Israel Medical Association Journal

Background: Diabetic ketoacidosis (DKA) is a common and serious complication of diabetes mellitus (DM).

Objectives: To evaluate the clinical characteristics, hospital management and outcomes of patients with DKA.

Methods: We performed a retrospective cohort study of patients hospitalized with DKA during the period 1 January 2003 to 1 January 2010. Three groups were compared: patients with mild DKA, with moderate DKA, and with severe DKA. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30 days all-cause mortality, length of hospital stay, and complication rate.

Results: The study population comprised 220 patients with DKA. In the mild (78 patients) and moderate (116 patients) groups there was a higher proportion of patients with type 1 DM (75.6%, 79.3%) compared with 57.7% in the severe group (26 patients, P = 0.08). HbA1C levels prior to admission were high in all three groups, without significant difference (10.9 ± 2.2, 10.7 ± 1.9, and 10.6 ± 2.4 respectively, P = 0.9). In all groups the most frequent precipitating factors were related to insulin therapy and infections. The patients with severe DKA had more electrolyte abnormalities (hypokalemia, hypomagnesemia, hypophosphatemia) compared with the mild and moderate forms of the disease. While 72.7% of the entire cohort was hospitalized in the general medical ward, 80.8% of those with severe DKA were admitted to the intensive care unit. The in-hospital mortality rate for the entire cohort was 4.1%, comparable with previous data from experienced centers. Advanced age, mechanical ventilation and bedridden state were independent predictors associated with 30 day mortality: hazard ratio (HR) 1.1, 95% confidence interval (CI) 1.02–1.11; HR 6.8, 95% CI 2.03–23.1; and HR 3.8, 95% CI 1.13–12.7, respectively.

Conclusions: Patients with DKA in our study were generally poorly controlled prior to their admission, as reflected by high HbA1c levels. Type 2 DM is frequently associated with DKA including the severe form of the disease. The most common precipitating factors for the development of DKA were related to insulin therapy and infections. Advanced age, mechanical ventilation and bedridden state were independent predictors of 30 day mortality.
 

Background: Alcohol consumption in Israel has increased over the last 20 years. Patients with alcohol use disorder (AUD) who present at a hospital enable early intervention. Objectives: To examine, for the first time, the characteristics of AUD patients in an Israeli general hospital, including whether their alcohol use is documented in their file.

Methods: A group of 178 consecutive patients referred for psychiatric consultation was compared to a second group of 105 hospitalized patients who were not referred. These two groups were studied to compare risk factors for AUD. Patients in both groups were prospectively interviewed using a CAGE questionnaire, demonstrated as an effective screening instrument for AUD. Patients' files in both groups were examined for documentation of alcohol use.

Results: There was no significant difference between the prevalence of AUD in the two groups. The groups were then merged since no significant difference in the risk factor effects between the two groups was found. The risk factors for AUD in the final statistical analysis were lower educational status, living alone, being born in the Former Soviet Union and weaker religious observance. Post-traumatic stress disorder (PTSD), cigarette smoking and substance use were found to be independent risk factors. Soldier status was associated with significant alcohol misuse and AUD (CAGE1–4). Alcohol consumption was documented in the files of AUD patients in 48% of the first group and 21% of the second.

Conclusions: Physicians often neglect to take a history of alcohol consumption. Routine use of the CAGEquestionnaire is recommended in Israeli general hospitals. Special attention should be given to PTSD patients and to soldiers.
 

Physicians have a great interest in discussions of life and its origin, including life's persistence through successive cycles of self-replication under extreme climatic and man-made trials and tribulations. We review here the fundamental processes that, contrary to human intuition, life may be seen heuristically as an ab initio, fundamental process at the interface between the complementary forces of gravitation and quantum mechanics. Analogies can predict applications of quantum mechanics to human physiology in addition to that already being applied, in particular to aspects of brain activity and pathology. This potential will also extend eventually to, for example, autoimmunity, genetic selection and aging. We present these thoughts in perspective against a background of changes in some physical fundamentals of science, from the earlier times of the natural philosophers of medicine to the technological medical gurus of today. Despite the enormous advances in medical science, including integration of technological changes that have led to the newer clinical applications of magnetic resonance imaging and PET scans and of computerized drug design, there is an intellectual vacuum as to how the physics of matter became translated to the biology of life. The essence and future of medicine continue to lie in cautious, systematic and ethically bound practice and scientific research based on fundamental physical laws accepted as true until proven false.
 

The incidence of invasive uterine cervical cancer in Israeli Jewish women is persistently lower than in many other countries, although the frequency of premalignant lesions is similar to that in other populations. Most characteristics, except certain traditional habits, are similar to those in other populations. The incidence among women born in North Africa and their Israeli born descendants is significantly higher than in those born in other continents, possibly due to genetic factors. In view of the similarities to other populations the reason for the low incidence in Israel remains obscure, and whether it may be attributed to genetic reasons or to some traditional habits remains to be confirmed
 

Background: Staphylococcus aureus infection is a major cause of morbidity and mortality worldwide. Clindamycin is widely used in the treatment of staphylococcal infections; however, it is our impression that in the last few years, inducible clindamycin resistance (ICR) has become more prevalent.

Objective: To assess the prevalence of ICR[1] in methicillin-sensitive Staphylococcus aureus (MSSA) infections among pediatric patients in Israel.

Methods: We reviewed the files of children diagnosed with MSSA[2] infections during the period January 2006 to June 2007 for full antibiogram (including the D-test for ICR), phage typing and randomly amplified polymorphic DNA.

Results: Altogether, 240 MSSA isolates were recovered, mainly from wounds and abscesses. ICR was detected in 62 of 68 erythromycin-resistant/clindamycin-sensitive strains (91%); the ICR rate for the total number of isolates was 26% (62/240). Phage type analysis demonstrated that 38 of 61 ICR isolates

(62%) were sensitive to group 2, compared to 42 of 172 isolates (24%) that did not express ICR (P < 0.01). On randomly amplified polymorphic DNA, phage type 2 isolates expressing ICR belonged to the same clone, which was different from ICR isolates sensitive to other phages and from isolates not expressing ICR.

Conclusions: Inducible clindamycin resistance is common among methicillin-sensitive Staphylococcus aureus in Israeli children. The D-test should be performed routinely in all isolates of MSSA.

In Israel, Yemenite Jews and other populations including Ethiopian Jews and Bedouins have a low neutrophil count. This phenomenon has been called “benign neutropenia” since it has not been associated with any increased risk of infection and has also been described in other populations around the world including Africans, African Americans and Afro-Carribeans. Here we describe the recent success in mapping the gene that underlies benign neutropenia in African American populations. We discuss the known function of the gene and consider potential mechanisms for the effect on neutropenia. We also consider the possibility that this gene underlies the same effect observed in Yemenite Jews, Ethiopian Jews and Bedouins in Israel.
 

Background: Gastric stump cancer is often described as a tumor with a poor prognosis and low resectability rates.

Objectives: To compare the pathological characteristics of gastric stump cancer patients with those of patients with proximal gastric cancer.

Methods: This retrospective study was based on the demographic and pathological data of patients diagnosed with gastric cancer and treated at Assaf Harofeh Medical Center during an 11 year period. The patients were divided into two groups: those undergoing proximal gastrectomy for proximal gastric cancer and those undergoing total gastrectomy for gastric stump cancer.

Results: Patients with gastric stump cancer were predominantly male, older (P = 0.202, not significant), and had a lower T stage with less signet-ring type histology, fewer harvested and fewer involved lymph nodes (P = 0.03, statistically significant) and less vascular/lymphatic involvement than patients with proximal gastric cancer.

Conclusions: The lower incidence of involved lymph nodes and lymphovascular invasion in gastric stump cancer as compared to proximal gastric cancer in this study may imply that the prognosis of gastric stump cancer may be better than that of proximal gastric cancer. However, to verify this assumption a study comparing patient survival is required.