Clinical Characteristics and Management of Snake Bite Injuries in the Jerusalem Area

Venomous snake bites can constitute medical emergencies, and without immediate care may be life-threatening. This study describes the characteristics and management of patients suffering from snake bite injuries (SNIs) in the Jerusalem area. A retrospective analysis of all patients who were admitted to the Hadassah Medical Center emergency departments (EDs) due to SNIs between 1 January 2004 and 31 March 2018 was conducted. During this period, 104 patients were diagnosed with SNIs, of whom 32 (30.7%) were children. Overall, 74 (71.1%) patients were treated with antivenom, 43 (41.3%) were admitted to intensive care units, and 9 (8.6%) required treatment with vasopressors. No mortality was recorded. On ED admission, none of the adult patients presented with an altered mental state compared to 15.6% of the children (p < 0.00001). Cardiovascular symptoms were observed in 18.8% and 5.5% of the children and adults, respectively. Fang marks appeared in all of the children. These findings underscore the severity of SNIs and the differences in clinical presentation between children and adults in the Jerusalem region.

Heart rate: control mechanisms, pathophysiology and assessment of the neurocardiac system in health and disease

The monitoring of physiological function and dysfunction is an important principle in modern medicine. Heart rate is a basic example of this type of observation, particularly assessing the neurocardiac system, which entails the autonomic nervous system and intracardiac processes. The neurocardiac axis is an underappreciated and often overlooked system which, if measured appropriately in the clinical setting, may allow identification of patients at risk of disease progression and even mortality. While heart rate itself is a simplistic tool, more information may be gathered through assessing heart rate variability and heart rate recovery time. Studies have demonstrated an association of slow heart rate recovery and lower heart rate variability as markers of elevated sympathetic and lower parasympathetic tone. These parameters have additionally been shown to relate to development of arrhythmia, heart failure, systemic inflammatory processes, ischaemic heart disease and an increased rate of mortality. The aim of this review is to detail how heart rate is homeostatically controlled by the autonomic nervous system, how heart rate can impact on pathophysiological processes, and how heart rate variability and heart rate recovery time may be used in the clinical setting to allow the neurocardiac system to be assessed.

302 MONITORING FALLS RISK IN THE COMMUNITY USING AN IMPLANTABLE CARDIAC MONITOR WITH EMBEDDED ACCELEROMETER

Background

Falls are the most common cause of injury amongst older adults. Falls can lead to hospitalisation, functional decline and are associated with increased morbidity and mortality. The holy grail for clinicians would be to predict increased likelihood of falls occurring and intervene before the event. Understanding underlying dynamic biophysiological changes may therefore inform novel predictor models and falls prevention. This study examines activity and cardiac data acquired from an implanted Medtronic Reveal LINQ™ Insertable Cardiac Monitor (ICM) with an embedded tri-axial accelerometer.

Methods

Thirty participants with at least one unexplained fall in the previous two years were prospectively recruited. All met criteria for ICM insertion following comprehensive assessment. Participants were followed for one year and attended every three-months for cardiac and gait assessment. Information pertaining to activity levels, posture changes and cardiac parameters were collected daily from the device. Summary metrics and trends were collected for inclusion in a continual assessment of falls risk.

Results

Mean age of participants was 68.0 years (±9.3). 19/30 (63.3%) were female. 22/30 (73.3%) had at least one cardiovascular condition documented in their medical history. There was seasonal variation in activity levels. Twelve participants had falls and cardiovascular, gait and activity variables were examined at the time of a fall to determine any trends in biophysiological changes.

Conclusion

Causes of falls are usually multifactorial. A holistic approach is necessary to manage and minimise risk factors. The use of an ICM with an embedded tri-axial accelerometer allows clinicians to formulate an algorithm to determine if a person is at an increased risk of falling based on biophysiological changes. This may create an opportunity for falls to be predicted and prevented.

Increased prevalence of attention-deficit hyperactivity disorder symptomatology in patients with familial Mediterranean fever

OBJECTIVES

Previous studies suggest that exposure to inflammation in infancy may increase the risk for attention-deficit and hyperactivity disorder (ADHD). We studied the ADHD manifestations among 124 familial Mediterranean fever (FMF) patients and examined the relationship between FMF patient characteristics and ADHD.

METHODS

Clinical, demographic, and genetic data were abstracted from patients' medical records and supplemented by information obtained during clinic visits. ADHD manifestations were assessed using the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) questionnaire.

RESULTS

ADHD was diagnosed in 42 (32.8%) FMF patients, a rate significantly higher than in unselected populations (∼8%). A majority (n = 27, 64.3%) had combined inattentive, hyperactive-impulsive manifestations. Eight (19%) had predominantly hyperactive-impulsive, and seven (16.6%) had predominantly inattentive symptoms. FMF patients with severe manifestations reported more ADHD symptoms. FMF patients with ADHD symptoms were less adherent to their treatment regimen, with only 61.9% of the patients with ADHD symptoms adhering to colchicine therapy compared to 92.7% of the patients without ADHD symptoms.

CONCLUSION

The high prevalence of ADHD characteristics in children with FMF may support the neuroimmune hypothesis that chronic inflammation increases the risk for ADHD. Children with FMF should be screened for ADHD as its presence may adversely affect adherence to treatment.

Arum palaestinum poisoning: revenge of the witch

The Arum palaestinum plant is one of the 26 species of the Arum genus of the Araceae family. This plant species is found through the Mediterranean region, Western Asia, and Europe. The leaves and seeds of the plant contain needle-shaped oxalate crystals that can irritate the affected tissue (skin, oral cavity, or GI tract) upon exposure. Up to this date, there is no available literature supporting the epidemiology or the clinical manifestations of poisoning by this plant. We retrospectively reviewed all Arum palaestinum exposures to children younger than 18 years of age reported to the Israel National Poison Information Center during 2017 from the IPIC computerized data system. We extracted demographic data and clinical data from those digital files. We reviewed the files of 53 patients' files and found slight male predominance (58% vs. 42%), and the age of exposure ranged from 9 month to 15 years. The main site of exposure was at home in most cases (47%) followed by outdoor exposure in 40% of the cases. In 66% of the cases, minor clinical manifestations were reported, mainly erythema and mouth irritation, agitation, and drooling. Asymptomatic patients composed 34% of the cases. In 17% of the cases, patients were recommended to visit an ambulatory facility, and other 15% of the cases were referred to the emergency department. There were no cases of severe poisoning, upper airways compromise, or death.Conclusion: Poisoning by Arum palaestinum is one of the most common pediatric plant poisoning in Israel. Our study supports with clinical data for the first time that this poisoning is self-limited, confined to the affected mucosa, and most likely does not necessitate any intervention. What is Known • A. palaestinum poisoning is one of the most common pediatric plant poisoning in Israel. • The leaves and seeds of the plant contain needle-shaped oxalates crystals. What is New • Pediatric exposure to A. palaestinum usually causes only mild and self-limited poisoning. • Expectant observation is the preferred management of such exposure.

Infective endocarditis: a retrospective cohort study

BACKGROUND

Infective endocarditis (IE) is a potentially life-threatening infection of the heart's endocardial surface. Despite advances in the diagnosis and management of IE, morbidity and mortality remain high.

AIM

To characterize the demographics, bacteriology and outcomes of IE cases presenting to an Irish tertiary referral centre.

DESIGN

Retrospective cohort study.

METHODS

Patients were identified using Hospital Inpatient Enquiry and Clinical Microbiology inpatient consult data, from January 2005 to January 2014. Patients were diagnosed with IE using Modified Duke Criteria. Standard Bayesian statistics were employed for analysis and cases were compared to contemporary international registries.

RESULTS

Two hundred and two patients were diagnosed with IE during this period. Mean age 54 years. Of these, 136 (67%) were native valve endocarditis (NVE), 50 (25%) were prosthetic valve endocarditis (PVE) and 22 (11%) were cardiovascular implantable electronic device-associated endocarditis. Culprit organism was identified in 176 (87.1%) cases and Staphylococcal species were the most common (57.5%). Fifty-nine per cent of NVE required surgery compared to 66% of PVE. Mean mortality rate was 17.3%, with NVE being the lowest (12.5%) and PVE the highest (32%). Increasing age was also associated with increased mortality. Fifty-three (26.2%) patients had embolic complications.

CONCLUSIONS

This Irish cohort exhibited first-world demographic patterns comparable to those published in contemporary international literature. PVE required surgery more often and was associated with higher rates of mortality than NVE. Embolic complications were relatively common and represent important sequelae, especially in the intravenous drug user population. It is also pertinent to aggressively treat older cohorts as they were associated with increased mortality.

Genetic polymorphisms in platelet-related proteins and coronary artery disease: investigation of candidate genes, including N-acetylgalactosaminyltransferase 4 (GALNT4) and sulphotransferase 1A1/2 (SULT1A1/2)

BACKGROUND

Both platelet function and heart disease show strong genetic components, many of which remain to be elucidated.

MATERIALS AND METHODS

The roles of candidate polymorphisms in ten platelet-associated genes were compared between 1,237 Acute Coronary Syndrome (ACS) cases (with myocardial infarction and unstable angina) and 386 controls, from an Irish Caucasian population. Additionally, 361 stable angina patients were investigated. Two genes of interest were followed up in a separate Irish study of 1,484 individuals (577 with IHD and 907 unaffected).

RESULTS

The GALNT4 (N-acetyl galactosaminyl transferase 4) 506I allele was significantly underrepresented in ACS (OR = 0.66, CI = 0.52-0.84; P = 0.001; P = 0.01 after correction for multiple testing), while the SULT1A1 (Sulphotransferase 1A1) 213H allele was associated with risk of ACS (OR = 1.37, CI = 1.08-1.74; P = 0.01; P = 0.1 after correction for multiple testing). Subsequent genotyping of further SNPs in GALNT4 in the family-based (IHD) group revealed that the 506I allele showed the same trend towards protecting against ACS but the haplotypic test over the four commonest haplotypes was not significant (P = 0.55). In contrast, the SULT1A1/SULT1A2 gene complex showed suggestive haplotypic association in the family-based study (P = 0.07), with the greatest increase in risk conferred by the SULT1A2 235T allele (P = 0.025).

CONCLUSION

We have identified two risk genes for cardiovascular disease, one of whose (GALNT4) effects may be on either platelet or endothelial function through modifications of PSGL1 or other important glycosylated proteins. The role of sulphotransferases (SULT1A1/2) in cardiovascular disease requires further exploration. Further validation of cardiovascular risks conferred by both genes in other populations (including gene copy number variation) is warranted.

Coronary stent insertion into a 20-year-old Blalock-Taussig Shunt

A 21 year-old female with complex congenital heart disease presented with declining exercise tolerance, presyncope and increasing cyanosis despite regular venesection. Her double inlet left ventricle with rudimentary right ventricle, restrictive ventricular septal defect and pulmonary stenosis had been managed with a Classic Left Blalock-Taussig (B-T) Shunt aged 2 months and a Modified Right B-T Shunt at 4 years. Aortography revealed a patent but significantly narrowed Left B-T shunt with impaired blood flow and an aneurysmal pulmonary artery. Angioplasty and stenting of the shunt was undertaken and a 4.0 x 12mm coronary stent deployed. The patient's arterial oxygen saturation improved from 76% on pulse oximetry to 85% post procedure and she reported significantly improved exercise tolerance upon follow-up.

Nitric oxide in streptozotocin-induced diabetes mellitus in rats

1. The present study was performed to determine the relationship between diabetic glomerular hyperfiltration and nitric oxide as modulated by the chronic administration of L-arginine and/or N-omega-nitro-L-arginine, a known nitric oxide synthase inhibitor in streptozotocin-induced diabetic rats. 2. Normal rats and rats drinking hypertonic glucose (10%) were used as time-controlled groups. Six weeks after administration of streptozotocin the diabetic rats had significantly higher creatinine clearance (667 +/- 53 microliters min-1 100 g-1 body weight) than before and streptozotocin (456 +/- 38 microliters min-1 100 g-1 body weight, P < 0.005) and very high plasma (37.8 +/- 10.9 mumol/l) and urinary (3.492 +/- 0.179 nmol min-1 100 g-1 body weight) nitrite+nitrate (stable metabolites of nitric oxide) values compared with before streptozotocin administration [19.3 +/- 2.8 mumol/l (P < 0.001) and 0.420 +/- 0.051 nmol min-1 100 g-1 body weight (P < 0.001) respectively]. The 6-week diabetic rats had higher systolic blood pressure (124.2 +/- 2.9 mmHg, P < 0.05) than before streptozotocin (108 +/- 8 mmHg), but had a value similar to that of the hypertonic-glucose-drinking rats. 3. The diabetic rats supplemented with L-arginine did not show an increase in creatinine clearance and had a lower urinary excretion of nitrite+nitrate (0.999 +/- 0.27 nmol min-1 100 g-1 body weight, P < 0.005) than the respective untreated streptozotocin-induced diabetic rats. Creatinine clearance increased in the normal and glucose-drinking rats that received L-arginine. The administration of L-arginine resulted in significant reduction in blood pressure in all groups studied. The chronic nitric oxide synthase inhibitor resulted in high blood pressure, and in a significant decrease in creatinine clearance and urinary nitrite+nitrate excretion in all groups studied. In both diabetic and glucose-drinking rats, the L-arginine therapy resulted in significantly lower plasma and urinary glucose levels than in their respective untreated control groups. 4. The nitric oxide synthase inhibitor increased the plasma and urinary glucose concentration in both diabetic and glucose-drinking rats. 5. Our results indicate that diabetic rats are characterized by high plasma concentrations and elevated urinary excretion of nitrite+nitrate, suggesting a state of high nitric oxide production. The vascular response to nitric oxide in diabetic rats may be different at the glomerular and peripheral vascular bed.

Role of nitric oxide (EDRF) in radiocontrast acute renal failure in rats

This study was undertaken to examine the possible role of endothelium-derived relaxing factor (EDRF), identified as nitric oxide (NO), in the pathogenesis of radiocontrast-induced acute renal failure in rats. Normal and salt-depleted rats were monitored for 60 min or 24 h after radiocontrast administration. The administration of L-arginine to normal rats abolished the immediate decrease in p-aminohippurate clearance (CPAH) and attenuated the decrease in inulin clearance (CIn). The administration of NO synthase inhibitor to the salt-depleted animals resulted in a significantly more pronounced decrease in CPAH compared with both the control and the L-arginine-treated animals. The recovery of CIn 24 h after radiocontrast administration to the salt-depleted rats was significantly better in the L-arginine-treated rats than in either the control or inhibitor-treated groups. The administration of radiocontrast material resulted in a significant decrease in urinary guanosine 3',5'-cyclic monophosphate as well as NO2 + NO3 excretion. This decrease was significantly attenuated by L-arginine. Our results 1) suggest that NO plays a major role in the pathogenesis of radiocontrast-induced acute renal failure and 2) suggest a novel therapeutic approach, i.e., the use of L-arginine in this form of acute renal failure.