The Israel Medical Association journal : IMAJ, 2007
Patients with end-stage renal disease are at high risk of mycobacterial infection. To analyze the... more Patients with end-stage renal disease are at high risk of mycobacterial infection. To analyze the difficulties in reaching an accurate diagnosis of tuberculosis in dialysis patients. We conducted a retrospective follow-up of patients who attended our peritoneal and hemodialysis units during the 10 year period 1995-2005. Our dialysis unit diagnosed 10 cases of tuberculosis caused by Mycobacterium tuberculosis and 9 cases of Mycobacterium other than tuberculosis. In the former group, five patients had Mycobacterium in the sputum, which was diagnosed by intraabdominal mass biopsy in one, culture of the gastric juices in one, and pleural fluid culture or pleural biopsy in three. One of these patients was suffering from pleural TB as well as Potts disease. Of the patients with Mycobacterium other than tuberculosis, five were diagnosed by sputum cultures, three by urine cultures and one in peritoneal fluid. Differences in treatment and outcome were also reviewed. The diagnosis of TB in di...
Spontaneous internal jugular thrombosis is a rare vascular disorder. It usually occurs as a resul... more 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.
We evaluated the significance of first visits to our pulmonary clinic with regard to diagnosis an... more We evaluated the significance of first visits to our pulmonary clinic with regard to diagnosis and treatment by reviewing records of 287 new referrals by medical care providers (Sept. 1998-Feb. 1999). At the first visit the diagnosis was changed in 30%, and treatment in 40%. These are minimal figures because evaluation had not been completed nor the diagnosis determined in all cases, while further investigation and follow-up continued. In light of these findings, we believe that recent pressure on primary care physicians to avoid referrals to specialty clinics would result in short-term savings, but in the long term, would increase expenses and diminish quality of care. It is important to consider ways to maximize the interaction between the primary care physician and the specialist to maintain quality of care and decreases costs.
Chronic obstructive pulmonary disease (COPD) is characterized by progressive exertional and resti... more Chronic obstructive pulmonary disease (COPD) is characterized by progressive exertional and resting dyspnea and is associated with major co-morbidities. Hemoglobin level disorders (anemia and polycythemia) prevalence among patients and the relationship between them and the clinical expression are still not characterized unequivocally. The main purpose of this work is to test the association between anemia and hospitalizations. The presence of such a link may promote the diagnosis and treatment aimed at the patient's hemoglobin levels. Anemia in patients with COPD is associated with an increased number of hospitalizations. A retrospective cohort study analysis, conducted on a group of COPD patients (n = 333) followed in the Pulmonology Institute of the Soroka University Medical Center in the years 2003-2009. Demographic physiological and clinical characteristics were compared between anemic, polycythemic and normal hemoglobin patients. Using statistical models, we examined the re...
A case of acute intoxication presented as toxic pneumonitis after exposure to Roundup (glyphosate... more A case of acute intoxication presented as toxic pneumonitis after exposure to Roundup (glyphosate) (Solaris Group, Monsanto; San Ramon, CA) herbicide in an agriculture worker. The correct etiologic factor causing this specific clinical picture was identified only 2 weeks later, after a thorough occupational history was taken and meticulous delineation of the working conditions and exposures of the involved worker were made. As a rule, occupational related diseases are not readily elucidated by nonoccupational physicians. However, most acute intoxication events are first encountered by such physicians. In these situations, rapid and comprehensive evaluation is necessary in order to clearly identify the causative agent(s) and to initiate the appropriate treatment. Consulting occupational physicians at this early stage may facilitate early and accurate diagnosis.
Archives of Environmental Health: An International Journal, 1998
Medical staff of two Negev kibbutzim invited epidemiologists to help them investigate cancer rate... more Medical staff of two Negev kibbutzim invited epidemiologists to help them investigate cancer rates among their members. Our objectives were (a) to determine whether the cancer rate in the kibbutzim was elevated or abnormal and (b) to determine the role of agricultural and other relevant exposures if cancer incidence was elevated. We validated cases of cancer by kibbutz records and by surveying other information; we computed expected values on the basis of the age-sex-calendar period and site-specific cancer incidence rates reported by the Israel Cancer Registry for the entire population; and we compared the data for the 2 kibbutzim with data derived for similar age and sex groups in 2 other kibbutzim, which were assumed not to have increased cancer rates. In addition, we planned and conducted a case-referent study, including the design, pretest, and use of questionnaires, including data about lifetime exposures (i.e., type of work and its duration, agricultural and industrial chemicals, smoking and alcohol use, demographic variables, health experiences, and family history). In only one of the kibbutzim, for which high cancer rates were suspected, was there significant excess for all sites in persons who were less than 40 y of age. In one of the "comparison" kibbutzim, we found increased cancer rates overall. Much of the excess in the high cancer kibbutzim was in hematological cancer (i.e., leukemia and lymphoma). Multiple years of work in fields, orchards, and landscape, as well as orchard work that commenced before 1960, were associated with increased risk of cancer (p < .08). We also found an association between cancer rate and numbers of industrial chemicals used (p < .08). Pipe and cigarette smoking were also associated with increased cancer incidence. In the multivariate analysis, the association with calendar year in which orchard work was started and multiple exposures to industrial chemicals was stronger than associations noted in the univariate analyses. Although duration of agricultural work or multiple industrial exposures were clearly associated with increase in cancer risk, we were unable to identify the causal role of specific agent(s). Nonetheless, educational programs for cancer prevention can be based, in part, on the results of such a study.
We report a hemodialysis patient with acute hypercapnic respiratory failure managed on noninvasiv... more We report a hemodialysis patient with acute hypercapnic respiratory failure managed on noninvasive intermittent positive pressure ventilation and progressive metabolic acidosis. Dialysate bicarbonate concentration of 25 mEq/l was associated with exacerbation of metabolic acidosis, while higher dialysate bicarbonate concentration of 30 mEq/l induced a dangerous increase in PCO(2) level. Excessive bicarbonate buffering and CO(2) production induced by severe metabolic acidosis, malnourishment and tissue hypoxia, could explain inadequate correction of metabolic acidosis and worsening of hypercapnia in this patient. Our findings suggest the need for close monitoring of blood gases and cautious modulation of dialysate bicarbonate concentration in the presence of progressive metabolic acidosis in hypercapnic hemodialysis patients.
ABSTRACT Desertification and climate warming trends pose a global ecological and environmental pr... more ABSTRACT Desertification and climate warming trends pose a global ecological and environmental problem. The city of Be'er Sheva (Southern Israel) is located at the margins of the Sahara-Arabian dust belt and is frequently subjected to dust storm (DS) with high levels of particular matter (PM), making it an ideal location for investigating the health effects. The objective of this study was to investigate the impact of DS on patients with chronic obstructive pulmonary disease (COPD) in an arid urban environment. We obtained health data of patients 18 years or older discharged from Soroka University Medical Center (SUMC) with a primary diagnosis consistent with COPD exacerbation. Data on meteorological parameters and air pollutants were obtained from two monitoring stations in the city of Be'er Sheva. Time series analysis was performed to assess the COPD exacerbation incidence rate ratio (IRR) resulting from dust storm exposures. We found that daily PM 10 concentrations were extremely high during dust storm days, and there is a positive association between dust storms and rate of hospitalization for COPD exacerbation: (IRR = 1.16; 95 %CI, 1.08–1.24; p<0.001). In addition, an increase per interquartile range in PM 10 concentrations increases the IRR by 1.03 (95 %CI, 1.01–1.06; p<0.001). The effect increased with age and was higher in women. Short-term exposure to natural PM 10 during dust storms increases the risk for hospital admission for COPD exacerbation. Further studies are needed to understand the impact of individual characteristics on the health effects of outdoor and indoor PM pollution from dust storms.
The Israel Medical Association journal : IMAJ, 2007
Patients with end-stage renal disease are at high risk of mycobacterial infection. To analyze the... more Patients with end-stage renal disease are at high risk of mycobacterial infection. To analyze the difficulties in reaching an accurate diagnosis of tuberculosis in dialysis patients. We conducted a retrospective follow-up of patients who attended our peritoneal and hemodialysis units during the 10 year period 1995-2005. Our dialysis unit diagnosed 10 cases of tuberculosis caused by Mycobacterium tuberculosis and 9 cases of Mycobacterium other than tuberculosis. In the former group, five patients had Mycobacterium in the sputum, which was diagnosed by intraabdominal mass biopsy in one, culture of the gastric juices in one, and pleural fluid culture or pleural biopsy in three. One of these patients was suffering from pleural TB as well as Potts disease. Of the patients with Mycobacterium other than tuberculosis, five were diagnosed by sputum cultures, three by urine cultures and one in peritoneal fluid. Differences in treatment and outcome were also reviewed. The diagnosis of TB in di...
Spontaneous internal jugular thrombosis is a rare vascular disorder. It usually occurs as a resul... more 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.
We evaluated the significance of first visits to our pulmonary clinic with regard to diagnosis an... more We evaluated the significance of first visits to our pulmonary clinic with regard to diagnosis and treatment by reviewing records of 287 new referrals by medical care providers (Sept. 1998-Feb. 1999). At the first visit the diagnosis was changed in 30%, and treatment in 40%. These are minimal figures because evaluation had not been completed nor the diagnosis determined in all cases, while further investigation and follow-up continued. In light of these findings, we believe that recent pressure on primary care physicians to avoid referrals to specialty clinics would result in short-term savings, but in the long term, would increase expenses and diminish quality of care. It is important to consider ways to maximize the interaction between the primary care physician and the specialist to maintain quality of care and decreases costs.
Chronic obstructive pulmonary disease (COPD) is characterized by progressive exertional and resti... more Chronic obstructive pulmonary disease (COPD) is characterized by progressive exertional and resting dyspnea and is associated with major co-morbidities. Hemoglobin level disorders (anemia and polycythemia) prevalence among patients and the relationship between them and the clinical expression are still not characterized unequivocally. The main purpose of this work is to test the association between anemia and hospitalizations. The presence of such a link may promote the diagnosis and treatment aimed at the patient's hemoglobin levels. Anemia in patients with COPD is associated with an increased number of hospitalizations. A retrospective cohort study analysis, conducted on a group of COPD patients (n = 333) followed in the Pulmonology Institute of the Soroka University Medical Center in the years 2003-2009. Demographic physiological and clinical characteristics were compared between anemic, polycythemic and normal hemoglobin patients. Using statistical models, we examined the re...
A case of acute intoxication presented as toxic pneumonitis after exposure to Roundup (glyphosate... more A case of acute intoxication presented as toxic pneumonitis after exposure to Roundup (glyphosate) (Solaris Group, Monsanto; San Ramon, CA) herbicide in an agriculture worker. The correct etiologic factor causing this specific clinical picture was identified only 2 weeks later, after a thorough occupational history was taken and meticulous delineation of the working conditions and exposures of the involved worker were made. As a rule, occupational related diseases are not readily elucidated by nonoccupational physicians. However, most acute intoxication events are first encountered by such physicians. In these situations, rapid and comprehensive evaluation is necessary in order to clearly identify the causative agent(s) and to initiate the appropriate treatment. Consulting occupational physicians at this early stage may facilitate early and accurate diagnosis.
Archives of Environmental Health: An International Journal, 1998
Medical staff of two Negev kibbutzim invited epidemiologists to help them investigate cancer rate... more Medical staff of two Negev kibbutzim invited epidemiologists to help them investigate cancer rates among their members. Our objectives were (a) to determine whether the cancer rate in the kibbutzim was elevated or abnormal and (b) to determine the role of agricultural and other relevant exposures if cancer incidence was elevated. We validated cases of cancer by kibbutz records and by surveying other information; we computed expected values on the basis of the age-sex-calendar period and site-specific cancer incidence rates reported by the Israel Cancer Registry for the entire population; and we compared the data for the 2 kibbutzim with data derived for similar age and sex groups in 2 other kibbutzim, which were assumed not to have increased cancer rates. In addition, we planned and conducted a case-referent study, including the design, pretest, and use of questionnaires, including data about lifetime exposures (i.e., type of work and its duration, agricultural and industrial chemicals, smoking and alcohol use, demographic variables, health experiences, and family history). In only one of the kibbutzim, for which high cancer rates were suspected, was there significant excess for all sites in persons who were less than 40 y of age. In one of the "comparison" kibbutzim, we found increased cancer rates overall. Much of the excess in the high cancer kibbutzim was in hematological cancer (i.e., leukemia and lymphoma). Multiple years of work in fields, orchards, and landscape, as well as orchard work that commenced before 1960, were associated with increased risk of cancer (p < .08). We also found an association between cancer rate and numbers of industrial chemicals used (p < .08). Pipe and cigarette smoking were also associated with increased cancer incidence. In the multivariate analysis, the association with calendar year in which orchard work was started and multiple exposures to industrial chemicals was stronger than associations noted in the univariate analyses. Although duration of agricultural work or multiple industrial exposures were clearly associated with increase in cancer risk, we were unable to identify the causal role of specific agent(s). Nonetheless, educational programs for cancer prevention can be based, in part, on the results of such a study.
We report a hemodialysis patient with acute hypercapnic respiratory failure managed on noninvasiv... more We report a hemodialysis patient with acute hypercapnic respiratory failure managed on noninvasive intermittent positive pressure ventilation and progressive metabolic acidosis. Dialysate bicarbonate concentration of 25 mEq/l was associated with exacerbation of metabolic acidosis, while higher dialysate bicarbonate concentration of 30 mEq/l induced a dangerous increase in PCO(2) level. Excessive bicarbonate buffering and CO(2) production induced by severe metabolic acidosis, malnourishment and tissue hypoxia, could explain inadequate correction of metabolic acidosis and worsening of hypercapnia in this patient. Our findings suggest the need for close monitoring of blood gases and cautious modulation of dialysate bicarbonate concentration in the presence of progressive metabolic acidosis in hypercapnic hemodialysis patients.
ABSTRACT Desertification and climate warming trends pose a global ecological and environmental pr... more ABSTRACT Desertification and climate warming trends pose a global ecological and environmental problem. The city of Be'er Sheva (Southern Israel) is located at the margins of the Sahara-Arabian dust belt and is frequently subjected to dust storm (DS) with high levels of particular matter (PM), making it an ideal location for investigating the health effects. The objective of this study was to investigate the impact of DS on patients with chronic obstructive pulmonary disease (COPD) in an arid urban environment. We obtained health data of patients 18 years or older discharged from Soroka University Medical Center (SUMC) with a primary diagnosis consistent with COPD exacerbation. Data on meteorological parameters and air pollutants were obtained from two monitoring stations in the city of Be'er Sheva. Time series analysis was performed to assess the COPD exacerbation incidence rate ratio (IRR) resulting from dust storm exposures. We found that daily PM 10 concentrations were extremely high during dust storm days, and there is a positive association between dust storms and rate of hospitalization for COPD exacerbation: (IRR = 1.16; 95 %CI, 1.08–1.24; p<0.001). In addition, an increase per interquartile range in PM 10 concentrations increases the IRR by 1.03 (95 %CI, 1.01–1.06; p<0.001). The effect increased with age and was higher in women. Short-term exposure to natural PM 10 during dust storms increases the risk for hospital admission for COPD exacerbation. Further studies are needed to understand the impact of individual characteristics on the health effects of outdoor and indoor PM pollution from dust storms.
Uploads
Papers by L. Avnon