The association between red cell distribution width and stroke in patients with atrial fibrillation

OBJECTIVE

Red cell distribution width is associated with increased risk of cardiovascular morbidity and mortality. We aimed to assess its association with stroke in patients with atrial fibrillation.

METHODS

By using the computerized database of the largest Health Maintenance Organization in Israel, we identified a cohort of adults with atrial fibrillation diagnosed before January 1, 2012. Eligible subjects were not taking anticoagulants at baseline and had at least 1 blood cell count performed in 2011 (41,140 subjects). The cohort was followed for the first occurrence of stroke until December 31, 2012.

RESULTS

Overall, 1692 subjects developed stroke during 38,024 person-years of follow-up (stroke rate, 4.45 per 100 person-years). Stroke incidence rate increased across red cell distribution width quartiles: 3.26, 3.71, 5.01, and 6.05 per 100 person-years in the lowest (≤ 13.4%), second (13.4%-14.1%), third (14.1%-15.0%), and highest (>15%) red cell distribution width quartiles, respectively. On multivariate analysis adjusting for Congestive heart failure, Hypertension, Age ≥ 75, Diabetes, and Prior Stroke or TIA (doubled) (CHADS2) score risk factors, the hazard ratio for stroke was 1.29 (95% confidence interval, 1.17-1.42) in subjects with red cell distribution width >14.5% compared with those with values ≤ 14.5% and was similar in subjects with and without anemia. When analyzed as quartiles, the hazard ratio for stroke was 1.33 (confidence interval, 1.15-1.53) in the highest quartile compared with the lowest quartile and was similar in subjects with and without anemia. The area under the receiver operating characteristic curve was 0.598 for (CHADS2) score and increased to 0.618 when red cell distribution width was included in the model (P < .001).

CONCLUSIONS

Red cell distribution width is directly associated with the risk of stroke regardless of anemia status and improves the predictive accuracy for stroke in patients with atrial fibrillation.

Urinary tract infections in patients with type 2 diabetes mellitus: review of prevalence, diagnosis, and management

Urinary tract infections are more common, more severe, and carry worse outcomes in patients with type 2 diabetes mellitus. They are also more often caused by resistant pathogens. Various impairments in the immune system, poor metabolic control, and incomplete bladder emptying due to autonomic neuropathy may all contribute to the enhanced risk of urinary tract infections in these patients. The new anti-diabetic sodium glucose cotransporter 2 inhibitors have not been found to significantly increase the risk of symptomatic urinary tract infections. Symptoms of urinary tract infection are similar to patients without diabetes, though some patients with diabetic neuropathy may have altered clinical signs. Treatment depends on several factors, including: presence of symptoms, severity of systemic symptoms, if infection is localized in the bladder or also involves the kidney, presence of urologic abnormalities, accompanying metabolic alterations, and renal function. There is no indication to treat diabetic patients with asymptomatic bacteriuria. Further studies are needed to improve the treatment of patients with type 2 diabetes and urinary tract infections.

The Effect of Vitamin D Supplementation on Thrombin Generation Assessed by the Calibrated Automated Thrombogram

Observational and in vitro studies suggest that vitamin D may have antithrombotic activity. This study aimed to examine the relationship between vitamin D supplementation and thrombin generation. Serum 25-hydroxyvitamin D (25(OH)D) and thrombin generation parameters were measured in 73 healthy volunteers. Participants with serum 25(OH)D <50 nmol/L (n = 53) were treated with vitamin D3and tested for 25(OH)D and thrombin generation at the end of treatment. Lag time and time to peak decreased after treatment by a mean of -0.49 ± 0.51 minute (P< .001) and -0.76 ± 0.70 minute (P< .001), respectively, whereas endogenous thrombin potential and peak height increased after treatment by a mean of 170.1 ± 339.8 nmol/L minute (P= .001) and 34.2 ± 47.8 nmol/L (P< .001), respectively. Treatment with vitamin D supplementation seems to have prothrombotic effect in patients with vitamin D insufficiency. These findings should be interpreted with caution and need to be replicated in future studies.

Multi-centre analysis of incidental findings on low-resolution CT attenuation correction images

OBJECTIVE

To review new incidental findings detected on low-resolution CT attenuation correction (CTAC) images acquired during single-photon emission CT (SPECT-CT) myocardial perfusion imaging (MPI) and to determine whether the CTAC images had diagnostic value and warrant reporting.

METHODS

A multicentre study was performed in four UK nuclear medicine departments. CTAC images acquired as part of MPI performed using SPECT were evaluated to identify incidental findings. New findings considered to be clinically significant were evaluated further. Positive predictive value (PPV) was determined at the time of definitive diagnosis.

RESULTS

Of 1819 patients studied, 497 (27.3%) had a positive CTAC finding. 51 (2.8%) patients had findings that were clinically significant at the time of the CTAC report and had not been previously diagnosed. Only four (0.2%) of these were potentially detrimental to patient outcome.

CONCLUSION

One centre had a PPV of 0%, and the study suggests that these CTAC images should not be reported. Two centres with more modern equipment had low PPVs of 0% and 6%, respectively, and further research is suggested prior to drawing a conclusion. The centre with best quality CT had a PPV of 67%, and the study suggests that CTAC images from this equipment should be reported.

ADVANCES IN KNOWLEDGE

This study is unique compared with previous studies that have reported only the potential to identify incidental findings on low-resolution CT images. This study both identifies and evaluates new clinically significant incidental findings, and it demonstrates that the benefit of reporting the CTAC images depends on the type of equipment used.

Padua prediction score and thrombin generation in hospitalized medical patients

INTRODUCTION

The Padua prediction score is a risk assessment model used to identify medical patients at high risk for venous thromboembolim (VTE).We aimed to assess the relationship between the severity of Padua score and thrombin generation as a measure of overall thrombotic activity.

MATERIALS AND METHODS

A total of 253 patients hospitalized in the medical wards, at the Haemek Medical Center, Israel, were enrolled in the study. Patients treated with anticoagulation, and those admitted for VTE were excluded. Padua score was classified into two categories; low-risk for VTE (<4 points), and high-risk for VTE (≥4 points). Thrombin generation was assessed by the Calibrated Automated Thrombogram (CAT) method.

RESULTS

Overall 187 (73.9%) patients had Padua score<4, and 66 (26.1%) patients had Padua score ≥4. Comparison of the thrombogram parameters between the two Padua score categories showed no significant difference; lag time (P=0.066), ETP (P=0.266), peak height (P=0.418), and time to peak (P=0.415). Among the individual Padua score risk factors, only active cancer was significantly associated with peak height, myocardial infarction or stroke with lag time, and none of the risk factors was significantly associated with ETP. Because of their low frequency, the association with previous VTE, known thrombophilia, hormonal treatment, and recent trauma or/and surgery was not assessed.

CONCLUSIONS

Single thrombin generation measurement obtained at the same time in acutely hospitalized patients didn't bear any correlation with the Padua prediction score. This finding should be interpreted with caution considering the underrepresentation of risk factors that may influence thrombin generation.

Statins use and risk of mortality in patient with Clostridium difficile infection

Current evidence suggests that statins may improve outcome in infectious diseases. This study aims to assess whether statins use is associated with reduced risk of 30-day mortality in Clostridium difficile infection (CDI). Using the computerized database of Clalit, the largest healthcare provider in Israel, we identified a cohort of adult subjects (age ≥40 years) who tested positive on a C. difficile toxin assay performed between January 2011 and December 2012. Subjects were defined as current statins users if they filled at least one prescription during the 90 days before the laboratory assay date. Current users were classified into long-term users if at least one additional prescription was filled during the previous 91-180 days; otherwise they were defined as short-term users. A total 1888 patients with CDI were included. Of them, 340 (18.0%) died during the first 30 days after diagnosis. The 30-day mortality rate was lower among current statins users 89/669 (13.3%) compared with 251/1219 (20.6%) in non-users (p <0.001). A significant reduced risk of 30-day mortality existed after adjustment for potential confounders; adjusted OR = 0.57 (95% CI 0.42-0.79) and was unique to long-term users; 0.53 (0.38-0.73) but not short-term users; 1.15 (0.56-2.34). The risk of 30-day mortality decreased with increasing number of filled statins prescriptions; adjusted OR = 0.77 (95% CI 0.67-0.89) for each additional prescription. Current aspirin use was also independently associated with reduced mortality; adjusted OR = 0.64 (95% CI 0.43-0.88). In conclusion, current statins use, particularly long-term use, has a dose-response protective effect on mortality in patients with CDI.

Primary effusion lymphoma-like lymphoma in a patient with inflammatory bowel disease

A 77-year-old man with inflammatory bowel disease (IBD) and who was treated with anti-tumor necrosis factor (TNF), 6-mercaptopurine and corticosteroids, presented with primary effusion lymphoma-like lymphoma (PEL-like lymphoma) with massive ascites. The patient’s clinical course was complicated by acute renal insufficiency and hypotension, which led to death within 2 wk. In general, patients with IBD may have an increased risk for development of lymphoma, which is frequently associated with immunosuppressive and/or anti-TNF antibody therapies. PEL is a rare subset of lymphoma localized to serous body cavities, lacks tumor mass or nodal involvement, and is associated with infection by human herpes virus 8 (HHV-8). Primary neoplastic effusion may also be present in patients with large B-cell lymphoma without evidence of human immunodeficiency virus or HHV-8 infections. This type of lymphoma is classified as PEL-like lymphoma. Both PEL and PEL-like lymphoma types have been reported in patients undergoing immunosuppressive therapy, but to the best of our knowledge, the case described herein represents the first PEL-like lymphoma occurring in a patient with IBD.

Clostridium difficile and inflammatory bowel disease: Role in pathogenesis and implications in treatment

Clostridium difficile (C. difficile) is the leading cause of antibiotic associated colitis and nosocomial diarrhea. Patients with inflammatory bowel disease (IBD) are at increased risk of developing C. difficile infection (CDI), have worse outcomes of CDI-including higher rates of colectomy and death, and experience higher rates of recurrence. However, it is still not clear whether C. difficile is a cause of IBD or a consequence of the inflammatory state in the intestinal environment. The burden of CDI has increased dramatically over the past decade, with severe outbreaks described in many countries, which have been attributed to a new and more virulent strain. A parallel rise in the incidence of CDI has been noted in patients with IBD. IBD patients with CDI tend be younger, have less prior antibiotic exposure, and most cases of CDI in these patients represent outpatient acquired infections. The clinical presentation of CDI in these patients can be unique-including diversion colitis, enteritis and pouchitis, and typical findings on colonoscopy are often absent. Due to the high prevalence of CDI in patients hospitalized with an IBD exacerbation, and the prognostic implications of CDI in these patients, it is recommended to test all IBD patients hospitalized with a disease flare for C. difficile. Treatment includes general measures such as supportive care and infection control measures. Antibiotic therapy with either oral metronidazole, vancomycin, or the novel antibiotic-fidaxomicin, should be initiated as soon as possible. Fecal macrobiota transplantation constitutes another optional treatment for severe/recurrent CDI. The aim of this paper is to review recent data on CDI in IBD: role in pathogenesis, diagnostic methods, optional treatments, and outcomes of these patients.

Founding an adverse drug reaction (ADR) network: a method for improving doctors spontaneous ADR reporting in a general hospital

Adverse drug reactions (ADR) are underreported by doctors despite numerous efforts. We aimed to determine if establishing an "ADR reporting doctor's network" within a hospital would increase the quantity of ADRs reported by hospital doctors. One hundred hospital doctors joined the network. Email reminders were sent to network members during the 1 year study period, conveying information about ADRs reported, amusingly and pleasantly reminding them to report ADRs in minimal detail, by phone, email, text message or mail to the Clinical Pharmacology Unit, who would further complete the report. A total of 114 ADRs were reported during the study period in comparison to 48, 26, and 17 in the previous 3 years (2008, 2009, 2010, respectively). In the 3 years prior, doctors reported 41.7% of the reported ADRs whereas in the study period, doctors reported 74.3% of ADRs (P < .001), reflecting an 80% increase in doctors reports. Ninety seven percent of doctors' reports were of ADR network members. Thirty-four (34%) network members reported an ADR during the study period and 31 of the 34 reporters had never reported ADRs before becoming network members. Establishing an ADR network of doctors substantially increases ADR reporting amongst its members.

Providing detailed information about latent tuberculosis and compliance with the PPD test among healthcare workers in Israel: a randomized controlled study

Background: The compliance of screening for latent tuberculosis (TB) with the tuberculin purified protein derivative (PPD) test is very low among healthcare workers (HCWs) in Israel.

Methods: This randomized controlled study uses the Health Belief Model (HBM) as a conceptual framework to examine whether providing more information about latent TB and the PPD test increases the response rate for PPD screening among HCWs. All candidate HCWs for latent TB screening were randomly allocated to one of the following two invitations to perform the PPD test: regular letter (control group, n = 97), and a letter with information about latent TB and the PPD test (intervention group, n = 196).

Results: 293 HCWs were included (185 nurses, and 108 physicians). Overall, 36 (12.3%) HCWs were compliant with the PPD test screening. Compliance with PPD testing in the intervention group was not statistically different from the control group, RR 0.87 (95% CI, 0.46–1.65).

Conclusions: Compliance for latent TB screening is low among HCWs in northeastern Israel. Providing detailed information about latent TB was not associated with increased test compliance. Understanding existing disparities in screening rates and potential barriers to latent TB screening among HCWs is important in order to move forward and successfully increase screening rates.

Effect of fat content, casing type and smoking procedures on PAHs contents of Portuguese traditional dry fermented sausages

Portuguese dry fermented sausages are traditionally processed through direct drying/smoking, making them susceptible to polycyclic aromatic hydrocarbons (PAHs) contamination. The purpose of this study was to assess the effect of added fat (20% and 40%), casing type (hog and collagen) and smoking procedures (direct and indirect exposure) on the 16 EPA priority PAHs in dry fermented sausages manufactured according traditional processing. The total PAHs content (sum of 16 PAHs) found in whole product (casing included) varied between 150 and 870 μg kg(-1), with more than 99% of this content corresponding to harmless low molecular weight compounds. Concerning benzo(a)pyrene (BaP) and PAH4, the respective maximum contents (0.32 and 10.35 μg kg(-1), respectively) did not exceed the imposed limits regulated by the European Union. According to our results, casing type was the most influential factor. For hog samples, fat content and smoking regime alone did not influenced the total PAHs amount. However, significantly higher (p<0.05) contamination levels were detected in hog casing samples combining high fat content and direct smoking procedures. In opposition, irrespective of the fat content and smoking regime, safer products, with significantly lower (p<0.001) contamination levels, were obtained when collagen casing was used.

[Sarcoidosis presenting with recurrent aseptic meningitis and acute hearing loss]

Neurologic complications occur in 5% of patients with sarcoidosis. Neurosarcoidosis ranges from mild neurologic deficits to a destructive, life-threatening disease, and at times is the only presenting symptom of sarcoidosis, thus posing a diagnostic challenge for the doctor neurologic symptoms include cranial nerve palsies, with the vestibulocochlear nerve rarely being involved. We present a patient with neurosarcoidosis manifesting as recurrent episodes of aseptic meningitis, vertigo, and acute hearing loss.

[Hepcidin and diabetic anemia: is there an association?]

BACKGROUND

Anemia is common in diabetes. The role of hepcidin in diabetic anemia is unknown.

OBJECTIVES

To assess the relationship between serum hepcidin and anemia in diabetic patients without renal failure.

METHODS

We prospectively studied 86 consecutive type II diabetic patients--39 with anemia (cases) and 47 without anemia (controls). Patients with renal failure, iron and vitamin B12 deficiency and chronic inflammatory diseases were excluded.

RESULTS

Univariate analyses showed that patients with anemia were older and had longer duration of diabetes compared to patients without anemia (P < 0.051). The median hepcidin level was 15 ng/mL (2-140 ng/ml) in patients with anemia compared to 14 ng/mL (2-128 ng/ml) in patients without anemia (P = 0.386]) Serum erythropoietin and creatinine levels were higher in patients with anemia compared to patients without anemia (P < 0.05). Patients with anemia had tower HbA1c levels (P = 0.035), and greater usage of anti-diabetic drugs; metformin 73% versus 46.8% (P = 0.016), and sulfonylurea 47.2% versus 19.1% (P = 0.006). After adjusting for age, the two groups still differed in duration of diabetes (P = 0.043), erythropoietin (P = 0.007) creatinine (P < 0.001), and usage of metformin, sulfonylurea and insulin (P < 0.05).

CONCLUSIONS

Subjects with diabetic anemia have Longer diabetes duration than subjects with diabetes without anemia. Based on the results of this small study, hepcidin was not associated with diabetic anemia.

Cutaneous nocardiosis: report of two cases and review of the literature

BACKGROUND

Cutaneous nocardiosis is an uncommon infectious disease that presents as a primary cutaneous infection or as a disseminated disease. It is often misdiagnosed because of its rarity and nonspecific clinical picture.

METHODS

We report a case of each type. The first case is an immunocompetent patient who was infected by Nocardia while gardening and developed a superficial skin infection--one of the three clinical manifestations of primary cutaneous nocardiosis. The second case is an immunocompromised patient with pulmonary nocardiosis that extended to the skin as part of a disseminated disease.

RESULTS

The immunocompetent patient with primary cutaneous nocardiosis had the classical features of a superficial skin infection. He had a nodular–pustular lesion on the right arm, which appeared 7 days after gardening with bare hands. Nocardia was identified in a skin culture taken from a pustule, unfortunately not to the species level. Treatment with minocycline for 3 months resulted in full remission of the lesion. The immunocompromised patient with disseminated nocardiosis had high fever, productive cough, hemoptysis, and erythematous nodules and pustules on the extremities. N. brasiliensis was isolated from bronchial samples and skin. Treatment with a high dose of trimethoprim and sulfamethoxazole for five months resulted in full recovery from cutaneous and pulmonary complaints. No relapse of the infection was found on follow-up in either patient.

CONCLUSION

These cases demonstrate the need for a high degree of suspicion, focused clinical search, and appropriate laboratory procedures in the diagnosis and management of cutaneous nocardiosis.

Antibiotic resistance and virulence factors among Enterococci isolated from chouriço, a traditional Portuguese dry fermented sausage

Enterococci are ubiquitous microorganisms, found as part of the normal intestinal microbiota of many animals. They can be present in food products, for example, the Portuguese dry fermented sausage chouriço. Twenty enterococci were isolated from chouriço in two processing units; after identification and typification by conventional-molecular methods, the isolates were screened for virulence factors and antibiotic resistance. Identification allocated all enterococci to the species Enterococcus faecalis, and PCR fingerprinting demonstrated that each isolate was specific to the processing unit and chouriço from which it was recovered. Regarding the screening for virulence factors, 1 strain produced cytolysin and 4 were gelatinase positive, but none produced lipase. The ace gene was detected in 1 enterococci, ebpABC and efaA(fs) in 16 isolates each, esp in 3, fsrB in 5, gelE in 7, and cylA in 1. A multiresistant phenotype was observed in 8 isolates, 6 belonging to factory A. The antibiotic resistance gene ere(B) was detected in 9 enterococci, whereas the genes tet(M), aac(6')-Ie-aph(2''), and vanA were detected in 8 isolates each. As some of the E. faecalis chouriço isolates present a multiresistant profile and harbor virulence and/or resistance genes, to assess further the safety of Portuguese dry sausages, a larger number of products and processing units must by analyzed.

Distribution of aminogenic activity among potential autochthonous starter cultures for dry fermented sausages

Any bacterial strain to be used as starter culture should have suitable characteristics, including a lack of amino acid decarboxylase activity. In this study, the decarboxylase activity of 76 bacterial strains, including lactic acid bacteria and gram-positive, catalase-positive cocci, was investigated. These strains were previously isolated from European traditional fermented sausages to develop autochthonous starter cultures. Of all the strains tested, 48% of the lactic acid bacteria strains and 13% of gram-positive, catalase-positive cocci decarboxylated one or more amino acids. Aminogenic potential was strain dependent, although some species had a higher proportion of aminogenic strains than did others. Thus, all Lactobacillus curvatus strains and 70% of Lactobacillus brevis strains had the capacity to produce tyramine and beta-phenylethylamine. Some strains also produced other aromatic amines, such as tryptamine and the diamines putrescine and cadaverine. All the enterococcal strains tested were decarboxylase positive, producing high amounts of tyramine and considerable amounts of beta-phenylethylamine. None of the staphylococcal strains had tyrosine-decarboxylase activity, but some produced other amines. From the aminogenic point of view, Lactobacillus plantarum, Lactobacillus sakei, and Staphylococcus xylosus strains would be the most suitable for use as autochthonous starter cultures for traditional fermented sausages.

Pulmonary hypertension in a patient with Schmidt syndrome

We describe a 26-year-old patient with long-standing autoimmune hypothyroidism. She was doing well until she developed Addisonian crisis accompanied by severe metabolic acidosis, hypoglycemia, hypomagnesemia, and hypokalemia. Subsequently she developed a life-threatening cardiac arrhythmia due to QT prolongation secondary to electrolyte imbalance. The association of autoimmune hypothyroidism and adrenal insufficiency in our patient suggests the diagnosis of autoimmune polyglandular syndrome type II or Schmidt syndrome. An echocardiography that was performed detected pulmonary hypertension without apparent cardiac or lung pathology. The association of pulmonary hypertension and Schmidt syndrome is rare and may be explained by a generalized immune activation leading to pulmonary endothelial damage or dysfunction.

Haloperidol-induced neuroleptic malignant syndrome complicated by hyperosmolar hyperglycemic state

Neuroleptic malignant syndrome (NMS) is a life-threatening neurologic emergency that may be caused by neuroleptic agents of any class. The association with hyperosmolar hyperglycemic state (HHS) is rare and carries a grave prognosis. We describe the case of a 25-year-old male patient with haloperidol-induced NMS complicated by HHS that culminated in the patient's death despite all treatment efforts. Physicians caring for diabetic psychiatric patients who are treated with neuroleptic agents should be aware of this association that may be prevented by tight glycemic control.

Effects of date ( Phoenix dactylifera L., Medjool or Hallawi Variety) consumption by healthy subjects on serum glucose and lipid levels and on serum oxidative status: a pilot study

The present pilot study analyzed, for the first time, the in vivo effect of Medjool or Hallawi date consumption by healthy subjects on serum glucose, lipids, and oxidative stress. Total phenolics concentration in the Hallawi versus Medjool dates was greater by 20-31%. The major proportion of the soluble phenolics in both date varieties consisted of phenolic acids, mainly ferulic acid and coumaric acid derivatives, and also chlorogenic and caffeic acid derivatives. Unlike the Medjool dates, Hallawi dates contained a significant proportion of catechins as well. In addition, both varieties contained a quercetin derivative. Both date varieties possess antioxidative properties in vitro, but the ferric ion reducing antioxidant power of Hallawi versus Medjool dates was higher by 24%. Ten healthy subjects consumed, for a period of 4 weeks 100 g/day of either Medjool or Hallawi dates. The date consumption did not significantly affect the subjects' body mass index (BMI), their serum total cholesterol, or their cholesterol levels in the VLDL, LDL, or HDL fractions. Most important, fasting serum glucose and triacylglycerol levels were not increased after consumption of either date variety, and serum triacylglycerol levels even significantly (p < 0.05) decreased, by 8 or 15% after Medjool or Hallawi date consumption, respectively. Basal serum oxidative status was significantly (p < 0.01) decreased by 33%, as compared to the levels observed before consumption, after Hallawi (but not Medjool) date consumption. Similarly, the susceptibility of serum to AAPH-induced lipid peroxidation decreased by 12%, but only after Hallawi date consumption. In agreement with the above results, serum activity of the HDL-associated antioxidant enzyme paraoxonase 1 (PON1) significantly increased, by 8%, after Hallawi date consumption. It is concluded that date consumption (and mainly the Hallawi variety) by healthy subjects, despite their high sugar content, demonstrates beneficial effects on serum triacylglycerol and oxidative stress and does not worsen serum glucose and lipid/lipoprotein patterns, and thus can be considered an antiatherogenic nutrient .

Consumption of wonderful variety pomegranate juice and extract by diabetic patients increases paraoxonase 1 association with high-density lipoprotein and stimulates its catalytic activities

Association of paraoxonase 1 (PON1) with high-density lipoprotein (HDL) stabilizes the enzyme. In diabetic patients, PON1 dissociates from HDL and, as a consequence, is less biologically active. Our aim was to investigate the effects of Wonderful variety pomegranate juice (WPJ) and pomegranate polyphenol extract (WPOMxl) consumption on PON1 association with HDL in diabetic patients. Thirty patients with type 2 diabetes mellitus participated in the study. Ten male patients and 10 female patients received concentrated WPJ (50 mL/day for 4 weeks), while another group of 10 male patients received WPOMxl (5 mL/day for 6 weeks). There were no significant effects of WPJ or WPOMxl consumption on fasting blood glucose or hemoglobin A1c levels. After 4 weeks of WPJ consumption by male patients, basal serum oxidative stress was significantly decreased by 35%, whereas serum concentrations of thiol groups significantly increased by 25%. Moreover, HDL-associated PON1 arylesterase, paraoxonase, and lactonase activities increased significantly after WPJ consumption by 34-45%, as compared to the baseline levels. PON1 protein binding to HDL was significantly increased by 30% following WPJ consumption, and the enzyme became more stable. In male patients that consumed WPOMxl and in female patients that consumed PJ, a similar pattern was observed, although to a lesser extent. We conclude that WPJ as well as WPOMxl consumption by diabetic patients does not worsen their diabetic parameters. Furthermore, WPJ as well as WPOMxl consumption contribute to PON1 stabilization, increased association with HDL, and enhanced catalytic activities. These beneficial effects of pomegranate consumption on serum PON1 stability and activity could lead to retardation of atherosclerosis development in diabetic patients.

Ten years surveillance of antimicrobial susceptibility of community-acquired Escherichia coli and other uropathogens in northern Israel (1995-2005)

BACKGROUND

In an era of increasing antimicrobial resistance, knowledge of local antimicrobial susceptibility patterns of common uropathogens is essential for prudent empiric therapy of community-acquired urinary tract infections.

OBJECTIVES

To define antimicrobial susceptibility of Gram-negative uropathogens in northern Israel over a 10 year period and to compare it with patterns of antibiotic use in the same community.

METHODS

We tested the susceptibility of all Gram-negative urinary isolates from outpatients at HaEmek Medical Center over the years 1995, 1999, 2002 and 2005 to common antimicrobial agents. MIC90 of Escherichia coli to some of these agents was determined and antibiotic consumption data over the years 2000-2005 (DDD/1000/day) were obtained.

RESULTS

We observed a rise in susceptibility rates of E. coli to amoxicillin-clavulanate, trimethoprim-sulfamethoxazole and nitrofurantoin and of other Gram-negative isolates to amoxicillin-clavulanate, ceftriaxone and cephalothin. Susceptibility rates of all Gram-negative uropathogens to ciprofloxacin decreased significantly. MIC90 of E. coli for all drugs tested remained stable. There was a significant decrease in the use of nitrofurantoin and TMP-SMX and a significant increase in the use of ampicillin, cephalothin and ceftriaxone.

CONCLUSIONS

Antibiotic resistance patterns mostly remained unchanged or improved slightly. There was, however, a constant decrease in susceptibility of all Gram-negative uropathogens to ciprofloxacin. Antibiotic use patterns could not explain the changes seen in antibiotic susceptibility patterns.

Color modeling of stratified pictorial layers using the radiative transfer equation solved by the auxiliary function method

The diffuse reflectance spectra and the trichromatic coordinates of diffusing stratified paints are modeled. Each layer contains its own pigments, and their optical properties are first determined from experiments. The radiative transfer equation is then solved by the auxiliary function method for modeling the total light scattered by the stratified systems. The results are in good agreement with experimental spectra and validate the modeling. The calculations are then applied on the same stratified systems to study the influence of the observation angle in a bidirectional configuration and to study the influence of the thickness of the layers in a given configuration. In both cases, the reflectance spectra and the trichromatic coordinates are calculated and compared.

Consumption of herbal remedies and dietary supplements amongst patients hospitalized in medical wards

AIMS

Herbal remedies may have adverse effects and potentially serious interactions with some commonly prescribed conventional medications. Little is known about consumption of herbal remedies and dietary supplements by hospitalized patients. The aim was to evaluate the rate of consumption and characterize the patients hospitalized in internal medicine departments who consume herbal remedies and dietary supplements. Also, to assess the medical teams' awareness and assess the percentage of patients with possible drug-herb interactions.

METHODS

Patients hospitalized in the medical wards of two hospitals in Israel were interviewed about their use of herbal remedies or dietary supplements. The medical records were searched for evidence that the medical team had knowledge of the use of herbal remedies or dietary supplements.

RESULTS

Two hundred and ninety-nine hospitalized medical patients were interviewed. Of the participants, 26.8% were herbal or dietary supplement consumers (HC). On multivariate analysis the only variates associated with herbal or dietary supplement consumption were the hospital [odds ratio (OR) 2.97, 95% confidence interval (CI) 1.29, 6.52], income (OR 0.39, 95% CI 0.15, 1.05), smoking habits (OR 0.17, 95% CI 0.05, 0.55) and benign prostatic hypertrophy (OR 4.64, 95% CI 1.3, 16.5). Ninety-four percent of the patients had not been asked specifically of herbal consumption by the medical team. Only 23% of the hospital's medical files of the HC patients had any record of the use of herbal or dietary supplements. Seven possible drug-herbal interactions were encountered (7.1%). The most serious was an interaction between camomile tea and ciclosporin.

CONCLUSIONS

Herbal remedy consumption is common amongst patients hospitalized in internal medicine wards and is often overlooked by the medical team. Patients and doctors should be more aware of the possible adverse effects and of the potential of herb-drug interactions.

Ionic dependence of the velocity of release of ATP from permeabilized cholinergic synaptic vesicles

Evidence is provided to show that synaptic vesicles have an internal matrix. Suspensions of cholinergic synaptic vesicles isolated from the electric organ of Torpedo marmorata fish were permeabilized in solutions containing low concentrations of Na(+) or Ca(2+). The release of ATP from the vesicular matrix was 10 times more effective with Ca(2+) than with Na(+). We ascertained whether these two cations induced a different velocity of release of ATP from the matrix. The release of ATP was monitored with the chemiluminescent reaction of luciferin-luciferase. The light signal generated was the result of the kinetics of ATP release of the enzymatic reaction. To overcome the kinetics of the enzymatic reaction, the light records were deconvoluted. The actual kinetics of ATP release of vesicles containing Na(+) or Ca(2+) were coincident. To validate this result, comparison was made with ATP release from intact nerve terminals which were already deconvoluted. The results show that the real time course of release is longer than that obtained from synaptic vesicles. This was as expected given that the release of neurotransmitters is due to successive molecular steps of synaptic vesicle exocytosis.

Altered gene expression in Choristoneura fumiferana and Manduca sexta in response to sublethal intoxication by Bacillus thuringiensis Cry1Ab toxin

In order to understand how lepidopteran insects react physiologically to Bacillus thuringiensis crystal toxin ingestion, transcriptional profiling of Choristoneura fumiferana larvae exposed to sublethal doses of Cry1Ab protoxin were monitored using a C. fumiferana-specific cDNA microarray derived from a protoxin-specific subtractive library. Differential gene expression occurred primarily between 2 and 5 h postingestion. Metabolic enzymes such as lipases and proteases were generally repressed, whereas genes involved in detoxification, immune system regulation or general stress response were upregulated. A similar protoxin-specific transcriptional pattern was also observed with Manduca sexta larvae, using three upregulated genes (serpin, cytochrome P450 and carboxyl/cholinesterase) and one downregulated gene (beta-glucosidase), suggesting that a susceptible larval response to Cry toxin exposure might be universal among lepidopterous insects.

Prothrombin complex concentrate (Octaplex®) in patients requiring immediate reversal of oral anticoagulation

INTRODUCTION

Rapid reversal of anticoagulant effect from the use of vitamin K antagonists (VKA) is essential when acute bleeding or emergency surgery occurs. Prothrombin complex concentrates (PCCs) produce a more rapid effect with a better clinical outcome, and do not cause volume overload as compared with fresh-frozen plasma (FFP). Octaplex is a modern, double virus safeguarded PCC with balanced content of vitamin K-dependent coagulation factors, which ensures fast onset of action and efficacious treatment, i.e. rapid correction of international normalized ratio (INR).

MATERIALS AND METHODS

The main purpose of this study was to demonstrate that Octaplex, when individually dosed, efficiently corrects INR to pre-determined levels in patients under oral anticoagulation who have bleeding complications or are undergoing invasive procedures. To measure the efficacy response, the INR achieved after PCC application per patient was calculated as geometric mean of three measurements within 1 h post-infusion.

RESULTS

Sixty patients received a median total Octaplex dose of 41.1 (15.3-83.3) IU/kg body weight (bw). Of 56 patients evaluable in terms of efficacy, 51 (91%) showed a response as pre-defined in the protocol and in 52 (93%) the INR decreased to a value below 1.4 within one hour after dosing. The median INR declined from 2.8 (1.5-9.5) to 1.1 (1.0-1.9) within 10 min. All prothrombin complex coagulation factors recovered in parallel. Three patients had minor adverse drug reactions. One patient showed a non-symptomatic parvovirus B19 seroconversion. No thrombotic side effects were observed.

CONCLUSIONS

Octaplex is efficacious and safe in immediate correction of dosage-dependent INR in patients with VKA-related deficiency of prothrombin complex coagulation factors.

[The risks of combining medicine and herbal remedies]

The risks of using herbal remedies, considered 'natural', should not be disregarded, as some have serious side effects and some interact with and influence conventional medical therapeutics. The effect may be pharmacokinetic by altering absorption or metabolism, and may be pharmacodynamic, by changing the final effect of the drug. St. John's wort, for example, an antidepressant herbal remedy, may pharmacodynamically interact with specific serotonin reuptake inhibitors (SSRI's), causing a serotonin syndrome. St. Johns wort also causes serious pharmacokinetic interactions by activating the cytochrome CYP3A4, dangerously decreasing blood levels of cyclosporin, warfarin, and theophylline, and reducing the efficacy of contraceptive pills and AIDS therapy. The article presents a review of a number of herbal remedies, commonly used in Israel, that have documented drug interactions, providing details of common indications, adverse reactions and drug interactions of each herbal remedy. Physicians should recognize the fact that patients use herbal remedies, purchased directly at pharmacies or health stores, and be aware of the potential interactions of these remedies with conventional drugs.

Systemic lupus erythematosus and inflammatory bowel disease

We hereby summarize a case reported by the authors, as well as all of the previously reported cases, of patients suffering from both systemic lupus erythematosus (SLE) and inflammatory bowel disease (IBD) that have been published in the English literature. In most cases, SLE was diagnosed prior to IBD, and the latter was of the ulcerative colitis subtype. Interestingly, the first disease diagnosed was almost never active at the time the second disease manifested itself. Patients with both diseases tended to have less photosensitivity, less arthritis, and less serositis than patients with SLE alone. There were no cases with neurological disorders or overt nephritis. All of these patients had anti-dsDNA and there was a tendency towards more anemia and thrombocytopenia. These patients had a relatively benign course with no flare-ups of lupus during follow-up and a favorable course of their bowel disease as well.