The association between the patient and the physician genders and the likelihood of intensive care unit admission in hospital with restricted ICU bed capacity.

BACKGROUND: Despite the evidence that the patient gender is an important component in the intensive care unit (ICU) admission decision, the role of physician gender and the interaction between the two remain unclear. OBJECTIVE: To investigate the association of both the patient and the physician gender with ICU admission rate of critically ill emergency department (ED) medical patients in a hospital with restricted ICU bed capacity operates with 'closed door' policy. METHODS: A retrospective population-based cohort analysis. We included patients above 18 admitted to an ED resuscitation room (RR) of a tertiary hospital during 2011-12. Data on medical, laboratory and clinical characteristics were obtained. We used an adjusted multivariable logistic regression to analyze the association between both the patient and the physician gender to the ICU admission decision. RESULTS: We included 831 RR admissions, 388 (46.7%) were female patients and 188 (22.6%) were treated by a female physicians. In adjusted multivariable analysis (adjusted for age, diabetes, mode of hospital transportation, first pH and patients who were treated with definitive airway and vasso-pressors in the RR), female-female combination (patient-physician, respectively) showed the lowest likelihood to be admitted to ICU (adjusted OR: 0.21; 95% CI: 0.09-0.51) compared to male-male combination, in addition to a smaller decrease among female-male (adjusted OR: 0.53; 95% CI: 0.32-0.86) and male-female (adjusted OR: 0.43; 95% CI: 0.21-0.89) combinations. CONCLUSION: We demonstrated the existence of the possible gender bias where female gender of the patient and treating physician diminish the likelihood of the restricted health resource use.

Dobutamine stress echocardiography in women with systemic lupus erythematosus: increased occurrence of left ventricular outflow gradient.

Dobutamine stress echocardiography (DSE) is an accurate noninvasive test used for the diagnosis and evaluation of patients with known or suspected coronary artery disease (CAD). The aim of this study was to determine the rate of positive findings in DSE, to define the echocardiographic and clinical characteristics of women with systemic lupus erythematosus (SLE) and to evaluate the safety of DSE in SLE patients. Thirty consecutive SLE patients were enrolled in the study and underwent DSE study. The mean age of patients was 44 years (range 20-76). Mean duration of SLE was 8.1 years and mean SLEDAI was 5.5. None of the DSE tests performed were positive for myocardial ischaemia. A left ventricular outflow gradient (LVOG) was found in 15/28 (54%) patients who completed the test, a result higher than the reported 20% prevalence of this finding in the literature. There were no significant differences in baseline characteristics between patients who developed a gradient and patients in whom a gradient was not found. There were no significant adverse effects during the study. In the general population, LVOG has been reported to be associated with an increased rate of chest discomfort and with a significantly lower prevalence of CAD. Whether this is true for SLE patients requires further study.

Balneotherapy at the Dead Sea area for patients with psoriatic arthritis and concomitant fibromyalgia.

BACKGROUND: Balneotherapy has been successfully used to treat various rheumatic diseases, but has only recently been evaluated for the treatment of fibromyalgia. Since no effective treatment exists for this common rheumatic disease, complementary methods of treatment have been attempted. OBJECTIVES: To assess the effectiveness of balneotherapy at the Dead Sea area in the treatment of patients suffering from both fibromyalgia and psoriatic arthritis. METHODS: Twenty-eight patients with psoriatic arthritis and fibromyalgia were treated with various modalities of balneotherapy at the Dead Sea area. Clinical indices assessed were duration of morning stiffness, number of active joints, a point count of 18 fibrositic tender points, and determination of the threshold of tenderness in nine fibrositic and in four control points using a dolorimeter. RESULTS: The number of active joints was reduced from 18.4 +/- 10.9 to 9 +/- 8.2 (P < 0.001). The number of tender points was reduced from 12.6 +/- 2 to 7.1 +/- 5 in men (P < 0.003) and from 13.1 +/- 2 to 7.5 +/- 3.7 in women (P < 0.001). A significant improvement was found in dolorimetric threshold readings after the treatment period in women (P < 0.001). No correlation was observed between the reduction in the number of active joints and the reduction in the number of tender points in the same patients (r = 0.2). CONCLUSIONS: Balneotherapy at the Dead Sea area appears to produce a statistically significant substantial improvement in the number of active joints and tender points in both male and female patients with fibromyalgia and psoriatic arthritis. Further research is needed to elucidate the distinction between the benefits of staying at the Dead Sea area without balneotherapy and the effects of balneotherapy in the study population.

Manifestations of three HHV-8-related diseases in an HIV-negative patient: immunoblastic variant multicentric Castleman's disease, primary effusion lymphoma, and Kaposi's sarcoma.

We describe a 73-year-old HIV negative patient who presented with symptomatic hypoglycemia. Over the course of several months she was diagnosed with three human herpesvirus-8 related diseases: multicentric Castleman's disease, primary effusion lymphoma and Kaposi's sarcoma. No improvement was observed following cytotoxic therapy and she died 16 months after her initial presentation. The etiology of the hypoglycemia remained obscure over the course of this patient's disease. This case is the first report of a patient with three human herpesvirus-8 related diseases, and the first report of severe hypoglycemia as the presenting symptom of any of these diseases.

Quality of life in systemic lupus erythematosus: a controlled study.

OBJECTIVE: To assess the quality of life (QOL) of patients with systemic lupus erythematosus (SLE) and to compare it with that of healthy women and patients with primary fibromyalgia (FM). METHODS: QOL was evaluated using the QOL scale, which includes 16 items, each scored on a 7 point scale. Healthy controls were chosen from hospital personnel. RESULTS: The study population comprised 75 female patients with SLE, 50 healthy women, and 30 women with primary FM. Compared to controls, patients with SLE had significantly lower scores for the health, work, active recreation, and independence items. The QOL scores were not associated with disease activity. Patients with SLE and FM had significantly lower scores for the health related items compared with patients with SLE without FM. CONCLUSION: The QOL of patients with SLE was found to be impaired compared with controls. FM adversely affects the QOL of patients with SLE.

Balneotherapy at the Dead Sea area for knee osteoarthritis.

BACKGROUND: Balneotherapy at the Dead Sea area has been applied in various inflammatory rheumatic diseases such as rheumatoid arthritis and psoriatic arthritis. The efficacy of balneotherapy at the Dead Sea area for the treatment of degenerative rheumatic diseases has not yet been formally evaluated. OBJECTIVE: To evaluate the efficacy of balneotherapy at the Dead Sea area in patients suffering from osteoarthritis of the knees. METHODS: Forty patients were randomly allocated into four groups of 10 patients. Group I was treated by bathing in a sulphur pool, group 2 by bathing in the Dead Sea, group 3 by a combination of sulphur pool and bathing in the Dead Sea, and group 4 served as the control group receiving no balneotherapy. The duration of balneotherapy was 2 weeks. RESULTS: Significant improvement as measured by the Lequesne index of severity of osteoarthritis was observed in all three treatment groups, but not in the control group. This improvement lasted up to 3 months of follow-up in patients in all three treatment groups. CONCLUSION: Balneotherapy at the Dead Sea area has a beneficial effect on patients with osteoarthritis of the knees, an effect that lastas at least 3 months.

Toxicity of intrapleural Bacillus Calmette-Guérin treatment in animals.

The toxicity of intrapleural Tice strain Bacillus Calmette-Guérin (BCG) infection was tested in hamsters. Doses above 10(6) colony-forming units caused significant systemic infection, which could be controlled with conventional antituberculosis therapy. Living BCG in the pleural space did not prevent the healing of bronchial or vascular closures after pulmonary resection. Prophylactic intrapleural BCG (10(6) colony-forming units) significantly reduced tumor growth in the lungs of mice following i.v. injection of 5 x 10(5) syngeneic sarcoma cells. These animal experiments suggest that intrapleural BCG may be administered in the pleural space after lung resection in limited doses if followed by a complementary course of antimicrobial therapy.

Mycotic wound infections. A new challenge of the surgeon.

Fungal wound infections have become more common because of the increased use of immunosuppressive and antineoplastic agents, prosthetic devices and grafts, broad-spectrum antibiotics, and hyperalimentation. Severe burns, renal failure, and other debilitating conditions also predispose to invasive mycoses. An aggressive diagnostic approach is particularly important, and tissue biopsy specimens are often necessary to establish a diagnosis. Meticulous surgical technique and minimization of the predisposing factors are crucial in the prevention of these infections, and prophylactic antimycotic agents may be of value in selected high-risk patients. Some mycotic wound infections can be managed effectively without systemic therapy; but when systemic agents are needed, combination antifungal therapy may provide improved results without increased drug toxicity.

Combined amphotericin B-flucytosine therapy in Aspergillus pneumonia.

The incidence of aspergillosis is increasing while the prognosis remains dismal. Standard single-drug therapy with amphotericin B offers unacceptably low cure rates. A patient with Aspergillus pneumonia was treated with a synergistic combination of amphotericin B and flucytosine. A prompt clinical response and progressive resolution of the infection were observed. Combination therapy appeared to decrease the dose of amphotericin B needed for effective therapy. It may provide improved results with decreased toxic effects.

Recent advances in the treatment of systemic mycotic infections.

Serious therapeutic problems are posed by the increasing incidence of invasive fungal infections in transplant recipients as well as in patients with compromised immune defenses, prosthetic devices and grafts and several other predisposing factors. A number of new approaches, including combination drug treatment and the development of newer agents, may justify increased optimism in the management of these infections.

BCG immunotherapy: effects of dose and route of administration on survival of mice bearing established tumors.

Bacillus Calmette-Guérin (BCG) was administered in various doses by four different routes to C3H/HeJ mice bearing well-established syngeneic MC-42 fibrosarcomas. Injections of BCG into established primary tumors decreased survival of tumor-bearing mice as compared to saline-injected controls. Of the three dosage groups, high-dose (10(8) viable organisms) intralesional BCG was most detrimental. The injection of low-dose BCG (10(4) organisms) into established tumors or subcutaneously at a distant site also shortened host survival times. Other subcutaneous injections and injections of BCG into the peritoneal or pleural cavities had no significant effect on survival, regardless of dosage. The dose-dependent effects of BCG immunotherapy which may prolong or shorten survival are discussed.

Possible active enhancement of a human cadaver renal allograft with antilymphocyte serum (ALS) and donor bone marrow: case report of an initial attempt.

Nonspecific immunosuppression of transplant patients frequently leads to complications which might be circumvented by inducing donor-specific immune unresponsiveness. Such specific immunosuppression has been produced experimentally, with use of donor antigen and antilymphocyte serum (ALS) for active enhancement. A case is presented in which the recipient of a cadaveric renal allograft (zero antigen match, cross-match negative) was given ALS (first 14 days after operation) and 11 X 10(9) donor bone marrow cells (twenty-fifth postoperative day) along with conventional doses of prednisone and Imuran in an attempt to produce donor-specific immune unresponsiveness. There were no rejection episodes, and serum creatinine remained less than 1.0 mg. per 100 ml. By the second month after transplantation there was no evidence for the persistence of donor erythrocytes or white cells. The conventional immunosuppressive agents were tapered and renal function was normal 8 months after transplantation, when the patient developed fatal peritonitis secondary to perforated sigmoid diverticulitis. At autopsy the renal allograft showed only minimal evidence of rejection. The present case illustrates an attempt to use ALS and donor bone marrow cells for active enhancement of a human cadaveric renal allograft. The infusion of stored donor marrow cells after transplantation is a particularly applicable technique for human cadaveric organ transplantation. The rejection-free course of this patient suggests that attempts to produce active enhancement clinically deserve further trial.

Survey of the current status of the clinical uses of antilymphocyte serum.

A limited degree of effectiveness of antilymphoid globulin in clinical kidney and bone marrow transplantation has been described. It may also be useful for the prolongation of temporary skin allografts for burn patients and may be valuable as an adjunct in the treatment of certain autoimmune diseases. The use of antilymphoid globulin with donor antigen to facilitate allograft enhancement has been reviewed. An instance of possible enhancement of a mismatched cadaveric renal allograft in a highly sensitized recipient given antilymphoid globulin and donor marrow is recorded. Use of antilymphoid globulin to facilitate enhancement with donor antigen is probably the next major application of antilymphoid globulin.

Immunological detection of human bladder carcinoma.

A rabbit antiserum (RABCa) to membrane antigenic extracts of human bladder carcinomas was produced. RABCa failed to detect bladder cancer-specific antigens in gel diffusion reaction against antigenic extracts of bladder carcinoma and normal bladder mucosa. However, RABCa showed higher complement fixation activity against urines from bladder cancer patients compared with normal urines. The micro-complement fixation (CF) assay (108 patients) was positive in 17 of 27 bladder cancer patients (62.9%) compared to only 1 of 29 normals (3.4%). However, 10 of 11 patients with urinary infections also were positive. A micro-Ouchterlony agar gel diffusion assay was also used to study urine samples (118 patients). RABCa produced separate precipitin bands against 20 of 30 bladder cancer urines (66.7%) while only 1 of 24 normal urines gave these bands (4.2%). Again, infected urines were positive (9 of 11). Additionally, urine from patients with benign urological disease was often positive in CF (11 of 41) and Ouchterlony (15 of 43) assays. RABCa serum was absorbed with normal bladder mucosa membrane extracts either once (1X) or three times (3X) to increase the specificity of the Ouchterlong gel diffusion assay. Using RABCa (1X) the per cent of positive bladder cancer urines and normals decreased only slightly, while the number of positive reactions against benign urological disease urines dramatically decreased (17.9%). RABCa (3X) further reduced the per cent of positive reactions with benign urological disease urines (10.3%), greatly reduced the reactivity with infected urines (60.0%), and gave no positive reactions with normal urines, without significantly decreasing the abiltiy to detect bladder carcinoma (51.9%). Although RABCa was 100% effective in detecting high grade (III) bladder tumors, almost two-thirds of all transitional cell papilloma urines were also positive. The nature of the material detected in bladder cancer and infected urines by RABCa is probably a product of in vivo inflammation. It does not appear to be part of the bacterial cell membrane or a bacterial metabolite. CEA (up to 10 ng/ml) did not produce positive precipitin bands with RABCa. Sephadex G-100 fractionation of urines suggests that RABCa reacts in the CF and Ouchterlony assays with a component or urine which has a molecular weight greater than 100,000-200,000 M.W. In summary, an antiserum has been prepared which may be used in micro-complement fixation and micro-Ouchterlony agar gel diffusion assays for immunological screening in the early detection of clinical disease, especially bladder cancer and urinary infection.