Doron Zamir

Influence of excessive weight loss after gastroplasty for morbid obesity on respiratory muscle performance.

BACKGROUND: Morbidly obese subjects are known to have impaired respiratory function and inefficient respiratory muscles. A study was undertaken to investigate the influence of excessive weight loss on pulmonary and respiratory muscle function in morbidly obese individuals who underwent gastroplasty to induce weight loss. METHODS: Twenty one obese individuals with mean (SE) body mass index (BMI) 41.5 (4.5) kg/m2 without overt obstructive airways disease (FEV1/FVC ratio > 80%) were studied before and six months after vertical banded gastroplasty. Only patients who had lost at least 20% of baseline BMI were included in the study. Standard pulmonary function tests and respiratory muscle strength and endurance were measured. RESULTS: Before operation the predominant abnormalities in respiratory function were significant reductions in lung volumes and respiratory muscle endurance and, to a lesser degree, reductions in respiratory muscle strength. All parameters increased towards normal values after weight loss with significant increases in functional residual capacity (FRC) from 84.0 (2.2) to 91.3 (2.5)% of predicted normal values (mean difference 7.3, 95% confidence interval of difference (CI) 4.2 to 10.5), total lung capacity (TLC) from 85.6 (3.0) to 93.5 (3.7)% of predicted normal values (mean difference 7.9, 95% CI 4.5 to 11.5), residual volume (RV) from 86.7 (3.1) to 96.4 (3.0) of predicted normal values (mean difference 9.7, 95% CI 5.2 to 14.1), expiratory reserve volume (ERV) from 76.6 (3.0) to 89.0 (3.4)% of predicted normal values (mean difference 12.4, 95%, CI 6.3 to 18.9), respiratory muscle strength: PImax from 92 (4.4) to 113 (4.6) cm H2O (mean difference 21, 95% CI 12.2 to 31.6), PEmax from 144 (5.6) to 166 (4.3) cm H2O (mean difference 22, 95% CI 12.9 to 32.0), and endurance: PmPeak/PImax from 56 (1.4) to 69 (2.0)% (mean difference 13, 95% CI 9.7 to 16.9). The strongest correlation was between weight loss and the improvement in respiratory muscle endurance. CONCLUSIONS: Lung volumes and respiratory muscle performance are decreased in obese individuals. Weight loss following gastroplasty is associated with improvement in lung volumes and respiratory muscle function.

The effect of incentive spirometry and inspiratory muscle training on pulmonary function after lung resection

BACKGROUND A predicted postoperative forced expiratory volume in 1 second (FEV1) of less than 800 ml or 40% of predicted is a common criterion for exclusion of patients from lung resection for cancer. Usually, the predicted postoperative lung function is calculated according to a formula based on the number of lung segments that will be resected. Incentive spirometry and specific inspiratory muscle training are two maneuvers that have been used to enhance lung expansion and inspiratory muscle strength in patients with chronic obstructive pulmonary disease and after lung operation. METHODS Thirty-two patients with chronic obstructive pulmonary disease who were candidates for lung resection were randomized into two groups: 17 patients received specific inspiratory muscle training and incentive spirometry, 1 hour per day, six times a week, for 2 weeks before and 3 months after lung resection (group A) and 15 patients were assigned to the control group and received no training (group B). RESULTS Inspiratory muscle strength increased significantly in the training group, both before and 3 months after the operation. In group B, the predicted postoperative FEV1 value consistently underestimated the actual postoperative FEV1 by approximately 70 ml in the lobectomy subgroup and by 110 ml in the pneumonectomy subgroup. In group A, the actual postoperative FEV1 was higher than the predicted postoperative FEV1 by 570 ml in the lobectomy subgroup and by 680 ml in the pneumonectomy subgroup of patients. CONCLUSIONS In patients undergoing lung resection the simple calculation of predicted postoperative FEV1 underestimates the actual postoperative FEV1 by a small fraction. Lung functions can be increased significantly when incentive spirometry and specific inspiratory muscle training are used before and after operation.

Prophylactic Inspiratory Muscle Training in Patients Undergoing Coronary Artery Bypass Graft

Pulmonary complications after cardiac surgery are a leading cause of postoperative morbidity and mortality. Respiratory muscle weakness may contribute to the postoperative pulmonary abnormalities. We hypothesized that: (1) there is a decrease in inspiratory muscle strength (PImax at residual volume) and endurance (Pmpeak/PImax) following coronary artery bypass graft (CABG); (2) this weakness is associated with reduced pulmonary function tests (PFTs), impaired gas exchange, and a higher rate of pulmonary complications; and (3) prophylactic inspiratory muscle training (IMT) can prevent those changes. Eighty-four candidates for CABG, with ages ranging from 33 to 82 years, were evaluated prior to operation and randomized into two groups: 42 patients underwent IMT using a threshold trainer for 30 min/day for 2 weeks, 1 month before operation (group A); 42 patients served as a control group and underwent sham training (group B). There was a significant decrease in respiratory muscle function, PFTs, and gas exchange in the control group following CABG, whereas these parameters remained similar to those before entering the study in the training group. The differences between the groups were statistically significant. In addition, 11 (26%) patients in the control group but only 2 (5%) in the training group needed postsurgical mechanical ventilation longer than 24 hours. CABGs have a significant deteriorating effect on inspiratory muscle function, PFTs, and arterial blood gases. The decrease in these parameters can be prevented by prophylactic inspiratory muscle training, which may also prevent postsurgical pulmonary complications.

Inflammatory pseudotumor of the liver—a rare entity and a diagnostic challenge

Inflammatory pseudotumors are rare benign lesions that occur throughout the body. Hepatic pseudotumors are uncommon lesions, accompanied by fever, malaise, abdominal pain, and mass effect, and therefore are commonly misdiagnosed as malignant tumors or liver abscesses. Because even routine imaging procedures usually fail to differentiate hepatic pseudotumors from liver neoplasms, a diagnostic histology procedure is usually needed. We present a case of hepatic pseudotumor that resolved spontaneously and review the literature, including 40 previously reported cases and the differential diagnosis.

The response to inhaled and oral steroids in patients with stable chronic obstructive pulmonary disease

Background. A significant minority of patients with COPD have favourable response to corticosteroid treatment. In addition, the benefit of corticosteroid treatment may be outweighed by the side‐effects. Long‐term administration of inhaled steroids is a safe means of treatment. However, only a few studies have addressed the role of inhaled steroids in patients with COPD, with conflicting results.

Cyclosporine-induced optic neuropathy, ophthalmoplegia, and nystagmus in a patient with Crohn disease

PURPOSE To report the cyclosporine-induced complications of optic neuropathy, partial external ophthalmoplegia, and other neurologic abnormalities. METHODS Case report. A 22-year-old man with severe active Crohn disease developed bilateral optic neuropathy, nystagmus, external ophthalmoplegia, and ataxia on the fifth day of cyclosporine A (CyA) parenteral therapy. RESULTS Cyclosporine therapy was discontinued as soon as toxic clinical manifestations appeared. Cyclosporine blood level detected then was 1,290 ng/ml (therapeutic level: 150 to 300 ng/ml). Partial external ophthalmoplegia improved dramatically; however, the patients optic neuropathy progressed to optic atrophy, leaving the patient visually impaired. Various possible mechanisms for cyclosporine-induced neurotoxicity are discussed. CONCLUSION It is important to closely monitor neuro-ophthalmologic and neurologic signs of patients treated with cyclosporine.

Toxoplasma Infection in Systemic Lupus Erythematosus Mimicking Lupus Cerebritis

An opportunistic infection is a known, although under-diagnosed, complication of systemic lupus erythematosus (SLE). A 48-year-old woman with a recent diagnosis of SLE was admitted to the hospital because of a fever, confused state, and convulsive episode. Her symptoms were interpreted as being compatible with lupus cerebritis. Treatment with methylprednisolone resulted in a temporary improvement in the patients condition. Nevertheless, during the next few weeks, her physical and mental condition deteriorated, and she died of massive pulmonary emboli. An autopsy revealed no signs of lupus cerebritis; however, disseminated cerebral toxoplasmosis was found. Cerebral toxoplasmosis is a rare complication of SLE that may be misdiagnosed as lupus cerebritis.

Is gastro-oesophageal reflux a factor in exercise-induced asthma?

Exercise-induced bronchoconstriction (EIB) occurs in the majority of patients with asthma. The relationship between asthma and gastro-oesophageal reflux (GER) is well defined, and the reports of exertional gastro-oesophageal acid reflux in healthy subjects, prompted us to study the relationship between EIB and GER. Following an overnight fast and medication withholding, 15 asthmatics and 15 normal subjects were placed on continuous monitoring of oesophageal pH and ECG. After baseline monitoring of oesophageal pH, at rest, for 30 min, spirometry was performed. Thereafter, the subjects underwent rigorous treadmill exercise for 8 min followed by spirometry, 10 min after running. Twelve out of 15 asthmatics and none in the control group demonstrated significant fall in FEV1 in response to exercise. However, only six out of 15 normal subjects and three in the asthmatic group had evidence of GER during or following exercise. We concluded that there is no significant correlation between EIB and GER in patients with asthma.

Hepatitis C virus seroconversion and genotype prevalence in patients and staff on chronic hemodialysis.

The prevalence of hepatitis C virus (HCV)-RNA positivity among hemodialysis patients varies between 10 and 70%. Few previous surveys revealed high frequency of seroconversion of HCV-RNA-negative patients over the years of hemodialysis. Only few studies reported HCV genotype variability. We evaluated all 65 patients on chronic hemodialysis in our dialysis unit. All sera positive to anti-HCV on ELISA were retested by reverse transcriptase polymerase chain reaction to HCV-RNA. Sixteen patients were found anti-HCV positive on ELISA, and 8 of them were also PCR positive. Three of these eight patients seroconverted during the year 1995. Four patients had both 1a and 1b genotypes of HCV, coexistence of genotypes 1b and 4a in one patient and genotypes 1a, 1b and 2a in the remaining three patients. Mean serum aminotransferase, duration of dialysis, and number of blood units transfused were significantly higher in the HCV-PCR-positive patients compared with the HCV-PCR-negative patients. Because strict isolation methods were initiated at the end of 1995, not one new case of HCV among dialysis patients was found in 1998, although new hemodialysis patients were diagnosed as having HCV. In conclusion, genotypes 1a and 1b, as is true for the general population in Israel, were also the predominant genotypes among hemodialysis patients; the coexistence of more than one genotype is common among hemodialysis patients; seroconversion is common among these patients and strict isolation methods are efficient and should be recommended.

Single-dose quinolone treatment in acute gastroenteritis.

Background Acute diarrhea is a common disease worldwide and in Israel, a Mediterranean country. Acute bacterial gastroenteritis (ABGE) is the leading cause of severe diarrhea in Israel in summer and early autumn. Although there are some reports showing some benefit from empiric antibiotic therapy in acute gastroenteritis, most are old reports using nondefinitive diagnostic criteria and using 5-day antibiotic regimens. Aims 1. To examine the efficiency of antibiotic therapy in relatively severe ABGE in general. 2. To check the efficiency of the different types of quinolones in the treatment of ABGE. 3. To compare various therapy regimens. Methods All patients admitted to the Barzilai Medical Center emergency room during the period June to October in 2002-2004 who were defined by protocol as having relatively severe gastroenteritis and required hospitalization in the Department of Internal Medicine were included in the study. All were randomized either to a supportive treatment only group (STG) or to the antibiotic treatment group (ATG) of ofloxacin or levofloxacin with a single dose or BID for 5 days in addition to STGs. All patients were interviewed a week later about their medical history and duration of symptomatology. Results One hundred thirty-nine patients were found eligible for the study in the above-mentioned period. Abdominal pain resolved 1.3 days earlier in the ATG in comparison to the STG whereas vomiting and diarrhea disappeared 1.0 and 0.8 days earlier, respectively, in the ATG versus the STG. In terms of fever abatement there was no difference between the regimens and no significant difference in symptomatology disappearance between various types of quinolones used or between the single antibiotic dose regimen and the 5-day antibiotic regimen groups. Conclusions 1. Antibiotic therapy was found to shorten duration of symptoms in patients with relatively severe gastroenteritis. 2. Single-dose therapy is as effective and certainly significantly more cost effective in comparison to the 5-day antibiotic treatment regimen.