Possible benefit from treatment of Helicobacter pylori in antihistamine-resistant chronic urticaria.

BACKGROUND: Some patients with chronic spontaneous urticaria (CU) are resistant to conventional doses of antihistamine (AH) medications. Some research groups have reported an association between CU and Helicobacter pylori infection. AIM: To determine whether H. pylori eradication can reverse AH resistance in CU. METHODS: We retrospectively reviewed cases of patients with CU, and recorded their Urticaria Activity Score (UAS) and results of a (13)C-urea breath test ((13)C-UBT) for H. pylori infection. Patients without improvement in CU despite a full 8 weeks of AH treatment at four times the initial dose comprised the resistant CU group, while the patients who did respond comprised the responsive CU group. Patients with resistant CU and a positive (13)C-UBT (n = 46) were offered a 14-day treatment with amoxicillin 1 g twice daily, clarithromycin 500 mg twice daily and omeprazole 20 mg twice daily. The effect of H. pylori eradication on CU was evaluated by the UAS, measured at baseline and at 8, 16, and 28 weeks after triple therapy. RESULTS: Of the 46 patients with resistant CU, 29 (63%) had a positive (13)C-UBT result. Treatment eradicated H. pylori in 18 of the 29 patients (subgroup A), and 11 patients refused the triple therapy (subgroup B). The remaining 17 patients had a negative (13)C-UBT result, (subgroup C). In subgroup A, baseline UAS reduced from 5.29 ± 0.94 to 3.62 ± 0.96 (P = 0.03) at week 8; to 1.43 ± 0.41 (P < 0.001) at week 16, and to 1.17 ± 0.32 (P = 0.04) at week 28. Five of the patients (27.8%) in this group were completely free of symptoms at week 28, whereas none of the untreated patients achieved complete remission. CONCLUSION: Some patients with resistant CU might benefit from H. pylori eradication.

Community acquired acute bacterial meningitis in children and adults: an 11-year survey in a community hospital in Israel.

OBJECTIVES: We aimed to investigate the association between the presenting clinical manifestations of bacterial meningitis and the duration of time elapsed before lumbar puncture and start of antibiotic treatment. DESIGN: Retrospective epidemiologic study using the clinical records in Barzilai Medical Center Emergency Department between 1988 and 1999. RESULTS: 97 patients, 72 children and 25 adults with ABM were identified. 30 of 97 (31%) were diagnosed by the primary physicians at primary care units. Acute meningitis was suspected by emergency department (ED) physicians in 51% of the referred patients. Patients with a scarce clinical picture at hospital arrival (those without fever, headache or nuchal rigidity) showed a trend toward a longer median delay until a diagnostic lumbar puncture was performed and antibiotic therapy was started (median of 14.7 h compared with 2.1 h for those with severe clinical picture) (p<0.02). Nevertheless, the clinical outcome for the total cohort did not yield a significant difference when analyzed regarding the duration of time between arrival to emergency department and antibiotic treatment initiation (p>0.3). CONCLUSIONS: The interval before diagnosis of community acquired ABM in both children and adults is longer for those patients who present to the emergency department with an atypical clinical picture, mostly, without fever and without nuchal rigidity. Until bacterial meningitis can be effectively prevented, we can expect this life-threatening infection to continue to cause diagnostic and medical difficulties.

Treatment of allergic rhinitis can improve blood pressure control.

Owing to high prevalence of arterial hypertension (AH) and allergic rhinitis (AR), these diseases frequently coexist. The study aimed to assess whether improvement of AR by conventional treatment can improve blood pressure (BP) control in this population. Sixty-eight subjects of both sexes aged 35-60 years with AR and AH were randomized into two groups to receive in addition to their antihypertensive medications: treatment group (n=34) Fluticasone nasal 50 microg/spray b.i.d. and Fenoxifenadine 180 mg tablets q.d., and control group (n=34) 0.9% NaCl nasal drops b.i.d. Office BP and AR severity (using the Relative Quality of Life Questionnaire (RQLQ)) and high-sensitive C-reactive protein (hs-CRP) were measured at study entry and after 8 weeks in both groups, without changing of antihypertensive medications. In Treatment group an improvement in RQLQ, significant reduction of systolic BP (SBP) (DSBP 7.4 +/- 4.3 mm Hg, P=0.006) and reduction of hs-CRP level (DCRP 2.05 +/- 1.08; P=0.028) were observed, whereas diastolic BP (DBP) remained unchanged (DDBP 0.9 +/- 1.7 mm Hg, P=0.7). There was a significant correlation between DRQLQ and DSBP (r=0.86; P=0.019) and between DCRP and DSBP (r=0.56; P=0.027). No statistically significant changes of RQLQ, BP and CRP were observed in the control group. In patients with coincidence of AH and AR, medications meant to improve AR attenuate low-grade systemic inflammation and can lower SBP, but not DBP.

Effects of low-dose aspirin on blood pressure and endothelial function of treated hypertensive hypercholesterolaemic subjects.

The main objective of this study was to assess whether aspirin 100 mg QD can improve blood pressure (BP) control and endothelial function in subjects with arterial hypertension (AH) and hypercholesterolaemia. In total, 21 patients of both sexes (52.1+/-11.5 years) with treated AH and hypercholesterolaemia on antihypertensive and statin therapy were included in the treatment group. In the control group, 20 matched patients of both sexes (51.3+/-12.7 years), but without statin therapy, were recruited. Treatment group subjects received aspirin (100 mg QD) for a duration of 12 weeks at randomization (Treatment phase-1), followed by single blind matching placebo for 12 weeks (Placebo phase) and then again received aspirin (100 mg QD) for an additional 12 weeks (Treatment phase-2). The control group participated in Treatment phase-1, but did not continue Placebo phase and Treatment phase-2. At randomization and at the end of each study phase, mean 24-h systolic BP (SBP) and diastolic BP (DBP) were assessed by 24-h ambulatory blood pressure monitoring (ABPM) and endothelium-dependent (flow mediated, FMD) and -independent (nitroglycerin induced, NTG) vasodilatations of brachial artery were measured using high-resolution ultrasound. In Treatment phase-1, reduction of SBP and DBP (DeltaSBP 5.7+/-2.6 mmHg, P=0.008; DeltaDBP 3.8+/-1.7 mmHg, P=0.014) and improvement of FMD (4.1+/-0.6%, P=0.019), in Placebo phase an elevation of SBP and DBP (DeltaSBP -6.2+/-2.9 mmHg, P=0.002; DeltaDBP -4.2+/-1.9 mmHg, P=0.031) and worsening of FMD (-3.8+/-0.9%, P=0.027), and in Treatment phase-2 reduction of SBP and DBP (DeltaSBP 4.9+/-2.3 mmHg, P=0.005; DeltaDBP 4.1+/-1.3 mmHg, P=0.024) and improvement of FMD (4.5+/-1.3%, P=0.009) were observed in the treatment Group but not in the control group. Addition of low-dose aspirin to antihypertensive medications and statins in hypertensive and hypercholesterolaemic subjects can reduce both SBP and DBP by improvement of endothelial function.

West Nile fever outbreak, Israel, 2000: epidemiologic aspects.

From August 1 to October 31, 2000, 417 cases of West Nile (WN) fever were serologically confirmed throughout Israel; 326 (78%) were hospitalized patients. Cases were distributed throughout the country; the highest incidence was in central Israel, the most populated part. Men and women were equally affected, and their mean age was 54+/-23.8 years (range 6 months to 95 years). Incidence per 1,000 population increased from 0.01 in the 1st decade of life to 0.87 in the 9th decade. There were 35 deaths (case-fatality rate 8.4%), all in patients >50 years of age. Age-specific case-fatality rate increased with age. Central nervous system involvement occurred in 170 (73%) of 233 hospitalized patients. The countrywide spread, number of hospitalizations, severity of the disease, and high death rate contrast with previously reported outbreaks in Israel.

Clinical characteristics of the West Nile fever outbreak, Israel, 2000.

West Nile (WN) virus is endemic in Israel. The last reported outbreak had occurred in 1981. From August to October 2000, a large-scale epidemic of WN fever occurred in Israel; 417 cases were confirmed, with 326 hospitalizations. The main clinical presentations were encephalitis (57.9%), febrile disease (24.4%), and meningitis (15.9%). Within the study group, 33 (14.1%) hospitalized patients died. Mortality was higher among patients >70 years (29.3%). On multivariate regressional analysis, independent predictors of death were age >70 years (odds ratio [OR] 7.7), change in level of consciousness (OR 9.0), and anemia (OR 2.7). In contrast to prior reports, WN fever appears to be a severe illness with high rate of central nervous system involvement and a particularly grim outcome in the elderly.

Two-stage evaluation and intervention program for control of methicillin-resistant Staphylococcus aureus in the hospital setting.

The aim of this study was to develop a 2-stage evaluation and intervention program for control of methicillin-resistant Staphylococcus aureus (MRSA) in the hospital setting. The first stage included evaluation of MRSA prevalence throughout the entire hospital; the presence of MRSA was determined in patients or medical staff who had a high risk of carrying it (i.e. as a result of contact with surgical wounds). In the second stage, "contact isolation" (which included the use of gloves, hand washing before and after treatment of a patient and isolation of patients' personal belongings) was carried out in every patient from whom MRSA was isolated in 4 intervention departments-Surgery, Orthopaedics, General ICU and Neonatal ICU-while the same policy of attempting to isolate MRSA was maintained. Both stages lasted 7 months. A comparison between MRSA prevalence in the evaluation and intervention stages disclosed a decrease in MRSA isolates from 91 to 56 in the entire hospital (p = 0.2) and from 45 to 24 in the intervention departments (p = 0.05), respectively; while the number of patients with MRSA decreased from 87 to 55 in the entire hospital (p = 0.2) and from 45 to 18 in the intervention departments (p = 0.007). The number of patients treated with vancomycin decreased from 48 before intervention to 23 after "contact isolation" was started in the entire hospital (p = 0.02) and from 31 to 5 in the intervention departments (p = 0.001). These results provide additional evidence in favor of establishing a program to control MRSA spread.

Comparative pharmacokinetics of once daily intravenous and intramuscular gentamicin in patients with post partum endometritis.

In patients with post partum endometritis once daily intramuscular administration of gentamicin may be convenient in certain clinical settings. However pharmacokinetic data on once daily intramuscular gentamicin are not reported. In this study 10 women with post partum endometritis were given once daily intravenous gentamicin (4 mg/kg ideal body weight) followed at a later day by a similar intramuscular dose. Gentamicin levels coincided at 30 min. Levels at 60 and 90 min were lower with the intravenous route. Further clinical studies are needed to confirm reduced nephrotoxicity and ototxicity with the intramuscular route.

Huge renal arteriovenous malformation mimicking a simple para-pelvic cyst.

The presenting symptoms of renal arteriovenous malformation are usually gross hematuria and hypertension. Herein we present an unusual case of a huge renal arteriovenous malformation without these signs, but with an ultrasound picture mimicking a simple para-pelvic cyst. Other imaging tests, including duplex ultrasound, computerized tomography and aortography, demonstrated the vascular lesion. We suggest that duplex ultrasound should accompany routine renal ultrasound in order not to miss such cases, especially when the physical examination suggests an intra-abdominal vascular lesion or bleeding.

Transient polycythemia and multi-organ failure due to acute alcohol ingestion.

Relative polycythemia is characterized by elevated hematocrit with normal red cell mass and results from decreased plasma volume. We present a case of a 39-year-old man who had at least two episodes of severe relative polycythemia and multi-organ failure following acute alcohol ingestion. Although the acute dehydrating effects of alcohol are well known, they usually result in an indolent course. This is the first report of recurrent severe polycythemia and multi-organ failure following acute alcohol consumption.

Early antibiotic treatment may prevent complete development of Lemierre's syndrome: experience from 2 cases.

Lemierre's syndrome is a rare fulminant condition caused by an acute oropharyngeal infection, with secondary septic thrombophlebitis of the internal jugular vein complicated by multiple metastatic infections. Herein we report 2 patients with internal jugular vein thrombosis secondary to oropharyngeal infection, whose clinical course was indolent, and who were asymptomatic shortly after antibiotic therapy was begun. Careful examination of the neck in patients presenting with sore throat could help identify the typical 'cord sign'. In such cases, intravenous antibiotic treatment should be started as soon as possible to prevent development of metastatic infections and septicaemia characterizing Lemierre's syndrome.

Huge renal arteriovenous malformation mimicking simple parapelvic cyst.

The presenting symptoms of renal arteriovenous malformations are usually gross hematuria and hypertension. Herein we present an unusual case of huge renal arteriovenous malformation without these signs, but with ultrasound picture mimicking simple parapelvic cyst. Other imaging test, including Duplex ultrasound, computerized tomography and aortography, demonstrated that vascular lesion. We suggest that Duplex ultrasound should accompany the routine renal ultrasound in order not to miss such cases, especially when the physical examination suggests intra-abdominal vascular lesion or bleeding.

Brucellosis outbreak: analysis of risk factors and serologic screening.

Israel is one of the Mediterranean countries in which Brucellosis is endemic. As recently there has been a Brucellosis outbreak in a kibbutz, the aim of this study is to identify asymptomatic infected Kibbutz members, and to delineate the manner of infection in this setting. Therefore, all the asymptomatic Kibbutz members were screened by the Rose Bengal test for Brucellosis, while both patients and healthy members were asked to fill in a questionnaire in order to pinpoint the manner of infection, and signs and symptoms of the disease. In addition to the 14 patients with Brucellosis, 2 other Kibbutz members were also found to be infected by the screening tests. Analysis of the data of the questionnaires from 142 healthy and 16 patients disclosed that almost all of the infected patients (15/16) worked in the cowshed, as opposed to only 24 out of 142 (16.9%) of the healthy members. The infected tended to participate more in calf deliveries, and had contact with cow's blood and placenta, compared with the healthy subjects (P<0.001), while there were no significant differences with respect to having cuts on hands, or working in the cowshed without gloves. In addition, 15 out of 16 (93.8%) infected persons also drank unpasteurized milk, as compared with only 17 of the 142 (12%) healthy members (P<0.001), and thus were exposed to 2 major risk factors (working in the cowshed and consumption of unpasteurized milk). As the cows of the Kibbutz's cowshed were affected by Brucella melitensis (which usually affects flocks of goats and sheep rather than cows), the microbe was probably transmitted to the cowshed from neighboring flocks by wandering dogs, and then to the infected humans.

Comprehensive individualised nonpharmacological treatment programme for hypertension in physician-nurse clinics: two year follow-up.

A comprehensive programme of nonpharmacological control of hypertension (balanced nutrition, satisfactory weight, enhanced physical activity, relaxation technique, smoking cessation) by primary care physician-nurse (PN) teams who were instructed and routinely advised by a paramedical professional (PP) team (psychologist, nutritionist and physical activity instructor) was developed with the aim of increasing long-term compliance. To evaluate effectiveness, 52 mild and moderate hypertensives without target organ damage were randomly allocated to six weekly meetings of individual intensive instruction by PN teams alone, or direct group instructions by PP teams (24 and 28 patients, respectively). The respective results at 11 months and 24 months follow-up compared with baseline were: (1) 56.9% and 58.8% showed minimal satisfactory reduction of weight, (2) 49% and 58.8% showed minimal satisfactory increase in physical activity, (3) the reported increase in physical activity at 11 months follow-up was validated by significantly correlated improved performance in ergometry, (4) 75% and 40% of the patients performed relaxation vs. 2% at baseline and (5) 71% and 59% needed no medication or reduced dose to control BP, and these changes were significantly (P < 0.02) correlated with weight reduction and increased physical activity. As no differences were found between the two modes of treatment, we conclude that our programme can be successfully applied by the PN primary care teams to increase adherence to nonpharmacological measures in the control of hypertension.

[The "Ashkelon" hypertension detection and follow-up program].

The program described aims at enhancing awareness of high blood pressure and other risk factors for cardiovascular disease (CVD) and promoting a healthy lifestyle. The study population consisted of 11,000 workers at worksites and visitors to community centers, aged 25-65 years. The program was carried out in cooperation with primary care clinics and non-pharmacological control of high blood pressure was by a community center for prevention of CVD. In 1980, 56.0% of hypertensives were unaware of their condition, while by 1988 this was reduced to 6.1%. Body weight reduction resulted in lowering of blood pressure which enabled cessation of all antihypertensive treatment in 25%. Deep muscle relaxation enabled cessation in 47%. The savings effected in terms of antihypertensive treatment outweight the total cost of the program 3-fold.

The antihypertensive effect of atenolol and bopindolol in the elderly.

The antihypertensive efficacy and tolerability of two betablockers: atenolol and bopindolol, was compared in a group of 30 elderly subjects aged 64.8 +/- 4.6 years. The daily dose of the two agents was relatively low. Atenolol 50-100 mg and bopindolol 0.5-1.0 mg sufficed to cause reduction of DBP to the target of less than or equal to 95 mm Hg, when applied as monotherapy. This was achieved in 75% of cases with bopindolol and in 93% of cases with atenolol. Atenolol, 50-100 mg/dd, lowered blood pressure from 173.7 +/- 13.2/103.7 +/- 3.0 (weekly) to 155.5 +/- 16.5/86.5 +/- 8.2 mm Hg (week 12) (P less than 0.005) while bopindolol, 0.5-1.0 mg, lowered blood pressure from 171.6 +/- 11.3/104.1 +/- 3.6 to 158.7 +/- 20.9/86.1 +/- 6.0 mm Hg (P less than 0.005). Heart rate was reduced from 80.5 (week 4) to 66.7 +/- 7.3 (week 12) by atenolol (P less than 0.0001), and from 83.7 +/- 11.8 (week 4) to 71.1 +/- 7.5 (week 12) by bopindolol (P less than 0.0001). Between treatment differences: comparisons yielded P values which were not sufficiently low to reject the null hypothesis of no difference between the two treatments. Well-being and short-term memory were not affected by either agent and tolerability of both drugs was good. These findings demonstrate that both bopindolol and atenolol are useful agents for control of hypertension in the elderly.

Normoglycemic diabetic retinopathy and nephropathy.

End-stage renal failure is one of the major complications of diabetes and a significant cause of death in this population. At present, its cause is unknown, and consequently, attempts to prevent it are arbitrary. It has been suggested that improved control of blood glucose and hypertension may prevent the onset of renal failure in patients with diabetes mellitus. We present a case in which, despite near-normal levels of blood glucose and blood pressure, a relentless downhill course ensued resulting in severe renal failure and near blindness as a result of diabetic nephropathy and retinopathy.