Assaf Harofeh Research Articles

Antiepileptic Drug Treatment in Community-Dwelling Older Patients with Epilepsy: A Retrospective Observational Study of Old- Versus New-Generation Antiepileptic Drugs.

The use of antiepileptic drugs (AEDs) in older patients with epilepsy is challenged by polypharmacy and decreased drug elimination. Newer AEDs have a lower potential for drug interactions and are reported to be better tolerated by the elderly than old-generation AEDs. The objective of this study was to evaluate AED use and the related adverse event rate in an outpatient cohort of older patients with epilepsy. We retrospectively reviewed the computerized database and medical records of all the patients aged ≥60years who visited our epilepsy outpatient clinic (Assaf Harofeh Medical Center, Zerifin, Israel) during a 4-year period from February 2012 to February 2016. In this study, phenytoin, valproic acid, carbamazepine, phenobarbital, clobazam, and clonazepam were defined as old-generation AEDs. Gabapentin, levetiracetam, lamotrigine, topiramate, oxcarbazepine, lacosamide, and perampanel were defined as new-generation AEDs. The study group included 115 patients aged 60-90years (mean 70.5±7.8years), 70 (61%) of whom were men. Co-morbidities were present in 98.3% of the patients, including neuropsychiatric illnesses in 21.2%. Present medical treatment included new-generation AEDs in 49 (44.5%) and both old- and new-generation AEDs in 20 (18.2%) patients. The most commonly used current AEDs were phenytoin, gabapentin, levetiracetam, and lamotrigine. Adverse reactions mainly included fatigue and CNS-related symptoms, and were more frequent among patients treated with new-generation AEDs than in those treated with old-generation AEDs or a combination of old- and new-generation AEDs; however, these reactions were mostly related to levetiracetam treatment. The likelihood of levetiracetam-related adverse events was increased by slow levetiracetam titration [defined as a weekly dose increase of ≤250mg/day in this study; odds ratio (OR) 16.35, 95% confidence interval (CI) 2.94-90.98], and by low- (OR 5.68, 95% CI 1.40-22.95) and high (OR 4.24, 95% CI 1.28-14.02) levetiracetam dosages compared with patients treated with lamotrigine or gabapentin. New-generation AEDs were administered to most of the patients in this outpatient clinic-based cohort of older patients with epilepsy. In order to decrease levetiracetam-related adverse events in this age group, we suggest that a slower titration rate (e.g., an increase of ≤125mg/day each week) and lower maximal dosage (e.g., 1500mg/day) of the drug should be considered.

Complementary and alternative medicine among hospitalized pediatric patients

ObjectivesTo estimate the prevalence and describe the characteristics of complementary and alternative medicine (CAM) use among hospitalized children, and to discover the awareness of medical staff regarding CAM use. Design/SettingParents of children aged 0–18 years admitted to the Pediatric Division at Assaf Harofeh Medical Center in Israel between January and July of 2015 (n=146) were provided a questionnaire regarding socio-economic status and evaluating the CAM use. The medical charts of the participants were reviewed in order to establish whether or not CAM use was documented. ResultsOf those who completed the questionnaire, 78 (54.3%) were using CAM. The major indications for CAM use were colic and teething. CAM use was advised by the family in 44.9%, physician 34.6%, pharmacist 34.6%, friends 30.8%, previous experience 23.1, advertisements 18%, nurses 6.4%, and homeopaths 2.6%. The family physician was aware of CAM use was in 42%. During the admission, only 5 patients were asked about CAM use (3.4%) by the medical staff. Reviewing the medical charts revealed there was no documentation of CAM use in any of the participants. Socio-demographic analysis of our population revealed no differences between users and non users of CAM, but significant differences in belief in CAM (p=0.018) were found. CAM use was age related; the older the child the less the use (p=0.010). ConclusionCAM use is common among hospitalized pediatric patients and is often overlooked by the medical staff. CAM use should be included in the medical history.

The MDR Upon Admission Score: Shortening Time to Initiation of Appropriate Antimicrobial Therapy in the Era of Resistance in the Community

Background Multi-drug-resistant organisms (MDRO) pose a growing burden, including in the community. Delay in initiation of appropriate antimicrobial therapy (DAAT) is common among patients with MDRO infection. In addition, DAAT is the strongest modifiable predictor of mortality in severe sepsis. The aim of this study was to develop a prediction score for MDRO infection upon admission to hospitals, in order to shorten DAAT and reduce misuse of broad-spectrum antibiotics administered to patients with non-MDRO infection.Methods Retrospective case–control analysis was conducted at Assaf Harofeh Medical Center, Israel, for two consecutive months (08-10/2016). Adult patients with MDRO infections were compared with patients presenting with non-MDRO sepsis (i.e., patients with microbiologically confirmed non-MDRO infection, or patients with non-microbiologically confirmed diagnosis). MDROs were determined in accordance to established criteria. A prediction score was developed based on the multivariable analysis (logistic regression) of predictors for MDRO infection upon admission.ResultsThe primary dataset consisted of 677 patients, 78 had MDRO infection. The final score included nine parameters: home therapy (IV therapy, wound care, or specialized nursing care, 23 points), history of MDRO colonization (13 points), invasive procedure in the past 6 months (11 points), any antibiotics in the past 3 months (10 points), elderly (over 65 years, 8 points), severe sepsis (i.e., severe sepsis, septic shock, or multi-organ failure, 6 points), resident of long-term care facility (5 points), acute kidney injury (5 points), and congestive heart failure (3 points),. A cut-off of ≥22 points had a sensitivity of 83%, specificity of 76%, and ROC AUC = 0.86 (figure).Conclusion This study presents a novel prediction score for MDRO infection upon admission, based on parameters that could easily be extracted at bedside during the initial presentation of a patient with sepsis. A future prospective interventional study is needed in order to quantify the performances of this score in terms of shortening DAAT, curbing misappropriate use of broad-spectrum antibiotics, and improving patients’ outcomes.Disclosures All authors: No reported disclosures.

Long-term outcome after pediatric intensive care unit asthma admissions.

Patients with asthma admitted to the pediatric intensive care unit (PICU) are often found to have had previous severe asthma exacerbations. To prospectively evaluate the outcome of children after PICU admission. Patients, ages 218 years, admitted to the PICU at Assaf Harofeh Medical Center over a 10-year period were assessed at a mean of 10 years after their admission and compared with matched patients admitted to the pediatric ward. Each patient filled out a questionnaire on subsequent hospitalizations and current asthma treatment and control. Pulmonary function studies and allergy skin tests were performed. Compared with patients admitted to the pediatric ward, those admitted to the PICU had more hospitalization and ICU admissions after their index admission (p = 0.022 and p = 0.021, respectively). Most patients in both groups (6070%) had uncontrolled asthma, and 47% of those (PICU) and 33% (ward) were not receiving controller therapy. Patients in the PICU group had more recent asthma exacerbations (p = 0.014), weekly wheezing (p = 0.017), and bronchodilator use (p = 0.007). Lung function tests were comparable between the two groups, but 3045% in each group had airflow obstruction. No significant differences were found between preschool and school-age children in any of the parameters. Compared with patients admitted to the pediatric ward, those admitted to the PICU with asthma exacerbations, experienced more asthma-related hospitalizations and their asthma was less controlled even years later. The lack of regular follow-up and controller therapy in most patients after asthma hospitalization indicated that this increased morbidity might be prevented.

Intra-abdominal Infections: The Role of Anaerobes, Enterococci, Fungi, and Multidrug-Resistant Organisms.

Background.Intra-abdominal infections (IAI) constitute a common reason for hospitalization. However, there is lack of standardization in empiric management of (1) anaerobes, (2) enterococci, (3) fungi, and (4) multidrug-resistant organisms (MDRO). The recommendation is to institute empiric coverage for some of these organisms in “high-risk community-acquired” or in “healthcare-associated” infections (HCAI), but exact definitions are not provided.Methods.Epidemiological study of IAI was conducted at Assaf Harofeh Medical Center (May–November 2013). Logistic and Cox regressions were used to analyze predictors and outcomes of IAI, respectively. The performances of established HCAI definitions to predict MDRO-IAI upon admission were calculated by receiver operating characteristic (ROC) curve analyses.Results.After reviewing 8219 discharge notes, 253 consecutive patients were enrolled (43 [17%] children). There were 116 patients with appendicitis, 93 biliary infections, and 17 with diverticulitis. Cultures were obtained from 88 patients (35%), and 44 of them (50%) yielded a microbiologically confirmed IAI: 9% fungal, 11% enterococcal, 25% anaerobic, and 34% MDRO. Eighty percent of MDRO-IAIs were present upon admission, but the area under the ROC curve of predicting MDRO-IAI upon admission by the commonly used HCAI definitions were low (0.73 and 0.69). Independent predictors for MDRO-IAI were advanced age and active malignancy.Conclusions.Multidrug-resistant organism-IAIs are common, and empiric broad-spectrum coverage is important among elderly patients with active malignancy, even if the infection onset was outside the hospital setting, regardless of current HCAI definitions. Outcomes analyses suggest that empiric regimens should routinely contain antianaerobes (except for biliary IAI); however, empiric antienterococcal or antifungals regimens are seldom needed.

Effect of the 2013 AHA/ASA guidelines on TPA use in acute ischemic stroke at Assaf Harofeh Medical Center in Israel

BackgroundUse of TPA to treat patients with acute ischemic stroke was introduced in Assaf Harofeh Medical Center (AHMC) in Israel in November 2007 initially with strict adherence to the inclusion/exclusion criteria of the pivotal NINDS TPA studies published in 1995. The treatment window was expanded in 2010 to 4.5h following the results of ECASS-III. Application of the 2013 AHA/ASA Guidelines resulted in further expanded inclusion and relaxed exclusion criteria. Design/MethodsA retrospective chart review was conducted of patients who received TPA at AHMC to evaluate the additional impact of applying the 2013 guidelines. Number of patients treated, outcomes at discharge, and safety were compared between two periods: May 2011–January 2013 (the 21months preceding the 2013 Guidelines); and February 2013–October 2014 (the 21months after publication of the 2013 Guidelines). Statistical analysis was done using z-tests for differences between proportions, and t-tests to compare means. Results63 patients were treated during the immediate pre-2013 Guideline period (36/year, or approximately 5% of patients with ischemic stroke), and 105 during the post-2013 Guidelines period (60/year, approximately 8.3% of patients with ischemic stroke) (p<0.001). During the two periods, respectively: discharges home were 22(34%) and 55(52%) (p<0.05); facility discharges were 29(46%) and 33(31%); and inter-hospital transfers were 6(9%), and 11(10% of treated patients). Most transfers were for endovascular treatment. Total treatment-related symptomatic bleeds in the two periods, respectively, was: 4(6%) and 4(4%), and the number of in-hospital deaths was 6 (9%) and 6 (6%) (unchanged). ConclusionsApplication of the 2013 AHA/ASA Guidelines resulted in a 64% increase in the number of acute ischemic stroke patients treated with TPA at AHMC with no worsening of aggregate outcomes and no increase in bleeds or deaths.

Dietary supplement consumption among cardiac patients admitted to internal medicine and cardiac wards

Dietary supplements may have adverse effects and potentially interact with conventional medications. They are perceived as "natural" products, free of side effects with no need for medical consultation. Little is known about consumption of dietary supplements by patients with cardiac diseases. The objective of this study was to investigate dietary supplement consumption among cardiac patients admitted to internal and cardiology wards. Potential drug-dietary supplement interactions were also assessed. During a period of 6 months, patients with cardiac disease hospitalized in the Internal Medicine and Cardiology Wards at Assaf Harofeh Medical Center were evaluated regarding their dietary supplement consumption. A literature survey examining possible drug-supplement interaction was performed. Out of 149 cardiac patients, 45% were dietary supplement consumers. Patients ad-mitted to the Internal Medicine Wards consumed more dietary supplements than those admit-ted to the Cardiology Division. Dietary supplement consumption was associated with older age (OR = 1.05, p = 0.022), female gender (OR = 2.94, p = 0.014) and routine physical activity (OR = 3.15, p = 0.007). Diabetes mellitus (OR = 2.68, p = 0.020), hematological diseases (OR = 13.29, p = 0.022), and the use of anti-diabetic medications (OR = 4.28, p = 0.001) were independently associated with dietary supplement intake. Sixteen potential moderate interactions between prescribed medications and dietary supplements were found. Consumption of dietary supplements is common among cardiac patients. It is more common in those admitted to Internal Medicine Departments than in those admitted to the Cardiology Wards. Due to the risk of various drug-supplement interactions consumed by patients with cardiac diseases, there is a need to increase awareness and knowledge among medical staff regarding the intake of dietary supplements.

The Complex Epidemiology of Carbapenem-Resistant Enterobacter Infections: A Multicenter Descriptive Analysis.

The pandemic of carbapenem-resistant Enterobacteriaceae (CRE) was primarily due to clonal spread of bla KPC producing Klebsiella pneumoniae. Thus, thoroughly studied CRE cohorts have consisted mostly of K. pneumoniae. To conduct an extensive epidemiologic analysis of carbapenem-resistant Enterobacter spp. (CREn) from 2 endemic and geographically distinct centers. CREn were investigated at an Israeli center (Assaf Harofeh Medical Center, January 2007 to July 2012) and at a US center (Detroit Medical Center, September 2008 to September 2009). bla KPC genes were queried by polymerase chain reaction. Repetitive extragenic palindromic polymerase chain reaction and pulsed-field gel electrophoresis were used to determine genetic relatedness. In this analysis, 68 unique patients with CREn were enrolled. Sixteen isolates (24%) were from wounds, and 33 (48%) represented colonization only. All isolates exhibited a positive Modified Hodge Test, but only 93% (27 of 29) contained bla KPC. Forty-three isolates (63%) were from elderly adults, and 5 (7.4%) were from neonates. Twenty-seven patients died in hospital (40.3% of infected patients). Enterobacter strains consisted of 4 separate clones from Assaf Harofeh Medical Center and of 4 distinct clones from Detroit Medical Center. In this study conducted at 2 distinct CRE endemic regions, there were unique epidemiologic features to CREn: (i) polyclonality, (ii) neonates accounting for more than 7% of cohort, and (iii) high rate of colonization (almost one-half of all cases represented colonization). Since false-positive Modified Hodge Tests in Enterobacter spp. are common, close monitoring of carbapenem resistance mechanisms (particularly carbapenemase production) among Enterobacter spp. is important.

The Use of Complementary and Alternative Medicine in Hospitalized Patients with Type 2 Diabetes Mellitus in Israel.

The use of complementary and alternative medicine (CAM) has been on the rise in recent years in the general population, as well as among patients with chronic diseases such as diabetes mellitus. The aim of this study was to add information regarding the use of CAM in patients with type 2 diabetes mellitus (DM2) in Israel and explore possible interactions between CAM and prescription medication (PM). This is a cross-sectional study based on questionnaires. The study included type 2 diabetic patients who were hospitalized in an internal medicine department at Assaf Harofeh Medical Center, Zerifin, Israel, between December 2013 and December 2014. Possible interactions between CAM and PM were evaluated by a clinical pharmacist and a clinical pharmacologist. Out of 111 diabetic patients, 23.4% used CAM. There was no significant difference between the consumers and nonconsumers in terms of age, education, income, smoking, or alcohol habits. Only 11 of the 26 CAM consumers informed their physician regarding the use. We found possible drug-herb interactions in 19 of the 26 CAM consumers. A major interaction was found between omega-3 and antiaggregants and was encountered in 7 (26.9%) of the CAM consumers. Other minor and major interactions were found with vitamin E, ginkgo-biloba, co-enzyme Q10, green tea, fenugreek seeds, pyridoxine, and dandelion. Since CAM consumption is on the rise, it is desirable to improve our knowledge concerning their potential effects and adverse effects, especially in conjunction with PM. Given the complexity of pharmaceutics in patients with chronic diseases, among them patients with DM, the use of supplementary medicine cannot be ignored.

Simple bedside score to optimize the time and the decision to initiate appropriate therapy for carbapenem-resistant Enterobacteriaceae.

BackgroundEpidemiological characteristics of patients with bloodstream infections (BSI) due to extended-spectrum β-lactamase producing (ESBL) and carbapenem-resistant (CRE) strains are often similar. Mortality rates for CRE BSI are 70 %, and mean time to initiation of appropriate therapy is ~5 days. A bedside score was developed to differentiate CRE-BSIs from ESBL-BSIs, in order to help decrease the time to initiation of appropriate therapy for CRE and mortality rates.FindingsScore was developed based of data (2007–2010) abstracted from charts of adult patients from Assaf Harofeh Medical Center (AHMC, Zeriffin, Israel), and validated on a cohort of patients from Detroit Medical Center (DMC, MI, USA). A multivariate model for presence of CRE was generated. A clinical prediction score and ROC curve was derived. 451 patients with ESBL BSIs (285 from AHMC and 166 from DMC) and 74 patients with CRE BSIs (58 from AHMC and 16 from DMC) were included. The prediction score included chemotherapy in the past 3 months (19 points), presence of foreign invasive devices (10 points), no peripheral vascular disease (10 points), reduced consciousness or cognition at time of acute illness (9 points), time in hospital prior to BSI ≥ 3 days (7 points), and age younger than 65 years (6 points). A score of ≥32 to define “high CRE risk” had sensitivity of 59 %, specificity of 76 %, PPV of 34 % and NPV of 90 %.ConclusionsThe score’s 90 % NPV implies it could reduce un-necessary (and toxic) empiric use of anti-CRE therapeutics, but this should be studied prospectively and on broader populations in order to test its potential role in reducing mortality.

In memory of Prof Yehiel (Chilik) Ziv

Yehiel (Chilik) Ziv passed away on December 2014, after approximately 3 months of courageous battle with a malignant disease. Dr. Yehiel Ziv, or as we all called him: ‘‘Chilik,’’ was born in Israel in June 1951, to a family of Holocaust survivors who immigrated to Israel. He earned his medical degree from the Hebrew University—Hadassah Medical School in Jerusalem, in a program of pre-military medical training, and served his country as a physician. Following his service, Dr. Ziv did his residency in general surgery at the Beilinson Medical Center, one of the top training programs in Israel. Following completion of his residency, he showed special interest in colorectal surgery, and had spent, in 1989, approximately 3 months at St. Marks hospital in London, enhancing his knowledge and capabilities in colorectal surgery. Between 1992 and 1994, he completed 2 years of colorectal surgery fellowship at the Department of Colorectal Surgery at the Cleveland Clinic, Ohio, headed by Dr. Victor Fazio. In addition to his clinical training, Dr. Ziv has made a significant effort to enhance the Ileoanal pouch registry of the Cleveland Clinic and published landmark papers on this topic. Upon return from his fellowship, Dr. Ziv served as the colorectal surgeon and head of colorectal surgery at the ‘‘Assaf Harofeh’’ Medical Center in Israel, where he rapidly established himself as a leader in this field. He was a renowned physician, especially known for his humane care of his patients and their families. Dr. Ziv has served as the president of the Israeli Society of Colon and Rectal Surgery for two consecutive terms and was a member of the editorial board of Techniques in Coloproctology and a member of the scientific committee of the ESCP. On November 2013, he was elected as the president of ECTA, a position he had held at the time of his death. Dr. Ziv was a teacher in nature, served as an associate professor at the Tel Aviv University faculty of medicine, and founded the Israeli fellowship program in colorectal surgery. No doubt that his professional achievements are remarkable. But above all, Chilik was a friend. A friend personally to me, and a friend to so many colorectal surgeons in Israel, Europe, Asia and the USA. We grieve his loss. Our minds are with his family and many friends. He will be cherished in our souls forever. Yehiel (Chilik) Ziv—1951–2014

Application of the 2013 AHA/ASA Guidelines for Use of TPA in Acute Ischemic Stroke at Assaf Harofeh Medical Center, a Tertiary Medical Center in Israel. (P4.293)

Application of the 2013 AHA/ASA Guidelines for Use of TPA in Acute Ischemic Stroke at Assaf Harofeh Medical Center, a Tertiary Medical Center in Israel. (P4.293)

Correlation Between Efficacy of Levetiracetam and Serum Levels Among Children With Refractory Epilepsy

BackgroundLevetiracetam is used as adjunctive therapy in various types of seizures. Studies evaluating the effect of levetiracetam on children with refractory epilepsy are scarce. The aim of this study was to evaluate the correlation between serum concentration of levetiracetam and either efficacy or tolerability in children with refractory epilepsy, and to determine the value of levetiracetam blood level monitoring. MethodsMedical records of 50 children with refractory epilepsy treated with levetiracetam and regularly followed at Assaf Harofeh Medical Center were retrospectively reviewed. Trough serum levetiracetam concentration was determined using high-performance liquid chromatography and correlated with the administered dose and clinical report. ResultsNo correlation between levetiracetam serum levels and clinical efficacy, tolerability or administered dosage was found. The average dose of levetiracetam was 43.7 ± 20.0 (range 14-100) mg/kg/day and the average serum concentration was 16.0 ± 9.5 (range 2.5-38.5) μg/mL. Forty-five patients (95%) had more than a 50% reduction of seizure frequency, with 22 (44%) patients becoming seizure-free for at least 6 months. Adverse events related to levetiracetam were reported in 15 (30%) patients. No correlation between serum concentrations and adverse events was found. These results were not affected by gender, age, type of seizure, and other drugs. ConclusionsDetermination of serum concentration is not needed in all children treated with levetiracetam. Serum concentrations may be valuable either in patients with refractory epilepsy for compliance evaluation or in patients with satisfactory control of seizures for determination of their therapeutic baseline.

A comparison of reproductive outcomes following hysteroscopic management versus dilatation and curettage of retained products of conception

ObjectiveTo compare the reproductive outcome of women who underwent blind dilatation and curettage (D&C) with those who underwent hysteroscopic resection of pathologically confirmed retained products of conception (RPOC). MethodsMedical records of women who underwent either D&C or hysteroscopic resection of RPOC at Assaf Harofeh Medical Center, Israel, between 2000 and 2010 were retrospectively reviewed. ResultsA total of 177 women with pathologically confirmed RPOC underwent either D&C (n=94, 53.1%) or hysteroscopy (n=83, 46.9%). Mean time to conception was significantly shorter after hysteroscopy than after D&C (7.4±7 vs 12.9±16.8months, P=0.037). Rate of occurrence of a newly diagnosed infertility problem was significantly higher following D&C than hysteroscopy (23 [24.5%] vs 10 [12.0%]; P=0.034). Etiology of the new problem was mechanical, including tubal occlusion and intrauterine adhesions. Logistic regression comparing both methods revealed that hysteroscopic resection was associated with a significant reduction in the occurrence of a new infertility problem compared with D&C (OR 0.42; 95% CI, 0.18–0.96, P=0.04). ConclusionHysteroscopic removal of RPOC is associated with a shorter mean time to further conception and a lower rate of occurrence of newly diagnosed infertility problems than D&C.

Seizure occurrence during pediatric short-term EEG.

To identify the patients who are more likely to experience a seizure during short-term EEG recording. We retrospectively reviewed the EEG recordings and medical records of 294 patients, who were admitted to the Pediatric Departments in Assaf Harofeh Medical Center, and referred for a short-term EEG during a 5-years period following a seizure. Fifteen (5.1%) patients had seizures during short-term EEG. The likelihood of seizure occurrence was increased by history of seizures (odds ratio 11.86, 95% confidence interval 2.54-55.37), abnormal neurological examination (odds ratio 3.33, 95% confidence interval 1.05-10.55), and the presence of interictal epileptiform discharges (odds ratio 10.07, 95% confidence interval 1.26-80.42). Treatment with antiepileptic drugs and mental retardation were significantly more common among patients with seizures. Children with a higher likelihood of a seizure during short-term EEG can be identified using data mainly obtained by history and neurological examination.

First trimester maternal serum placental protein 13 levels in singleton vs. twin pregnancies with and without severe pre-eclampsia

To determine first trimester maternal serum placental protein 13 (PP13) in singletons vs. twins with and without severe preeclampsia (PE). Serum samples were prospectively collected at 8-14 weeks of gestation. PP13 was determined by solid-phase immunoassay. Patients were recruited in community clinics throughout the country, and from the twin antenatal assessment clinic in Assaf Harofeh Medical Center, Zerifin, Israel. Demographics, medical, and pregnancy history were obtained at enrollment. Pregnancy outcome was collected after delivery. PP13 was compared by the Wilcoxon rank sum test. In singletons, PP13 declined with maternal weight and was lower in in vitro fertilization. Levels were converted into multiples of the median (MoMs) accordingly. In twins, the median was 1.74 MoM (n=76) vs. 1.00 in singletons (n=676, P<0.0001). Among twins with severe PE (n=10), the median was 1.53 MoM vs. 1.74 in unaffected twins (P=0.10), and 2.26 (n=6) for mild PE (P=0.30). Among singletons with severe PE, the median was 0.44 MoM (n=26, P<0.0001), and for mild PE 0.62 (n=17, P<0.001). PP13 is higher in twins than singletons, corresponding to the larger placental mass. Among singletons with severe PE, levels were significantly reduced, however, among twins, only a non-significant tendency for a reduction was recorded, and warrants further investigation in a larger series.

Comparison of Lower Urinary Tract Symptoms Between Women with Detrusor Overactivity and Impaired Contractility, and Detrusor Overactivity and Preserved Contractility

We compared symptoms in women with detrusor overactivity with impaired contractility and women with detrusor overactivity who had preserved contractility. The study included 359 consecutive women with detrusor overactivity who underwent multichannel urodynamics at our department between 2009 and 2011. The women were divided into 2 groups, including 151 (42%) with detrusor overactivity and impaired contractility, and 208 (58%) with detrusor overactivity and preserved contractility. We compared the 2 groups. Women with detrusor overactivity and impaired contractility were older (mean ± SD age 73.2 ± 17.3 vs 54.1 ± 20.7 years) with a higher frequency of diabetes mellitus (49% vs 31%, each p <0.001). The prevalence of previous urinary retention and recurrent cystitis was significantly higher in women with impaired contractility (7% vs 1%, p <0.01 and 22% vs 7%, p <0.001, respectively). Mean post-void residual urine was greater in the group with impaired contractility (89 ± 42 vs 21 ± 18 ml) and the mean maximal flow rate was lower (11 ± 6 vs 23 ± 5 ml per second, each p <0.001). The frequency of storage symptoms was similar in the 2 groups. However, voiding symptoms were more common in women with impaired contractility, including a slow stream in 69% vs 42%, an intermittent stream in 72% vs 26%, hesitancy in 35% vs 22%, straining in 84% vs 26%, terminal dribbling in 73% vs 42% and incomplete emptying in 71% vs 49% (p <0.001). Women with detrusor overactivity and impaired contractility are older than women with detrusor overactivity and preserved detrusor contractility. Urinary retention and recurrent cystitis are more frequent in women with detrusor overactivity and impaired contractility, and voiding symptoms are significantly more common.

Lamotrigine Serum Concentration in Children With Epilepsy

The correlation between lamotrigine serum concentration, efficacy, and toxicity in children is controversial. The database of the Clinical Pharmacology Laboratory at Assaf Harofeh Medical Center was retrospectively searched to identify lamotrigine serum concentrations in children aged 2-19 years with refractory epilepsy who received lamotrigine as monotherapy or polytherapy from 2007-2010. Data collected included age at epilepsy onset, additional antiepileptic drugs, lamotrigine dose, monthly seizure frequency before and after lamotrigine treatment, and side effects. Sixty blood samples were collected from 42 children aged 10.1 ± 4.9 years (range, 2-20 years). Seizure types included complex partial (n = 28), simple partial (n = 7), absence (n = 2), and generalized tonic-clonic (n = 23). Decreased seizure frequency was observed in 38 (63.3%) patients. No correlation with lamotrigine serum concentration was evident, but seizure frequency was significantly influenced by age and lamotrigine dose. Side effects were reported in 21 (35%) patients. Only diplopia was significantly correlated with lamotrigine serum concentration. Lamotrigine was more effective at lower doses and in older children. Lamotrigine serum concentration correlated significantly with diplopia, but not with other side effects or with clinical efficacy. Overall, lamotrigine is effective and safe in children with refractory epilepsy.

The relationship between the new taxonomy of Streptococcus bovis and its clonality to colon cancer, endocarditis, and biliary disease

The nomenclature of Streptococcus bovis has changed. The study aims were to examine and compare the clinical characteristics and outcomes of infections based on the new taxonomy and the genetic relatedness of strains. Bacteremic cases from 2004 to 2010 at Assaf Harofeh Medical Center were reviewed. VITEK 2 later confirmed with polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) was used for subspecies identification. VITEK 2 later confirmed with Etests was used for minimal inhibitory concentration (MIC) testing. Repetitive extragenic palindromic polymerase chain reaction (rep-PCR) was used to determine the genetic relatedness of strains. Twenty-four bacteremia cases were included. The median age of patients was 81 years (range 1 day to 91 years), two were neonates, three were pregnant, and 18 were elderly (≥ 65 years of age). The Charlson's combined conditional age-related score was 8.2 ± 2.9, and 11 (58 %) patients were immunosuppressed. There were 13 patients who had S. gallolyticus subsp. pasteurianus, six had S. gallolyticus subsp. gallolyticus, four had S. infantarius subsp. coli, and one had S. infantarius subsp. infantarius. Ten of 19 non-pregnant adult patients had colon adenoma or carcinoma, three had acute biliary disease, and five had endocarditis. Two patients died in the hospital. rep-PCR revealed polyclonality. There were no significant associations between subspecies or genotypes and the various clinical characteristics or outcomes. S. bovis bacteremia is a serious disease that affects elderly immunosuppressed individuals. Infection is strongly associated with colon pathology and endocarditis, regardless of the new taxonomy or clone complex. The identification of S. bovis is of paramount importance, and microbiology laboratories should differentiate its processing from that of other S. viridans.

Orthostatic Hypotension in Children with Acute Febrile Illness

BackgroundChildren presenting to the Pediatric Emergency Department (PED) with fever often describe symptoms such as lightheadedness, dizziness, fatigue, and weakness, and may appear pale. They may also present with a chief complaint of syncope. Such symptoms may result from orthostatic hypotension. ObjectiveTo determine whether children with an acute febrile illness have a higher incidence of orthostatic hypotension compared to afebrile children. MethodsA prospective cohort study was conducted at the PED at Assaf Harofeh Medical Center, a university-affiliated hospital in Israel. Eighty children aged 4–18 years were recruited. Thirty-nine had fever (>38°C for 6–48h) and 41 were afebrile. All subjects had their blood pressure measured in the supine position (after 5min of rest) and again after standing for 3min. The main outcome measure was orthostatic hypotension, that is, a reduction of systolic blood pressure of at least 20mm Hg, or a fall in diastolic blood pressure of at least 10mm Hg within 3min of standing. ResultsThere were no differences between the groups in gender, age, height, or weight. Orthostatic hypotension was found in 10/39 (25.6%) of febrile children and in 2/41 (5%) of afebrile children (p=0.012). ConclusionsThe incidence of orthostatic hypotension among febrile children in the PED is high, and may explain common symptoms such as dizziness or syncope. Such patients should be instructed to drink properly and to avoid rapid changes in body posture.