergency room. This study suggests that quality gains and cost-effective measures may be achieved by such a project, although a randomized controlled trial is necessary to support this hypothesis.

Sigal Ringel, MD, Ernesto Kahan, MD, MPH, Revital Greenberg, Shlomo Arieli, MD, Amihood Blay and Matitiahu Berkovitch, MD

Background: Many women stop smoking before or during pregnancy, or while breast-feeding (nursing).

Objectives: To assess the relation between breast-feeding and smoking habits.

Methods: A survey was conducted among 920 women attending family health clinics (group 1) and a maternity department (group 2) on their breast-feeding and smoking habits.

Results: A total of 156 women (16.95%) smoked during pregnancy. A significant correlation was found between breast-feeding and not smoking after delivery (P=0.009 in group 1, P=0.03 in group 2). A higher tendency to nurse was found among women with an uneventful pregnancy, who vaginally delivered a singleton at term weighing 2,500-4000 g, and who received guidance on breast-feeding.

Conclusion: Professional guidance in favor of breast­feeding is crucial to increase the rate of nursing. Encouraging breast-feeding will probably decrease the rate of cigarette smoking.

Maurizio Cutolo, MD, Bruno Seriolo, MD, Carmen Pizzorni, MD and Alberto Sulli, MD
Maurizio Cutolo, MD, Bruno Seriolo, MD, Carmen Pizzorni, MD and Alberto Sulli, MD
Hagit Cohen, PhD, Lily Neumann, PhD, Moshe Kotler, MD and Dan Buskila, MD

Fibromyalgia syndrome is a chronic, painful musculoske­letal disorder of unknown etiology and/or pathophysiology. During the last decade many studies have suggested autonomic nervous system involvement in this syndrome, although contradictory results have been reported. This review focuses on studies of the autonomic nervous system in fibromyalgia syndrome and related disorders, such as chronic fatigue syndrome and irritable bowel syndrome on the one hand and anxiety disorder on the other, and highlights techniques of dynamic assessment of heart rate variability, It raises the potentially important prognostic implications of protracted autonomic dysfunction in patient populations with fibromyalgia and related disorders, especially for cardiovas­cular morbidity and mortality.

Michalis Voulgarelis, MD and Haralampos M. Moutsopoulos, MD, FACP, FRCP (Edin)

Sjogren’s syndrome is a chronic inflammatory process invol­ving primarily the exocrine glands. Its association with lymphoma is well documented. A low grade marginal-zone lymphoma related to mucosa-associated lymphoid tissue is the commonest lymphoid neoplasia in Sjogren’s syndrome. We review the literature and comment on the molecular, clinical, histopathologic and therapeutic aspects of these tumors in Sjogrens syndrome.

Case Communications
Dvora Aharoni, MD, Sergey Mekhmandarov, MD, Menachem Itzchaki, MD, Nurith Hiller, MD and Deborah Elstein, PhD
Leonid feldman, MD, Amalia Kleiner-Baumgarten, MD and Maximo Maislos, MD
Lotan Shilo, MD, Dania Hirsch, MD, Martin Ellis, MD and Louis Shenkman, MD
Medical Missions
Imad Kasis, MD, Lea Lak, MD, Jakov Adler, MD, Rinat Choni, MD, Gila Shazberg, MD, Tewade-Doron Fekede, MD, Ehud Shoshani, MD, Douglas Miller, MD and Samuel Heyman, MD

Background: Following the recent drought in Ethiopia, the Jewish Agency, aided by the Israel Ministry of Foreign Affairs, launched a medical relief mission to a rural district in Ethiopia in May-August 2000.

Objectives: To present the current medical needs and deficiencies in this representative region of Central Africa, to describe the mission’s mode of operation, and to propose alternative operative modes.

Methods: We critically evaluate the current local needs and existing medical system, retrospectively analyze the mission’s work and the patients’ characteristics, and summar­ize a panel discussion of all participants and organizers regarding potential alternative operative modes.

Results: An ongoing medical disaster exists in Ethiopia, resulting from the burden of morbidity, an inadequate health budget, and insufficient medical personnel, facilities and supplies. The mission operated a mobile outreach clinic for 3 months, providing primary care to 2,500 patients at an estimated cost of $48 per patient. Frequent clinical diagnoses included gastrointestinal and respiratory tract infections, skin and ocular diseases (particularly trachoma), sexually trans­mitted diseases, AIDS, tuberculosis, intestinal parasitosis, malnutrition and malaria.

Conclusions: This type of operation is feasible but its overall impact is marginal and temporary. Potential alternative models of providing medical support under such circum­stances are outlined.

Rivka Zissin, MD and Myra Shapiro-Feinberg, MD
Galya Rozen, MD, David R. Samuels, MD and Annat Blank, MD
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