Israel Medical Association Journal

Background: C-reactive protein (CRP) is often used to distinguish bacterial from viral infections. However, the CRP level does have implications, which depend on the clinical scenario and are still under research.

Objectives: To evaluate the distribution of CRP levels in children with primary herpetic gingivostomatitis.

Methods: The electronic database of a tertiary pediatric medical center was searched for all inpatients with a diagnosis of primary herpetic gingivostomatitis without bacterial co-infection. Background and clinical information was collected and CRP levels were analyzed.

Results: The study group consisted of 66 patients aged 8 months to 7.1 years who met the study criteria. The average CRP was 7.4 mg/dl (normal < 0.5 mg/dl). More than a third of the patients had a level higher than 7 mg/dl.

Conclusions: High values of CRP are prevalent in patients with primary herpetic gingivostomatitis, similar to adenoviral infections and some bacterial infections. 

Objectives: To characterize common obstetric anesthesia practices after cesarean deliveries in Israel in order to standardize postoperative pain relief protocols.

Methods: A questionnaire was completed during an interview with every obstetric anesthesia unit in all 25 delivery wards in Israel. Data were gathered on intraoperative anesthesia and analgesia protocols as well as postoperative pain relief protocols. A sub-analysis compared units whose director completed a formal obstetric anesthesia training program with those whose directors did not.

Results: Neuraxial morphine was used routinely in 12% of hospitals. No unit providing intrathecal morphine complied with American Society of Anesthesiologists guidelines for respiratory monitoring after use of neuraxial opioids. Additionally, non-steroidal anti-inflammatory drugs (NSAIDs) were used routinely in only half the wards, while patient-controlled analgesia was used infrequently. Postoperative verbal analog scores were not recorded routinely in 71% of units on postoperative day 1. The unit director's training significantly influenced the unit protocols.

Conclusions: Intrathecal morphine, the gold standard of care in cesarean deliveries, is rarely used, mainly due to shortage of staff and lack of formal obstetric anesthesia training. In addition, NSAIDs are also underused. There is a need for more formal training for obstetric anesthesiologists in Israel.

Objectives: To determine if low plasma vitamin D level is a risk factor for MAEs in statin users.

Methods: Plasma levels of 25(OH) vitamin D were measured as part of the routine evaluation of unselected statin-treated patients attending the coronary and lipid clinics at our hospital during the period 2007–2010. Medical data on muscle complaints and statin use were retrieved from the medical files. Creatine kinase (CK) levels were derived from the hospital laboratory database.

Results: The sample included 272 patients (141 men) aged 33–89 years. Mean vitamin D level was 48.04 nmol/L. Levels were higher in men (51.0 ± 20.5 vs. 44.7 ± 18.9 nmol/L, P = 0.001) and were unaffected by age. MAEs were observed in 106 patients (39%): myalgia in 95 (35%) and CK elevation in 20 (7%); 11 patients (4%) had both. There was no difference in plasma vitamin D levels between patients with and without myalgia (46.3 ± 17.7 vs. 48.9 ± 21.0 nmol/L, P = 0.31), with and without CK elevation (50.2 ± 14.6 vs. 47.8 ± 20.3 nmol/L, P = 0.60), or with or without any MAE (50.4 ± 15.0 vs. 47.8 ± 10.2 nmol/L, P = 0.27). These findings were consistent when analyzed by patient gender and presence/absence of coronary artery disease, and when using a lower vitamin D cutoff (< 25 nmol/L).

Conclusions: There is apparently no relationship between plasma vitamin D level and risk of MAEs in statin users.

Objectives: To determine the effect of vitamin K on hip fracture patients treated with warfarin.

Methods: We retrospectively examined the management of 21 patients with hip fractures who were being treated with warfarin at the time of admission. Vitamin K was given to 11 of the 21 patients. A third group, which served as a control, consisting of 35 hip fracture patients who were not being treated with anticoagulants was also evaluated.

Results: Patients who received vitamin K took fewer days to reach target international normalized ratio (INR) (1.73 ± 0.90 vs. 4.30 ± 1.89, P < 0.001) and had less preoperative time (2.64 ± 1.12 vs. 5.10 ± 2.42 days, P < 0.008) when compared with patients who did not receive vitamin K. In addition, these patients had statistically significantly shorter hospitalization stays (9.4 ± 1.9 and 13.2 ± 4.9 days, one-sided P < 0.06). There was no difference in the amount of blood found in the wound drains (111.8 ± 68.5 vs. 103.0 ± 69.4 ml) or the number of blood units administered (1.45 ± 1.29 vs. 2.00 ± 2.75 units).

Conclusions: Treatment with vitamin K for hip fracture patients who receive warfarin shortens preoperative time, reduces the length of hospitalization and probably reduces morbidity and mortality.

Objectives: To evaluate glycemic control, prevalence of diabetic ketoacidosis (DKA) at presentation, diabetic complications rate, and associated autoimmune diseases in a pediatric T1DM patient population in the Negev area.

Methods: Clinical and demographic details of 168 T1DM patients were evaluated, including HbA1C levels, long-term complications, related autoimmune diseases, and insulin pump usage. The data were analyzed and the Jewish and Bedouin patient groups compared.

Results: Only 13.1% of the patients had reached the HbA1C levels recommended by the current guidelines at the first and second year follow-up visits, and 9.5% and 7.1% at the third and fourth year visits, respectively. A significant difference in HbA1c levels between Jewish and Bedouin patients was found (P = 0.045 at the first year follow-up, P ≤ 0.01 thereafter). Significant difference was found between the Jewish and the Bedouin groups regarding presentation with DKA, 33% and 56% of the patients respectively (P = 0.01).

Conclusions: Existent glycemic control in daily practice is far from the guideline goals. Bedouin ethnicity was associated with less favorable diabetes control, emphasizing the need for better awareness of T1DM and its treatment options in this population. More resources should be directed to address T1DM in the general population, especially among the Bedouin.

Objectives: To examine prospectively the feasibility of vessel sealing in tracheostomy.

Methods: A vessel-sealing device was used in 24 consecutive patients undergoing tracheostomy. There were no exclusion criteria for enrolling the patients. No other hemostatic technique was used for dividing the isthmus.

Results: There were no bleeding events throughout the postoperative period. The operating time savingwas 5–10 minutes.

Conclusions: Use of the vessel sealer was found to be straightforward, efficacious, rapid and safe. 

Background: Vascular insufficiency is considered to play an important role in the pathogenesis of normal-tension glaucoma (NTG). Autoregulation of blood flow in the eye has been shown to be impaired in NTG, resulting in the inability to compensate for changes in intraocular pressure or blood pressure in order to maintain adequate perfusion. Objectives: To evaluate the occurrence of combined bradycardia-hypotension during 24 hour monitoring of blood pressure and heart rate in patients with NTG.

Methods: Eleven NTG patients participated in the study. All had episodic symptoms of dizziness or lightheadedness, but were confirmed as not having a diagnosis of orthostatic hypotension. Twenty-four hour monitoring was performed with systemic blood pressure and heart rate automatically measured every 20 minutes during daytime and every hour during the night. The cardiac diastolic and systolic double products (dDP and sDP) at each reading were calculated by multiplying the heart rate by the respective blood pressure. dDP < 3600 and sDP < 5400 (corresponding to a heart rate of 60 beats/min and a blood pressure of 60 and 90 mmHg, respectively) were considered abnormally low, and dDP < 2500 and sDP < 4000 (corresponding to a heart rate 50 beats/min and a blood pressure of 50 and 80 mmHg, respectively) were considered severely abnormal.

Results: dDP was abnormally low in all 11 NTG patients on at least one occasion, the majority occurring during the night-time hours, while abnormally low sDP was present in 8 of the 11 patients. The mean cumulative duration of low dDP readings was 4.2 ± 3.2 hours. Severely low dDP readings were observed in six patients.

Conclusions: Abnormally low dDP was recorded in all NTG patients, lasting more than an hour in the majority of cases. Abnormally decreased dDP may represent a state of cardiovascular autonomic dysregulation, resulting in low ocular perfusion in certain NTG patients.

Background: Maternal exposure to alcohol during pregnancy can lead to a wide range of clinical manifestations in their offspring, termed fetal alcohol spectrum disorder (FASD). In Israel, relatively few cases of FASD have been diagnosed and the prevalence has not been systematically evaluated.

Objectives: To determine the number of children with FASD or at risk for FASD in a select population of high risk patients seen at a clinic evaluating foster and adopted children.

Methods: Israeli children under 2 years old who were candidates for domestic adoption or in foster care were prospectively evaluated for clinical manifestations of FASD, and information was obtained regarding parental use of alcohol or other illicit drugs.

Results: Of the 100 patients prospectively evaluated, 8 had mothers with a known history of alcohol consumption during pregnancy. Two of the children had fetal alcohol syndrome (FAS) without known maternal exposure to alcohol and two had partial FAS. Eleven other children were at risk for development of one of the diagnostic categories of FASD.

Conclusions: In a population of pre-adoption and foster children, 15% either had manifestations of FASD or were at risk for developing FASD. Although this is a select high risk population, the data from this study strongly suggest a greater prevalence of FASD than previously assumed. Under-diagnosis of FASD is detrimental to affected children who could benefit from interventions designed to meet the needs of FASD victims.